CASE REPORT Esophageal Cancer and Double Aortic Arch: Right-Sided Thoracoscopic Esophagectomy and Reconstruction Naveena AN Kumar 1 & Nawaz Usman 1 & Keshava Rajan 1 & Yogesh K Gaude 2 # Springer Science+Business Media, LLC, part of Springer Nature 2020 Introduction Aortic arch anomalies occur due to the failure of normal re- gression of one or more segments of six pairs of aortic arches that arise from truncus arteriosus [1]. These anomalies may include the combination of a double aortic arch (DAA) with an equal/smaller right or left arch and a right- or left-sided descending thoracic aorta [1]. The DAA results from the per- sistence of both right and left arches, as against the normal embryological development, where one of the six arches per- sist as ductus arteriosus and is classified as a Stewart & Edwards type I vascular malformation [1, 2]. The DAA forms a complete “vascular ring,” which encircles trachea and esophagus [1]. It is known to cause respiratory symptoms and dysphagia in infancy [1, 3]. However, it is detected by chance in adults, as they are usually asymptomatic [1, 3]. The prevalence of aortic arch anomalies ranges from 1 to 2% and incidence of DAA is 46–76% among the reports of vascular rings [4, 5]. Association of DAA with esophageal cancer is rare [3, 6] and makes surgery very difficult and challenging due to the complex anatomy. There are few previously report- ed cases, where surgery was performed through right or left thoracotomy and gastric tube was transferred through retrosternal route or through the left thorax [3, 6–9]. There is only one report of left thoracoscopic approach and retrosternal reconstruction [2]. We report a esophageal cancer patient with DAA, who successfully underwent right thoracoscopic esophagectomy and reconstruction through right thoracic approach. Case Report A 62-year-old lady presented with grade 2 dysphagia. She was diagnosed to have locally advanced squamous cell carcinoma of mid thoracic esophagus without any distant metastasis. On contrast enhanced computed tomography (CECT), there was right arch of aorta connecting left dominant arch to the right- sided descending aorta forming a complete “vascular ring” encircling the esophagus and trachea (Fig. 1A). The descend- ing aorta was located on the right side of the posterior medi- astinum, pushing the lower and mid esophagus to the left thorax (Fig. 1B). The patient was taken up for surgery 6 weeks following completion of neoadjuvant chemo radiation (NACTRT). Surgical Procedure Thoracic Part The patient was intubated using single lumen endotracheal tube and was placed in semi-prone (dorso-lateral) position. The Camera port was placed at 7th intercostal space (ICS) in mid axillary line and assistant ports were placed in 5th and 9th ICS in posterior axillary line. Pneumothorax was maintained at 6–8 mmHg. The first step was to dissect and clip the azy- gous vein (Fig. 2A). The second step was to identify and dissect the right arch of aorta, which was encircling trachea and esophagus completely (Fig. 2B). The esophagus, which was pushed to left thorax by right-sided descending aorta, was * Naveena AN Kumar nkoncol@gmail.com Nawaz Usman nawaz.usman@manipal.edu Keshava Rajan keshava.rajan@manipal.edu 1 Department of Surgical Oncology, Manipal Comprehensive Cancer Care Center, Kasturba, Medical College, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka 576104, India 2 Department of Anesthesiology, Kasturba Medical College, Manipal Academy of Higher, Education (MAHE), Manipal, Karnataka 576104, India Journal of Gastrointestinal Cancer https://doi.org/10.1007/s12029-020-00469-x