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Microanatomy-based standardization of left upper mediastinal lymph node dissection in thoracoscopic esophagectomy in the prone position

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Abstract

Background

Although thoracoscopic esophagectomy in the prone position (TEPP) has become a standard procedure for esophageal cancer surgery, upper mediastinal lymph node dissection (UMLND) on the left side remains an issue. We have recently developed a new standardized approach to left UMLND in TEPP based on the microanatomy of the membranes and layers with the aim of achieving quick and safe surgery. The purpose of this study was to establish and evaluate our new standardized procedure in left UMLND.

Patients and methods

Patients were divided into 2 groups: a pre-standardization group (n = 100) and a post-standardization group (n = 100). Eventually, 83 paired cases were matched using propensity score matching. In our new standardized procedure, left UMLND was performed while focusing on the visceral sheath, vascular sheath, and the fusion layer between them using a magnified view.

Results

The thoracoscopic operative time was significantly shorter (P < 0.001) in the post-standardization group [n = 83; 209.0 (176.0–235.0) min] than in the pre-standardization group [n = 83; 235.5 (202.8–264.5) min]. No significant differences were found in the number of mediastinal lymph nodes dissected or intraoperative blood loss between the two groups. There was a tendency for the total postoperative morbidity to decrease in the post-standardization group. Furthermore, the left recurrent laryngeal nerve palsy rate was significantly lower in the post-standardization group (18.1% to 8.7%, P = 0.015).

Conclusion

Microanatomy-based standardization contributes to safe and efficient left UMLND.

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References

  1. Parkin DM, Bray F, Ferlay J, Pisani P (2005) Global cancer statistics, 2002. CA Cancer J Clin 55:74–108

    Article  Google Scholar 

  2. Akiyama H, Tsurumaru MA, Kawamura T, Ono Y (1981) Principles of Surgical Treatment for Carcinoma of the Esophagus AnalysisofLymph Node Involvement. Ann Surg 194:438–445

    Article  CAS  Google Scholar 

  3. Akiyama H, Tsurumaru M, Udagawa H, Kajiyama Y (1994) Radical Lymph Node Dissection for CanceroftheThoracicEsophagus. Ann Surg 220:364–373

    Article  CAS  Google Scholar 

  4. Fujita H, Sueyoshi S, Tanaka T, Fujii T, Toh U, Mine T, Sasahara H, Sudo T, Matono S, Yamana H, Shirouzu K (2003) Optimal lymphadenectomy for squamous cell carcinoma in the thoracic esophagus: comparing the short- and long-term outcome among the four types of lymphadenectomy. World J Surg 27:571–579

    Article  Google Scholar 

  5. Igaki H, Tachimori Y, Kato H (2004) Improved survival for patients with upper and/or middle mediastinal lymph node metastasis of squamous cell carcinoma of the lower thoracic esophagus treated with 3-field dissection. Ann Surg 239:483–490

    Article  Google Scholar 

  6. Watson A (1994) Operable esophageal cancer: current results from the West. World J Surg 18:361–366

    Article  CAS  Google Scholar 

  7. Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA (2003) Complications and costs after high-risk surgery: where should we focus quality improvement initiatives? J Am Coll Surg 196:671–678

    Article  Google Scholar 

  8. Atkins BZ, Shah AS, Hutcheson KA, Mangum JH, Pappas TN, Harpole DH, Amico TA (2004) Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 78:1170–1176; discussion 1170–1176

    Article  Google Scholar 

  9. Cuschieri A, Shimi S, Banting S (1992) Endoscopic oesophagectomy through a right thoracoscopic approach. J R Coll Surg Edinb 37:7–11

    CAS  PubMed  Google Scholar 

  10. Cuschieri A (1993) Endoscopic subtotal oesophagectomy for cancer using the right thoracoscopic approach. Surg Oncol 2(Suppl 1):3–11

    Article  Google Scholar 

  11. Cuschieri A (1994) Thoracoscopic subtotal oesophagectomy. Endosc Surg Allied Technol 2:21–25

    CAS  PubMed  Google Scholar 

  12. Akaishi T, Kaneda I, Higuchi N, Kuriya Y, Kuramoto J, Toyoda T, Wakabayashi A (1996) Thoracoscopic en bloc total esophagectomy with radical mediastinal lymphadenectomy. J Thorac Cardiovasc Surg 112:1533–1540

    Article  CAS  Google Scholar 

  13. Osugi H, Takemura M, Higashino M, Takada N, Lee S, Kinoshita H (2003) A comparison of video-assisted thoracoscopic oesophagectomy and radical lymph node dissection for squamous cell cancer of the oesophagus with open operation. Br J Surg 90:108–113

    Article  CAS  Google Scholar 

  14. Palanivelu C, Prakash A, Senthilkumar R, Senthilnathan P, Parthasarathi R, Rajan PS, Venkatachlam S (2006) Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position–experience of 130 patients. J Am Coll Surg 203:7–16

    Article  Google Scholar 

  15. Noshiro H, Iwasaki H, Kobayashi K, Uchiyama A, Miyasaka Y, Masatsugu T, Koike K, Miyazaki K (2010) Lymphadenectomy along the left recurrent laryngeal nerve by a minimally invasive esophagectomy in the prone position for thoracic esophageal cancer. Surg Endosc 24:2965–2973

    Article  Google Scholar 

  16. Tsujimoto H, Takahata R, Nomura S, Yaguchi Y, Kumano I, Matsumoto Y, Yoshida K, Horiguchi H, Hiraki S, Ono S, Yamamoto J, Hase K (2012) Video-assisted thoracoscopic surgery for esophageal cancer attenuates postoperative systemic responses and pulmonary complications. Surgery 151:667–673

    Article  Google Scholar 

  17. Ozawa S, Ito E, Kazuno A, Chino O, Nakui M, Yamamoto S, Shimada H, Makuuchi H (2013) Thoracoscopic esophagectomy while in a prone position for esophageal cancer: a preceding anterior approach method. Surg Endosc 27:40–47

    Article  Google Scholar 

  18. Yatabe T, Kitagawa H, Yamashita K, Hanazaki K, Yokoyama M (2013) Comparison of the perioperative outcome of esophagectomy by thoracoscopy in the prone position with that of thoracotomy in the lateral decubitus position. Surg Today 43:386–391

    Article  Google Scholar 

  19. Shirakawa Y, Noma K, Maeda N, Katsube R, Tanabe S, Ohara T, Sakurama K, Fujiwara T (2014) Assistant-based standardization of prone position thoracoscopic esophagectomy. Acta Med Okayama 68:111–117

    PubMed  Google Scholar 

  20. Oshikiri T, Yasuda T, Harada H, Goto H, Oyama M, Hasegawa H, Ohara T, Sendo H, Nakamura T, Fujino Y, Tominaga M, Kakeji Y (2015) A new method (the "Bascule method") for lymphadenectomy along the left recurrent laryngeal nerve during prone esophagectomy for esophageal cancer. Surg Endosc 29:2442–2450

    Article  Google Scholar 

  21. Akagawa S, Hosogi H, Yoshimura F, Kawada H, Kanaya S (2018) Mesenteric excision for esophageal cancer surgery: based on the concept of mesotracheoesophagus. Int Cancer Conf J 7:117–120

    Article  Google Scholar 

  22. Parsons FG (1910) On the carotid sheath and other fascial planes. J Anat Physiol 44:153–155

    CAS  PubMed  PubMed Central  Google Scholar 

  23. Grodinsky M, Holyoke EA (1938) The fasciae and fascial spaces of the head, neck and adjacent regeions. Am J Anat 63:367–408

    Article  Google Scholar 

  24. Range RL, Woodburne RT (1964) The gross and microscopic anatomy of the transverse cervical ligament. Am J Obstet Gynecol 90:460–467

    Article  CAS  Google Scholar 

  25. Salassa JR, Pearson BW, Payne WS (1977) Gross and microscopical blood supply of the trachea. Ann Thorac Surg 24:100–107

    Article  CAS  Google Scholar 

  26. Japanese Classification of Esophageal Cancer (2017) 11th Edition: part I. Esophagus 14:1–36

    Article  Google Scholar 

  27. Japanese Classification of Esophageal Cancer (2017) 11th Edition: part II and III. Esophagus 14:37–65

    Article  Google Scholar 

  28. Brierley JD, Gospodarowicz MK, Wittekind C (2017) TNM classification of malignant tumors (UICC international union against cancer), 8th edn. Wiley-Blackwell, Oxford

    Google Scholar 

  29. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  Google Scholar 

  30. Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation—technical notes and outcome. Colorectal Dis 11:354–364

    Article  CAS  Google Scholar 

  31. Heald RJ (1988) The 'Holy Plane' of rectal surgery. J R Soc Med 81:503–508

    Article  CAS  Google Scholar 

  32. Havenga K, Grossmann I, DeRuiter M, Wiggers T (2007) Definition of total mesorectal excision, including the perineal phase: technical considerations. Dig Dis 25:44–50

    Article  Google Scholar 

  33. Cuesta MA, Weijs TJ, Bleys RL, van Hillegersberg R, van Berge Henegouwen MI, Gisbertz SS, Ruurda JP, Straatman J, Osugi H, van der Peet DL (2015) A new concept of the anatomy of the thoracic oesophagus: the meso-oesophagus. Observational study during thoracoscopic esophagectomy. Surg Endosc 29:2576–2582

    Article  Google Scholar 

  34. Tokairin Y, Nakajima Y, Kawada K, Hoshino A, Okada T, Ryotokuji T, Okuda M, Kume Y, Kawamura Y, Yamaguchi K, Nagai K, Akita K, Kinugasa Y (2018) Histological study of the thin membranous structure made of dense connective tissue around the esophagus in the upper mediastinum. Esophagus 15:272–280

    Article  Google Scholar 

  35. Hayashi S (2007) Histology of the human carotid sheath revisited. Okajimas Folia Anat Jpn 84:49–60

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Gastroenterological Surgery, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, 2-5-1 Shikatacho, Kita-ku, Okayama, 700-8558, Japan

    Yasuhiro Shirakawa, Kazuhiro Noma, Naoaki Maeda, Shunsuke Tanabe, Kazufumi Sakurama & Toshiyoshi Fujiwara

Authors
  1. Yasuhiro Shirakawa
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  2. Kazuhiro Noma
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  3. Naoaki Maeda
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  4. Shunsuke Tanabe
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  5. Kazufumi Sakurama
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  6. Toshiyoshi Fujiwara
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Corresponding author

Correspondence to Yasuhiro Shirakawa.

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Disclosures

Drs. Yasuhiro Shirakawa, Kazuhiro Noma, Naoaki Maeda, Shunsuke Tanabe, Kazufumi Sakurama, and Toshiyoshi Fujiwara have no conflicts of interest or financial ties to disclose.

Ethical approval

All procedures followed were in accordance with the Helsinki Declaration of 1964 and its later versions. This study was approved by the Ethics Committee of Okayama University Hospital (1811–009).

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Shirakawa, Y., Noma, K., Maeda, N. et al. Microanatomy-based standardization of left upper mediastinal lymph node dissection in thoracoscopic esophagectomy in the prone position. Surg Endosc 35, 349–357 (2021). https://doi.org/10.1007/s00464-020-07407-9

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  • DOI: https://doi.org/10.1007/s00464-020-07407-9

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