A Mediastinoscopic Approach With Bilateral Cervicopneumomediastinum in Radical Thoracic Esophagectomy

Abstract

We previously reported the performance of ''mediastinoscopic esophagectomy with lymph node dissection'' (MELD) under pneumomediastinum using a transcervical and transhiatal approach, as a method of radical esophagectomy. The procedure included the dissection of the left tracheobronchial lymph nodes (106tbL). We described our technique for dissecting the upper mediastinal lymph nodes. We revealed that the 106tbL lymph nodes were almost completely retrieved but that the upper thoracic paraesophageal lymph nodes (105) and the right recurrent nerve lymph nodes (106recR) were not completely retrieved. We are therefore of the opinion that a right cervical pneumomediastinal approach is necessary to achieve total dissection. We herein describe a case that was surgically treated using a bilateral cervicopneumomediastinal approach. A 68year-old male patient was referred to our institution to undergo treatment for lower thoracic esophageal squamous cell carcinoma. The right recurrent nerve was first identified using an open approach. Pneumomediastinum was then initiated to allow for the 105 and 106recR lymph nodes to be completely dissected along the right mediastinal pleura, the right vagus nerve, the proximal portion of the azygos vein, and the right bronchial artery. The left recurrent nerve lymph nodes (106recL) and 106tbL lymph nodes were dissected as described previously. In order to perform bilateral upper mediastinal

Mediastinoscopic esophagectomy with lymph node dissection using a bilateral transcervical and transhiatal pneumomediastinal approach

“…The subaortic arch to the left tracheobronchial lymph nodes is dissected using the crossover technique, as described previously [15][16][17][18] . The crossover technique consists of the transhiatal, right transcervical, and/or left transcervical approach and is suitable for dissection in narrow and relatively deep operative fields, as the approach can be made from two directions.…”

“…However, due to the blind maneuvering in the upper and middle mediastinum that is necessary in this procedure and the difficulty of systematic lymph node dissection, it is usually only applied in limited cases, such as cases of esophagogastric junction cancer, very early-stage cancers, or some cases of advanced thoracic esophageal cancer for the purpose of palliative resection [12] . Recently, we developed and reported the performance of "mediastinoscopic esophagectomy with lymph node dissection (MELD)" under pneumomediastinum using a bilateral transcervical and transhiatal approach, as a method of radical esophagectomy [15][16][17][18] . This procedure achieves curative radical esophagectomy with minimal invasiveness.…”