Total Mediastinal Lymphadenectomy Research Articles

566. SUPERIOR MEDISTINAL LYMPHADENECTOMY IN PRONE POSITION UTILIZING 3D-ASSISTED THORACOSCOPY. A NOVEL APPROACH

Abstract Introduction Routine lymphadenectomy during esophagectomy includes 2-field lymphadenectomy for distal-esophageal or esophago-gastric junction adenocarcinoma. Superior mediastinal lymphadenectomy (SML) refers to extended 2-field lymphadenectomy (right or left para-tracheal nodes) or total mediastinal lymphadenectomy. The exact benefits of (SML) have long been debated, but with the evolution of prone position 3D-assisted thoracoscopy favorable outcomes can be achieved in the hand of experts. Aim This study aims to describe our surgical technique of 3D-assisted thoracoscopic SML during minimally invasive esophagectomy in prone position. Material and Methods SML included right paratracheal nodes and lymph nodes (LNs) along the right recurrent laryngeal nerve throughout its mediastinal route (including the paratracheal-retrocaval compartment) in cases of extended 2-field lymphadenectomy, as well as left paratracheal nodes and LNs along the left recurrent laryngeal nerve during total mediastinal lymphadenectomy. Results Among the identified eligible cases (n=30), there was no mortality at 30- or 90-post-operative days. No anastomotic or chyle leaks were observed. Pulmonary complications occurred in 15% of patients; right recurrent laryngeal nerve palsy was noted in one patient (3.3%). The median number of resected LNs was 45, with a median count of 12 SML LNs. Conclusions Although limited by a small cohort sample, this study suggests that minimally invasive esophagectomy with SML may offer some benefits in terms of oncological outcomes without significant additional morbidity. https://wetransfer.com/downloads/6329dbd1f817d7e492f8905291f946e120240309180637/42ee79017067b59a4a73138377d9d95620240309180649/f28a32

205. MINIMALLY INVASIVE IVOR LEWIS ESOPHAGECTOMY WITH TOTAL MEDIASTINAL LYMPHADENECTOMY FOR THORACIC ESOPHAGEAL CANCER: SHORT- AND LONG-TERM OUTCOMES IN 139 PATIENTS

Abstract Background The McKeown approach is a standard surgery for thoracic esophageal cancer in Japan, as lymph node dissection of upper mediastinum and neck is mandatory. The thoracoscopic approach allows access to the lymph node chain along the laryngeal nerves from the chest and led us to introduce minimally invasive Ivor Lewis esophagectomy (MIILE) with radical lymphadenectomy for middle and lower esophageal cancer. Although circular-stapled anastomosis is popular in MIILE, the frequency of anastomotic complications has been reported to be high. We introduced MIILE with linear-stapled anastomosis in 2010. Methods To evaluate the short- and long-term outcomes of MIILE with radial lymphadenectomy and linear stapled anastomosis, we performed a retrospective cohort study of 139 consecutive patients. The endpoints included overall complications, anastomotic leak rate, nutritional status at 12 months after MIILE, and 5-year overall survival, and disease-free survival. Surgical Procedure After laparoscopic gastric tube construction, thoracoscopic or robotic esophagectomy with total mediastinal lymphadenectomy was done in the prone position. ICG angiography was used to assess gastric tube viability and sacrifice the ischemic portion in recent cases. Esophago-gastric anastomosis was performed using a linear stapler. The opening was closed with interrupted sutures and covered with the omentum to secure the anastomosis. Results There was 122 male and 17 female patients with median age of 69 years. Preoperative diagnosis was stage I/II/III/IV in 44/46/37/12 patients. Pathology results were SCC in 108 cases. Tumor location was middle/lower/EGJ in 58/64/17 patients. Preoperative chemotherapy or CRT was administered in 77 patients. Median thoracic surgery time was 297 minutes and blood loss was 53 mL. Median hospital stay was 17 days. The short-term complication rate of grade IIIa or higher was 8.7%. Anastomotic leak occurred in 8 patients (5.8%), three of whom required intervention. No leakage occurred after introduction of intraoperative ICG angiography. 90-day mortality was 0.7%. With a median follow-up of 41 months, 5-year overall survival rate was 68.3% and disease-free survival rates was 56.7%. For the 65 SCC patients with clinical stage II/III disease, 5-year OS rate was 58.7%. During follow-up period, 2 patients (1.4%) required balloon dilatation due to anastomotic stenosis. At 12 months after MIILE, the mean weight loss was 11.6% and the mean albumin level was 3.9. Discussion Compared to benchmark complication rates reported by the international Esophagectomy Complication Consensus Group (ECCG), the overall complication rate (47% vs. 59%) was not significantly lower, but the anastomotic leak rate was significantly lower (5.8 vs. 11.4%). Overall survival, disease-free survival, and nutritional outcomes were similar to those reported in Japanese clinical trials. Conclusions MIILE with linear-stapled anastomosis is a safe procedure with a low rate of serious complications. Survival and nutritional outcomes were excellent. It may be recommended as a standard procedure for lower and middle esophageal cancer. https://www.dropbox.com/scl/fi/z6zyllnmie9qh3zhz2wd5/Okabe_ISDE.wmv?rlkey=4mig28fv5z2vhaui31tbk0mr9&dl=0

465. INNOVATION TO STANDARDIZATION OF THORACOLAPAROSCOPIC ESOPHAGECTOMY: CULMINATION OF THREE DECADES OF EXPERIENCE

Abstract Minimally invasive esophagectomy has seen a great deal of evolution over the last three decades. As one of the earliest adopters of minimally invasive approach for esophagectomy, we present our experience and the lessons we have learnt in over 1300 cases. We adopted the prone position and later modified to mid prone position for the thoracic phase of esophagectomy. This position has several advantages of better exposure due to gravity aided retraction of the lungs, clear operating field as blood trickles away as well as feasibility of rapid conversion to open thoracotomy in emergencies. A major transformation in our surgery was the technical modifications and the extent of mediastinal lymphadenectomy. With refinements in technique and greater understanding of the lymphatic spread, we evolved from standard to extended and even total mediastinal lymphadenectomy improving the oncological outcomes without increasing the operative morbidity. The mean total lymph node yield is over 35. Recurrent laryngeal nerve injury was noted in 7% of cases. The technique of anastomosis was also extensively modified from hand sewn to circular stapler to semi mechanical and finally fully mechanical side to side anastomosis using triangulation technique. The triangulation technique has led to significant reduction in leak rates to less than 5% and stricture formation (<1%). Finally, our innovative railroading technique for specimen extraction through the neck is oncologically safe that avoids large incisions in the chest or abdomen. The 30 day mortality rate is less than 1%

RETML-4: Advancements in esophageal cancer surgery with four-arm robotic thoracic esophagectomy with total mediastinal lymphadenectomy

Surgery remains a primary treatment for esophageal cancer. As the field has progressed from open esophagectomy (OE) to minimally invasive esophagectomy (MIE) and further to robot-assisted minimally invasive esophagectomy (RAMIE), not only has the surgeon's understanding and perception of the disease deepened, but the advancements in operative techniques have also led to improved post-operative recovery and oncological outcomes for patients. The esophageal surgery team at the National Cancer Center Hospital has elevated RAMIE to a new theoretical and practical level with their technique: esophageal cancer surgery with four-arm robotic esophagectomy with total mediastinal lymphadenectomy (RETML-4), rooted in the robotically enhanced surgical anatomy (RESA) philosophy. This article provides a comprehensive overview of the conceptual foundation and operative process of this innovative surgical approach.

Robotic esophagectomy with outermost layer-oriented dissection for esophageal cancer: technical aspects and a retrospective review of a single-institution database.

Systematic lymph node dissection in patients with gastric cancer could be sufficiently and reproducibly achieved along the outermost layer of the autonomic nerves and similar concept has been extensively used for robotic esophagectomy (RE) since 2018. This study aimed to determine the surgical and oncological safety of RE using the outermost layer-oriented approach for esophageal cancer (EC). Sixty-six patients who underwent RE with total mediastinal lymphadenectomy for primary EC between April 2018 and December 2021 were retrospectively reviewed. All underwent the outermost layer-oriented approach with intraoperative nerve monitoring (IONM). Postoperative complications within 30 days were analyzed. Among the patients, 51 (77.3%) were male. The median age was 64 years, and the body mass index was 21.8 kg/m2. Furthermore, 58 (87.9%) patients had squamous cell carcinoma and eight (12.1%) patients had adenocarcinoma. Clinical stages I, II, and III were seen in 23 (34.8%), 23 (34.8%), and 16 (24.2%) patients, respectively. Thirty-four (51.5%) patients received preoperative treatment. No patient shifted to conventional thoracoscopic or open procedure intraoperatively. The median operative time was 716 min with 119 mL of blood loss. Additionally, 64 (97%) patients underwent R0 resection. The morbidity rates based on Clavien-Dindo grades ≥ II and ≥ IIIa were 30.3% and 10.6%, respectively, within 30 postoperative days. None died within 90 days postoperatively. Three (4.5%) patients exhibited recurrent laryngeal nerve (RLN) palsy (CD grade ≥ II). The sensitivity and specificity of IONM for RLN palsy were 50% and 98.3% at the right RLN and 33.3% and 98.0% at the left RLN, respectively. RE with the outermost layer-oriented approach can provide safe short-term outcomes.

Modified En Bloc Esophagectomy for Squamous Cell Carcinoma After Neoadjuvant Chemoradiotherapy

BackgroundThe optimal type of esophagectomy and extent of lymphadenectomy for patients after neoadjuvant chemoradiotherapy (nCRT) for esophageal squamous cell carcinoma remain controversial. We hypothesized that a more radical resection is associated with better survival. MethodsData of patients who received nCRT followed by resection for esophageal squamous cell carcinoma between 2012 and 2021 were analyzed. Modified en bloc esophagectomy (mEBE) involves total mediastinal lymphadenectomy and resection of all periesophageal node-bearing tissues. Perioperative outcomes and survival rates of mEBE were compared with those of conventional esophagectomy (CE). ResultsA total of 238 patients were included. Compared with CE, mEBE was associated with a longer operative time, higher total number of resected lymph nodes, fewer complications, and less anastomotic leakage; length of stay was similar between the 2 groups. There was no difference in overall survival rates between patients with ypT0 N0 stage in the mEBE and CE groups; however, in patients with non–ypT0 N0 stage in the mEBE and CE groups, the 3-year overall survival rates were 58.5% and 28.5%, respectively (P < .001). On disease-free survival analysis, no difference was observed in patients with ypT0 N0 stage, whereas patients with non–ypT0 N0 stage after nCRT had significantly better disease-free survival after mEBE compared with CE (49.7% vs 27.2%; P = .017). ConclusionsSurvival after mEBE was significantly better than that after CE. The mEBE did not increase postoperative hospital stay and complication rates.

284. VALUE OF EXTENDED AND TOTAL MEDIASTINAL LYMPHADENECTOMY IN ESOPHAGEAL TUMORS

Abstract The extent of lymphadenectomy in esophageal cancer surgery is a point of controversy at present, although the most recent evidence shows that survival is directly related to the number of nodes removed during surgery. Descriptive study of patients with esophageal neoplasia who underwent esophagectomy with extended and total mediastinal lymphadenectomy by minimally invasive approach (right prone thoracoscopy, laparoscopy and left cervicotomy) in our center from January 2019 to December 2021. The data of patients included were retrospectively examined. Extended lymphadenectomy was indicated in patients with distal third adenocarcinoma type tumors while total lymphadenectomy was indicated in patient with squamous tumors and middle third adenocarcinoma. The primary endpoint was the incidence of affected lymph nodes in the upper mediastinum based on pathological examination. The secondary endpoint was to analyze the short-term outcomes. A total of 45 patients were included (26.7% extended and 73.3% total mediastinal lymphadenectomy). The median number of removed nodes was 2 (IQR 4–1) and 2 (IQR 3–1) in the right and left recurrent area, respectively. Overall, the median incidence of recurrent lymph node metastases was 11.1%. Twenty percent of the patients with adenocarcinoma (100% distal third) and 0% of the patients with squamous cell carcinoma had positive recurrent nodes. Ninety-day mortality was 15.6%. With respect to postoperative complications such as recurrent laryngeal nerve paralysis was present in 24.4%. Anastomotic leakage was present in 20% (4.4% thoracic and 15.6% cervical). Based on our results, extended and total lymphadenectomy increases both the overall number of lymph nodes removed and the number of affected nodes. This prevalence of positive recurrent nodes is not negligible. This greater radicality is associated with significant morbidity. The results of this study support the performance of extended lymphadenectomies also in distal third adenocarcinomas.

593. UPPER MEDIASTINAL LYMPHADENECTOMY IN PRONE POSITION TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Minimally invasive esophagectomy (MIE) is a challenging procedure associated with high rate of complications and mortality. Routine lymphadenectomy includes 2-field lymphadenectomy for distal esophageal or esophago-gastric junction Siewert I-II cancers. SML refers to extended 2-field lymphadenectomy or total mediastinal lymphadenectomy. The exact benefits of superior mediastinal lymphadenectomy (SML) have long been debated with no clear evidence pertaining to improved outcomes. N=150 consecutive patients underwent totally MIE under a surgical team from September 2016 to September 2020. SML included right paratracheal nodes and lymph nodes along the right recurrent laryngeal nerve throughout its mediastinal route (including the paratracheal-retrocaval compartment) in cases of extended 2-field lymphadenectomy, as well as left paratracheal nodes and lymph nodes along the left recurrent laryngeal nerve during total mediastinal lymphadenectomy. Eligible patients underwent SML during 2-stage or 3-stage MIE. N=20 consecutive cases were identified as eligible according to the inclusion criteria during the study period. 30- and 90- day mortality rates were 0. There were no anastomotic or chyle leaks noted. Pulmonary complications were observed in 16.5% of the patients. There was 1 right recurrent laryngeal nerve palsy noted. Median length of hospital stay was 9 days. Median number of resected lymph nodes was 45 (Range: 37-68), with median SML nodes count being 8 (Range: 2-25). Median follow up was 24 months. The small sample size is immediately recognised as a limiting and influencing factor in the results of this study. However, MIOs with SML may provide some, although not comprehensive, benefit in oncological outcomes without adding any further significant morbidity. Larger studies are needed to assess the role SML can play in improving patient outcomes.

285. HOW TO DO IT? SUPRACARINAL APPROACH OF THE LEFT RECURRENT LARYNGEAL NERVE AREA FOR LYMPHADENECTOMY DURING THORACOSCOPIC ESOPHAGECTOMY

Abstract It is important to know the anatomical relationships of the left recurrent laryngeal nerve during the total mediastinal lymphadenectomy. The objective of this procedure is to resect the lymph nodes located in this area without damaging the nerve. In order to approach the left recurrent laryngeal nerve (LRLN) area it is important to know different strategies to achieve this objective. This video illustrates different ways of approaching the LRLN area during thoracoscopic esophagectomy. The first approach illustrated, the esophagus is completely retracted to the right side. With this strategy it is possible to visualize the left paratracheal groove, and tissues and lymph nodes around LRLN are tented. The next approach consists of leaving the esophagus attached on its right and anterior side, creating an ample window, through which the LRLN area can be approached. Another approach involves section of the proximal esophagus. Once that the esophagus is dissected to the thoracic apex, it is divided proximal of the tumor with a stapler. Retraction of this stump creates an optimal view of the area. Standardization of the supracarinal approach is necessary to improve dissection of the LRLN area and achieve a more adequate surgical resection with a low rates of complications.

745 YIELD OF EXTENDED AND TOTAL MEDIASTINAL LYMPHADENECTOMY IN OESOPHAGEAL CANCER

Abstract The extent of lymphadenectomy in oesophageal cancer surgery is currently controversial, although current evidence shows that survival is directly related to the number of lymph nodes removed during surgery. Methods Descriptive study of patients with oesophageal cancer who underwent oesophagectomy with extended and total mediastinal lymphadenectomy using a minimally invasive approach (right prone thoracoscopy, laparoscopy and left cervicotomy) in our hospital for 2 years (2019 and 2020). Extended lymphadenectomy was indicated in patients with adenocarcinoma of the distal oesophagus, while total lymphadenectomy was indicated in patients with squamous tumours and adenocarcinoma of the middle oesophagus. The characteristics of the series studied and the results obtained in the 90 days postoperatively are described. Results 26 patients, mean age 65 ± 7.8 years, were operated. 21 with total mediastinal lymphadenectomy and 5 with extended lymphadenectomy. 80.7% received neoadjuvant treatment (CROSS scheme). The mean number of lymph nodes removed was 33.6 ± 14.3, with a 50% probability of being affected. As much in the lymphadenectomy of the right (106R) as in the left (106 L) recurrent groups, it was more frequently affected in the distal oesophagus adenocarcinomas. Postoperative morbidity was not negligible, with anastomotic leak rate of 7.7% (thoracic location) and 23.1% (cervical location) the majority mild, 23.1% of recurrent injury and 11.5% of chylothorax. Mortality at 90 days was 15.38%. Conclusion Based on our results, extended and total lymphadenectomy increases as much the global number of lymph nodes removed as the lymph nodes cancer-positive. In addition, it supports the performance of wide lymphadenectomies also in adenocarcinomas of the distal oesophagus. We cannot forget the greater radicalism is taxed with significant morbidity. We should remember the limitation of this study is the low number of cases, the extent of lymphadenectomy continues to be a matter of controversy.

Robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms alone in esophageal and esophagogastric cancer (RETML-4): a prospective feasibility study.

Robotic-assisted esophagectomy is still in the implementation phase. Robotic surgical systems refine visualization via robotically-enhanced surgical anatomy (RESA), and the stable articulated robotic arms provide precise movements. This prospective feasibility study was conducted to evaluate robotic esophagectomy with total mediastinal lymphadenectomy using four robotic arms exclusively (RETML-4). The inclusion criterion was clinical stage I-IIIB esophageal cancer with stable general condition. Patients were positioned hemi-prone with single-lung ventilation, and the operation table was tilted until the patient was prone. The first, second, third, and fourth robotic ports were inserted into the ninth intercostal space (ICS) on the angulus inferior scapulae line, seventh ICS on the posterior axillary line, and the fifth and third ICS on the mid-axillary line, respectively. RETML-4 was performed by precise sharp dissection in wide stable operation fields, with countertraction created by a tip-up fenestrated grasper with gauze. Esophagectomy was performed separately for the middle to lower, and upper esophagus. After mobilizing the middle to lower esophagus and performing lymph node dissection, the upper esophagus was mobilized, with bilateral lymph node dissection along the recurrent laryngeal nerves. The assistant surgeon was involved only during removing gauze and collecting harvested lymph nodes in the thorax. RETML-4 was performed in all ten patients enrolled in 2018. The median postoperative hospital stay was 15days, and the complication rate was 60%. Nine cases achieved R0 resection. Recurrence occurred in two cases. RETML-4 is feasible, and may facilitate minimally invasive esophagectomy by providing precise instrument movements and RESA.

Review of different approaches of the left recurrent laryngeal nerve area for lymphadenectomy during minimally invasive esophagectomy.

In order to perform the total mediastinal lymphadenectomy during minimally invasive esophageal resection, doing the lymphadenectomy along the left recurrent laryngeal nerve (LRLN) may be a difficult part of this intervention. One reason is the need for the correct visualization of the area; another is not wanting to compromise the integrity of the nerve. In this review article the different modalities for approaching this upper mediastinal area by thoracoscopy are described.

Robotic-assisted minimally invasive oesophagectomy for cancer: An initial experience.

Background:The morbidity related to radical oesophagectomy can be reduced by adopting minimally invasive techniques. Over 250 thoraco-laparoscopic oesophagectomy (TLE) was done in our centre over the last 15 years, before adopting robotic surgery as the latest innovation in the field of minimally invasive surgery. Here, we share our initial experience of robotic-assisted minimally invasive oesophagectomy (RAMIE) for carcinoma oesophagus.Methods:A prospective observational study conducted from February to December 2017. A total of 15 patients underwent RAMIE in this period. Data regarding demography, clinical characteristics, investigations, operating techniques, and post-operative outcome were collected in detail.Results:There were 10 (66.7%) male patients and the median age of all patients was 62.9 (range 36–78) years. The median body mass index was 24.4 (range 15–32.8) kg/m2. Twelve (80.0%) patients had squamous cell carcinoma (SCC) of the oesophagus and 3 (20%) patients had adenocarcinoma (AC). Five (33.3%) patients received neoadjuvant therapy. All 15 patients underwent RAMIE. Patients with SCC underwent McKeown's procedure, and those with AC underwent Ivor Lewis procedure. Extended two-field lymphadenectomy (including total mediastinal lymphadenectomy) was done for all the patients. The median operating time was 558 (range 390–690) min and median blood loss was 145 (range 90–230) ml. There were no intra-operative adverse events, and none of them required conversion to open or total thoracolaparoscopic procedure. The most common post-operative complications were recurrent laryngeal nerve paresis (3 patients, 20.0%) and pneumonia (2 patients, 13.3%). The median hospital stay was 9 (range 7–33) days. In total, 9 (60%) patients required adjuvant treatment.Conclusion:Adequate experience in TLE can help minimally invasive surgeons in easy adoption of RAMIE with satisfactory outcome.

Extent of Mediastinal Lymphadenectomy and Survival in Superficial Esophageal Squamous Cell Carcinoma

BackgroundThe aim of this study is to investigate the utility of total mediastinal lymphadenectomy (ML) in superficial esophageal squamous cell carcinoma (ESCC). MethodsThe medical records of 129 patients who underwent esophagectomy and lymph node dissection for pathologically confirmed pT1 ESCC between July 2006 and December 2014 were retrospectively reviewed. Limited ML, such as traditional 2-field or transhiatal esophagectomy, was performed in 42 patients (group 1), and total ML, including the bilateral recurrent laryngeal nerve nodes, was performed in 87 patients (group 2). ResultsR0 resection was achieved in all patients, and the number of dissected nodes was 28.0±11.4 and 44.8±16.1 in groups 1 and 2 (p < 0.001), respectively. The complication profile was similar in the two groups, but there were two operative mortalities in group 2. During a median follow-up of 32.4 months, loco-regional failure was found in 14.3% of group 1 and 3.5% of group 2 (p = 0.001). There was a significant difference in the 3-year overall survival (95.1% in group 2 vs. 83.3% in group 1, p = 0.043), and the 3-year disease-free survival rates (92.3% in group 2 vs. 73.7% in group 1, p = 0.001). On multivariate analysis, the extent of ML (HR, 5.200; 95% CI, 1.532 ~ 17.645; p = 0.008) and pT1b lesion classification (HR, 4.747; 95% CI, 1.024 ~ 21.997; p = 0.047) was a factor predictive of disease-free survival. ConclusionsTotal ML might be beneficial, especially in cases of pT1b ESCC, because it could lead to a lower incidence of recurrence and longer survival times.

Safety and feasibility of thoracoscopic esophagectomy after neoadjuvant chemotherapy for esophageal cancer

Neoadjuvant chemotherapy (NAC) with cisplatin and fluorouracil is the recommended standard treatment for resectable locally advanced esophageal cancer (EC) in Japan. We investigated the effects of NAC on the safety and feasibility of thoracoscopic esophagectomy with total mediastinal lymphadenectomy for EC. This retrospective study analyzed data from 225 consecutive patients who underwent thoracoscopic esophagectomy with lymph node dissection between April 2007 and December 2015. Patients with clinical stage IB, IIA, IIB, IIIA, or IIIB EC, and no active concomitant malignancy were included. We compared intraoperative outcomes, and postoperative morbidity and mortality between patients who received NAC (n=139; NAC group) and patients who did not (n=86; non-NAC group). Preoperative laboratory data revealed that anemia, thrombopenia, and renal dysfunction were more common in the NAC group than in the non-NAC group. There were no differences between the groups in operating times, blood loss, number of dissected lymph nodes, overall complication rates, or length of postoperative hospital stay. Based on our findings, thoracoscopic esophagectomy is safe and effective for locally advanced EC, even after NAC.

The Oncologic Outcome of Esophageal Squamous Cell Carcinoma Patients After Robot-Assisted Thoracoscopic Esophagectomy With Total Mediastinal Lymphadenectomy

The oncologic outcome of esophageal squamous cell carcinoma (ESCC) patients after robot-assisted thoracoscopic esophagectomy (RATE) with total mediastinal lymphadenectomy (ML) has not been reported. This study was performed to determine the oncologic outcome of RATE and the effectiveness of total ML for ESCC. The 115 patients who underwent RATE without neoadjuvant therapy from 2006 to 2014 were reviewed. The efficacy index (EI) was calculated bymultiplying the incidence of metastasis by the 3-year survival rate of the patients for each node station. The majority of patients were male (92.2%), and the mean age was 63.2 ± 0.8 years. Tumor location was the upper esophagus in 12 patients (10.4%), the middle esophagus in 59 patients (51.3%), and the lower esophagus in 44 patients (38.3%). R0 resection was achieved in 110 (95.7%) patients; the mean number of dissected nodes was 49.0 ± 1.9. Operative mortalities were 4 (3.5%) cases; in the remaining 111 patients, the mean follow-up time was 32.4 ± 2.2 months. Overall survival (OS) and recurrence-free interval (RFI) at 3 years were 85.0% and 79.4%, respectively. The 3-year OS and RFI were 94.4% and 96.2% in patients with stage I disease, 86.2% and 80.1% in stage II disease, and 77.8% and 79.5% in stage IIIA disease, respectively. High EI values were determined in the bilateral recurrent laryngeal nerve (RLN) nodes in upper and middle ESCC, and in the left gastric and paracardial nodes in lower ESCC. The oncologic outcome of RATE was acceptable. Total ML, including dissection of the RLN nodes, is recommended especially in upper or middle ESCC.

603. Thoracoscopic esophagectomy with total mediastinal lymphadenectomy in esophageal cancer patients with near complete response to neoadjuvant chemoradiotherapy: Feasibility and significance

Background: Neoadjuvant therapy followed by surgery is the current recommended treatment for esophageal cancer. However, there is controversy over the extent of lymphadenectomy in patients with near complete response to neoadjuvant chemoradiotherapy. Hence, this prospective study was performed to determine the feasibility, short-term outcomes and significance of thoracoscopic esophagectomy with total mediastinal lymphadenectomy in patients with near complete response to neoadjuvant chemoradiotherapy.

Thoracoscopic and laparoscopic radical esophagectomy with lateral-prone position.

With 20 years of development, minimally-invasive treatment for esophageal cancer has been widely spread. However, surgeons have not reached consensus about the optimal minimally-invasive operation method, or whether the effect of radical lymph nodes dissection is comparable to the traditional open procedure. Thoracoscopic esophagectomy with lateral-prone position combines the advantages of both lateral position (allowing quick conversion to open procedure) and prone position (good visual area and complete lymphadenectomy). Together with laparoscopic abdominal lymphadenectomy, gastric tube formation and jejunostomy, this approach provides an easier way for minimally-invasive radical esophagectomy. In this article, approaches for thoracoscopic esophagectomy with lateral-prone position and total mediastinal lymphadenectomy, combined with totally laparoscopic gastric mobilization, abdominal lymphadenectomy, gastric tube formation and jejunostomy, will be presented by video instructions. All the procedures were under the rule of radical lymphadenectomy. Cervical lymph nodes dissection and esophago-gastrostomy were the same as those in open procedure, which will not be discussed here.

Feasibility of a robot-assisted thoracoscopic lymphadenectomy along the recurrent laryngeal nerves in radical esophagectomy for esophageal squamous carcinoma

Lymph node dissection along bilateral recurrent laryngeal nerves (RLNs) is an essential component of radical esophagectomy for esophageal squamous carcinoma. However, it is associated with significant morbidity and requires a great deal of skill when performed with minimally invasive surgery. Between October 2010 and July 2012, 40 consecutive patients underwent a robot-assisted thoracoscopic esophagectomy and total mediastinal lymphadenectomy. The lymph nodes along the dorsal side of the RLNs were removed in the initial 18 patients (group 1), and the RLNs were skeletonized by dissection of all the lymph nodes and surrounding fatty tissues in the following 22 patients (group 2). All but one patient underwent a successful robot-assisted, thoracoscopic esophagectomy. The mean operation time was 428.6 ± 75.0 min, and the mean robot console time was 186.7 ± 52.1 min. An average of 42.6 ± 14.1 nodes was retrieved, and the mean number of dissected nodes from the mediastinum and the RLN chains were 25.5 ± 9.6 and 9.6 ± 6.5, respectively. One mortality occurred (2.5%), and the incidences of pneumonia and RLN palsy were 12.5 and 20%, respectively. The mean robot console time was longer in group 2 (211.4 ± 49.5 min) than in group 1 (156.6 ± 38.2 min) (p < 0.001), and group 2 had higher mean numbers of dissected nodes from the mediastinum (30.3 ± 7.9 vs 19.6 ± 8.2; p < 0.001) and the RLN chains (13.5 ± 5.7 vs 4.8 ± 3.6; p < 0.001). Although RLN palsy was more common in group 2 (31.8 vs 5.6%; p = 0.054), all palsies resolved within 1 year. Robot-assisted thoracoscopic lymphadenectomy along bilateral RLNs was technically feasible and safe. Skeletonization of the RLNs yields more lymph nodes, but efforts should be made to decrease the incidence of RLN palsy.

Should mediastinal lymphadenectomy be performed during lung metastasectomy of renal cell carcinoma?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether radical mediastinal lymphadenectomy should be performed during lung metastasectomy of renal cell carcinoma (RCC). Of the 13 papers found through a report search, seven represent the best evidence to answer this clinical question. The authors, journal, date, country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that on the whole, the seven-retrieved studies support the realization of systematic radical mediastinal lymphadenectomy. The published literature showed a prevalence of lymph node involvement (LNI) that approaches 30%. The majority of the studies conclude that LNI is a significant, independent prognostic of survival. Indeed, some authors did not report any 5-year survival in the case of LNI. On the contrary, however, a 5-year survival of ~50% was reported when no LNI was present. To date, the published data do not allow conclusions to be drawn regarding the prognosis of hilar vs mediastinal LNI: only one paper focused on the difference between hilar and mediastinal location and showed no difference. In addition, only one study has compared the survival of patients with or without lymphadenectomy, showing greater survival when mediastinal lymphadenectomy was performed. Despite the poor prognosis of patients with LNI, surgery seems to be the best treatment for potentially curative RCC with metastases. It is known that RCC metastases do not respond well to chemotherapy and radiotherapy. Indeed, reported 5-year survival rate ranged between 3 and 11% for non-operated patients. Consequently, resection must be as complete as possible and include a systematic total mediastinal lymphadenectomy, which will probably yield better loco-regional control and evaluation of prognostic factor. However, the published evidence remains quite limited and mainly based on retrospective studies on highly selected patients, with a low level of evidence. Indeed, most patients referred to surgery are younger, fitter, and have fewer metastases. Consequently, the survival gain could be biased, related more to the resectability and the good performance status rather to the resection itself. Consequently, although these preliminary results are interesting, they must be interpreted with caution.