Mediastinoscopic Esophagectomy for Esophageal Cancer with Right Aortic Arch: A Case Report

Esophageal cancer with a right aortic arch (RAA) is rare and technically demanding because anomalous vascular anatomy and altered recurrent laryngeal nerve (RLN) courses complicate safe dissection. While thoracoscopic approaches have been reported, this is the first report of mediastinoscopic esophagectomy for thoracic esophageal cancer with an RAA and a Kommerell's diverticulum (KD).

A 74-year-old woman who had undergone endoscopic submucosal dissection (ESD) for lower esophageal cancer (T1a-EP) 6 months prior required balloon dilation every 2 weeks for post-ESD stricture. Follow-up endoscopy revealed a 10-mm 0-IIc lesion in the upper thoracic esophagus, and the biopsy confirmed squamous cell carcinoma. CT showed no lymph nodes or distant metastasis. CT also demonstrated an RAA with branching in the order of the left common carotid artery, right common carotid artery, right subclavian artery, and an aberrant left subclavian artery arising from a KD and coursing dorsally to the esophagus (Edwards IIIB). The clinical diagnosis was upper thoracic esophageal cancer, cT1aN0M0 (Union for International Cancer Control [UICC]-8th edition). After 3D-CT assessment, mediastinoscopic esophagectomy was performed via a right cervical approach under pneumomediastinum. The transcervical mediastinoscopic approach provided a favorable view for upper mediastinal dissection and allowed safe manipulation while confirming the relationship between the esophagus and anomalous vessels. Nevertheless, at the aortic arch level, the esophagus lies within the narrowest corridor between the trachea and the arch, which may restrict maneuverability and limit mobilization. The procedure was completed with subsequent laparoscopic transhiatal dissection. Reconstruction was performed via a retrosternal route with cervical anastomosis. The pathological stage was pT1aN0M0. Postoperative transient bilateral RLN palsy required a tracheostomy, which closed within 6 months. The patient had an adequate oral intake and remains recurrence-free at 5 years postoperatively.

Mediastinoscopic surgery may constitute a feasible therapeutic method for esophageal cancer with an RAA. The mediastinoscopic approach facilitated identification of the RLN and enabled dissection under magnified visualization while confirming the spatial relationship between the esophagus and anomalous vascular structures.