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Surgical Endoscopy

, Volume 29, Issue 9, pp 2576–2582 | Cite as

A new concept of the anatomy of the thoracic oesophagus: the meso-oesophagus. Observational study during thoracoscopic esophagectomy

  • Miguel A. Cuesta
  • Teus J. Weijs
  • Ronald L. A. W. Bleys
  • Richard van Hillegersberg
  • Mark I. van Berge Henegouwen
  • Suzanne S. Gisbertz
  • Jelle P. Ruurda
  • Jennifer Straatman
  • Harushi Osugi
  • Donald L. van der Peet
Article

Abstract

Background

During thoracoscopic oesophageal surgery, we observed not previously described fascia-like structures. Description of similar structures in rectal cancer surgery was of paramount importance in improving the quality of resection. Therefore, we aimed to describe a new comprehensive concept of the surgical anatomy of the thoracic oesophagus with definition of the meso-oesophagus.

Methods

We retrospectively evaluated 35 consecutive unedited videos of thoracoscopic oesophageal resections for cancer, to determine the surgical anatomy of the oesophageal fascia’s vessels and lymphatic drainage. The resulting concept was validated in a prospective study, including 20 patients at three different centres. Additional confirmation was sought by a histologic study of a cadaver’s thorax.

Results

A thin layer of connective tissue around the infracarinal oesophagus, involving the lymph nodes at the level of the carina, was observed during thoracoscopic esophagectomy in 32 of the 35 patients included in the retrospective study and in 19 of the 20 patients included in the prospective study. A thick fascia-like structure from the upper thoracic aperture to the lower thoracic aperture was visualized in all patients. This fascia is encountered between the descending aorta and left aspect of the infracarinal oesophagus. Above the carina it expands on both sides of the oesophagus to lateral mediastinal structures. This fascia contains oesophageal vessels, lymph vessels and nodes and nerves. The histologic study confirmed these findings.

Conclusions

Here we described the concept of the “meso-oesophagus”. Applying the description of the meso-oesophagus will create a better understanding of the oesophageal anatomy, leading to more adequate and reproducible surgery.

Keywords

Oesophagus Meso-oesophagus Anatomy Surgical resection Thoracoscopy 

Notes

Acknowledgments

We acknowledge the valuable contributions of BM Zonderhuis en JJ Scheepers in the drafting of this manuscript.

Disclosures

Miguel A. Cuesta, Teus J. Weijs, Ronald L. A. W. Bleys, Richard van Hillegersberg, Mark I. van Berge Henegouwen, Suzanne S. Gisbertz, Jelle P. Ruurda, Jennifer Straatman, Harushi Osugi, and Donald L van der Peet have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    Vesalius A (1998). On the fabric of the human body (trans: Richardson WF and Carman JB). Norman Publishing, San Francisco and Novato. (original work published 1543)Google Scholar
  2. 2.
    Testut L, Latarjet A (1895) Traite d’anatomie humaine, 3rd edn. Doin, ParisGoogle Scholar
  3. 3.
    Spalteholz W, His W (1903) Handatlas der anatomie des menschen. Hirzel, LeipzigGoogle Scholar
  4. 4.
    Gray H (2000) Chapter XI: Splanchnology. In: Lewis WH (ed) Anatomy of the human body, 20th edn. Bartleby.com, New York (original work published 1918 Philadelphia: Lea & Febiger)Google Scholar
  5. 5.
    Rouvière H (1930) Précis d’anatomie et de dissection. Tome II-Thorax, abdomen, bassin, membre inférieur, 5th edn. Masson, ParisGoogle Scholar
  6. 6.
    Davis ED (1948) The applied anatomy and physiology of the pharynx and oesophagus. Ann R Coll Surg Engl 3:139–153PubMedCentralPubMedGoogle Scholar
  7. 7.
    Marchand P (1951) The anatomy and applied anatomy of the mediastinal fascia. Thorax 6:359–368PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Healy JE, Seybold WD (1969) A synopsis of clinical anatomy. WB Saunders, PhiladelphiaGoogle Scholar
  9. 9.
    Netter FH (1948) The CIBA collection of medical illustrations, 5th edn. Ciba Pharmaceutical Products, New YorkGoogle Scholar
  10. 10.
    Sato T, Lizuka T (1992) Color atlas of surgical anatomy for esophageal cancer. Springer, TokyoCrossRefGoogle Scholar
  11. 11.
    Pinotti HW (1999) Acesso ao esôfago torácico por transecção mediana do diafragma. Atheneu, São PauloGoogle Scholar
  12. 12.
    Biere SSAY et al (2012) Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 379:1887–1892CrossRefPubMedGoogle Scholar
  13. 13.
    van Hagen P et al (2012) Preoperative chemoradiotherapy for esophageal or esophagogastric junction cancers improves survival. N Engl J Med 366:2074–2084CrossRefPubMedGoogle Scholar
  14. 14.
    Bancroft JD, Cook HC (1984) Manual of histological techniques. Churchill Livingstone, EdinburghGoogle Scholar
  15. 15.
    Heald RJ, Ryall RDH (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1:1479–1482CrossRefPubMedGoogle Scholar
  16. 16.
    Kluth D, Fiegel H (2003) The embryology of the foregut. Semin Pediatr Surg 12:3–9CrossRefPubMedGoogle Scholar
  17. 17.
    Brugger PC, Weber M, Prayer D (2011) Magnetic resonance imaging of the normal fetal esophagus. Ultrasound Obstet Gynecol 38:568–574CrossRefPubMedGoogle Scholar
  18. 18.
    Metzger R, Wachowiak R, Kluth D (2011) Embryology of the early foregut. Semin Pediatr Surg 20:136–144CrossRefPubMedGoogle Scholar
  19. 19.
    Luketich JD, pennathur A, Awais O et al (2012) Outcomes after Minimally Invasive Esophagectomy: a review of over 1000 patients. Ann Surg 256:95–103PubMedCentralCrossRefPubMedGoogle Scholar
  20. 20.
    Salassa JR, Pearson BW, Payne WS (1977) Gross and microscopical blood supply of the trachea. Ann Thorac Surg 24:100–107CrossRefPubMedGoogle Scholar
  21. 21.
    Matsubara T et al (1998) Cervicothoracic approach for total mesoesophageal dissection in cancer of the thoracic esophagus. J Am Coll Surg 187:238–245CrossRefPubMedGoogle Scholar
  22. 22.
    Riddell AM et al (2007) High-resolution MRI in evaluation of the surgical anatomy of the esophagus and posterior mediastinum. Am J Roentgenol 188:37–43CrossRefGoogle Scholar
  23. 23.
    Izon AS, Jose P, Hayden JD, Grabsch HI (2013) Significant variation of resected meso-esophageal tissue volume in two-stage subtotal esophagectomy specimen: A retrospective morphometric study. Ann Surg Oncol 20:788–797CrossRefPubMedGoogle Scholar
  24. 24.
    Lieberman-Meffert D (2001) Anatomical basis for the approach and extent of surgical treatment of esophageal cancer. Dis Esophagus 14:81–84CrossRefGoogle Scholar
  25. 25.
    Oezcelik A, DeMeester SR (2011) General anatomy of the esophagus. Thorac Surg Clin. 21:289–297CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Miguel A. Cuesta
    • 1
  • Teus J. Weijs
    • 2
  • Ronald L. A. W. Bleys
    • 2
  • Richard van Hillegersberg
    • 3
  • Mark I. van Berge Henegouwen
    • 4
  • Suzanne S. Gisbertz
    • 4
  • Jelle P. Ruurda
    • 3
  • Jennifer Straatman
    • 1
  • Harushi Osugi
    • 5
  • Donald L. van der Peet
    • 1
  1. 1.Department of SurgeryVrije Universiteit Medical CentreAmsterdamThe Netherlands
  2. 2.Department of AnatomyUniversity Medical CentreUtrechtThe Netherlands
  3. 3.Department of SurgeryUniversity Medical CentreUtrechtThe Netherlands
  4. 4.Department of SurgeryAcademic Medical CentreAmsterdamThe Netherlands
  5. 5.Department of Gastroenterological SurgeryOsaka City University Graduate School of MedicineOsakaJapan

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