McKeown esophagectomy for a thoracic esophageal carcinoma patient who has a history of definitive chemoradiotherapy for esophageal carcinoma and total pharyngolaryngectomy for hypopharyngeal cancer

**Background:** Esophageal squamous cell carcinoma (ESCC) and head and neck cancers frequently occur synchronously or metachronously. Esophagectomy is technically challenging in patients with a history of total pharyngolaryngectomy (TPL) with free jejunal graft reconstruction due to adhesions around the cervical jejunoesophageal anastomosis and the need to preserve tracheal blood supply. Salvage esophagectomy after definitive chemoradiotherapy (dCRT) carries high risks of anastomotic leakage and tracheal necrosis due to radiation-induced fibrosis. This case report documents a rare ESCC patient who underwent McKeown esophagectomy after both dCRT and TPL.

**Methods:** The patient was a 64-year-old man with a complex history: endoscopic mucosal resection for superficial ESCC (pT1b, lymphovascular invasion+) followed by chemoradiotherapy (50 Gy and 2 cycles of cisplatin+5-fluorouracil) in April 2008; TPL with free jejunal graft reconstruction and tracheostomy for hypopharyngeal cancer in April 2009; and multiple curative endoscopic submucosal dissections (ESDs) for superficial ESCC in 2016, 2018, and 2020. In February 2022, a new type 0-2c lesion was detected in the middle thoracic esophagus (33-35 cm from incisors), classified as cT1aN0M0. ESD was performed but pathological diagnosis was difficult due to scar tissue; the possibility of pT2 and resection margin positivity could not be excluded. Close observation was initially selected due to high surgical risk. Two months later (May 2022), follow-up endoscopy detected stenosis from intramural tumor recurrence. Endoscopic ultrasound-guided fine needle aspiration confirmed ESCC, and the tumor was reclassified as cT3N0M0 (stage 2). Neoadjuvant chemotherapy was not given. The surgical approach was thoracoscopic McKeown esophagectomy with the patient in prone position using five access ports. Limited lymph node dissection was performed, harvesting only swollen or suspicious nodes. Prophylactic upper mediastinal lymphadenectomy was minimized to preserve tracheal blood supply. Both bronchial arteries, pulmonary branches of bilateral vagus nerves, and the azygos arch were preserved. Only paraesophageal lymph nodes (no. 105) were harvested in the upper mediastinum, while middle and inferior mediastinal lymph nodes (no. 107, 108, 109, 110, 111, 112) were totally removed. A cervical incision was made along the upper side of the tracheostomy, and the free jejunal graft and remnant esophagus were mobilized. A gastric conduit was created via laparotomy and raised via the posterior mediastinal route. End-to-side anastomosis between the jejunal graft and gastric conduit was performed.

**Key Results:** Operating time was 455 minutes, and estimated blood loss was 332 g. Experienced head and neck surgeons confirmed good color tone of the tracheostomy after surgery. On postoperative day 4, chyle pleural effusion was recognized and resolved by changing enteral nutrition from a lipid-containing diet (E-7II) to a lipid-free diet (Erental). On postoperative day 7, minor pneumothorax was noted and treated with thoracic catheter drainage. The patient was discharged on postoperative day 44. Pathological examination revealed moderately differentiated squamous cell carcinoma widely invading 155 × 30 mm beyond the proper muscular layer (pT3), with marked vessel invasion (ly3, v3). Surgical margins were free (pPM0, PDM0, pRM0). The effect of preoperative therapy was slight (grade 1a). Lymph node metastases were detected in middle mediastinal lymph nodes (no. 107, no. 109) and perigastric lymph nodes (no. 1, no. 3, and no. 7). The tumor was classified as pT3N2M0 stage 3B.

**Clinical Implications:** This is the first reported case of thoracoscopic McKeown esophagectomy after both dCRT for ESCC and TPL with free jejunal graft reconstruction. The case demonstrates that careful preservation of tracheal blood supply through selective lymphadenectomy and preservation of bilateral bronchial arteries is feasible and may prevent tracheal necrosis. The interval between TPL and esophagectomy may be crucial for allowing formation of tracheal blood flow bypass. Thoracoscopic approach may help surgeons recognize optimal dissection layers in fibrotic tissue. However, long-term outcomes remain to be addressed, and the safety, oncological radicality, and survival benefits of thoracoscopic esophagectomy in locally advanced esophageal cancer require further confirmation through ongoing randomized trials.