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Medial approach for subcarinal lymphadenectomy during thoracoscopic esophagectomy in the prone position

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Abstract

Purpose

In esophageal squamous cell carcinoma (ESCC), lymph nodes (LNs) around the subcarina and main bronchi are thought to be highly involved. Therefore, complete dissection of these LNs with preservation of the pulmonary branches of the vagus nerves, which control important pulmonary functions, is recommended. The aim of this retrospective study was to investigate the feasibility of reliable method for lymphadenectomy around the subcarina and main bronchi, named the medial approach, during thoracoscopic esophagectomy in the prone position (TEP).

Methods

This was a case-matched control study of patients who underwent TEP for ESCC. The fundamental concept in this method is to first exfoliate the LNs around the subcarina and main bronchi from the pericardium. Developing the operative field contributes to visualizing and preserving the pulmonary branches of the right vagus nerve. Twenty-three patients who underwent the medial approach and 23 patients who underwent the conventional approach were selected by the use of propensity score matching to compare the operative outcomes.

Results

The medial approach significantly reduced operative time for procedure (16 ± 3 vs 30 ± 6 min, p < 0.0001) and operative blood loss (123 ± 108 vs 207 ± 162 ml, p = 0.046) comparing with conventional approach. The incidence of postoperative pneumonia was lower in the medial approach group (4%) than in the conventional approach group (15%) (p = 0.069).

Conclusions

The medial approach for lymphadenectomy around the subcarina and both main bronchi during TEP is technically safe and feasible in shorting the operative time with possibility to reduce postoperative pneumonia.

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Authors and Affiliations

  1. Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan

    Taro Oshikiri, Gosuke Takiguchi, Susumu Miura, Hiroshi Hasegawa, Masashi Yamamoto, Shingo Kanaji, Kimihiro Yamashita, Tetsu Nakamura & Yoshihiro Kakeji

  2. Division of Minimally Invasive Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan

    Takeru Matsuda

  3. Department of Gastroenterological Surgery, Hyogo Cancer Center, 13-70, kitaoji-cho, Akashi, Hyogo, 673-8558, Japan

    Yasuhiro Fujino & Masahiro Tominaga

  4. Division of Community Medicine and Medical Network, Department of Social Community Medicine and Health Science, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan

    Satoshi Suzuki

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  1. Taro Oshikiri
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  2. Gosuke Takiguchi
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Contributions

(1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. Conception or design of the work: Taro Oshikiri, Susumu Miura, Gosuke Takiguchi, Hiroshi Hasegawa. Acquisition of data: Taro Oshikiri, Yasuhiro Fujino, Gosuke Takiguchi, Masahiro Tominaga, Masashi Yamamoto, Kimihiro Yamashita, Yoshihiro Kakeji. Interpretation of data for the work: Taro Oshikiri, Gosuke Takiguchi, Yoshihiro Kakeji. (2) Drafting the work or revising it critically for important intellectual content. Drafting the work: Taro Oshikiri, Susumu Miura, Yoshihiro Kakeji. Revising the work critically for important intellectual content: Taro Oshikiri, Masashi Yamamoto, Shingo Kanaji, Takeru Matsuda, Tetsu Nakamura, Satoshi Suzuki, Yoshihiro Kakeji. (3) Final approval of the version to be published. All authors. (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Taro Oshikiri.

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The authors declare that they have no conflicts of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

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Informed consent was obtained from all individual participants included in the study.

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Oshikiri, T., Takiguchi, G., Miura, S. et al. Medial approach for subcarinal lymphadenectomy during thoracoscopic esophagectomy in the prone position. Langenbecks Arch Surg 404, 359–367 (2019). https://doi.org/10.1007/s00423-019-01772-3

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