Feasibility and strategy for left tracheobronchial lymph node dissection in thoracolaparoscopic esophageal cancer surgery

Abstract

BackgroundThis study evaluates the feasibility and strategy of left tracheobronchial lymph node (LN) dissection in the surgical treatment of esophageal cancer, and its impact on surgical outcomes following thoracoscopic esophagectomy.MethodsData of 265 patients with thoracic esophageal cancer who underwent thoracoscopic and laparoscopic esophagectomy was retrospectively reviewed. In 80 cases, thoracoscopic esophagectomy was performed without left tracheobronchial LN dissection (group non‐4L), while 185 cases underwent thoracoscopic esophageal mobilization with routine left tracheobronchial node dissection (group 4L). We introduced a “mesoesophageal suspension” method in order to facilitate complete dissection of the left tracheobronchial nodes, along with left recurrent laryngeal nerve nodes. Both univariate and multivariate analyses were performed to evaluate risk factors correlated to left tracheobronchial node metastasis.ResultsThe non‐4L group experienced less blood loss than the 4L group (P = 0.009). More mediastinal LNs were dissected in the 4L group (P < 0.001). There was no significant difference with regard to the incidence of major postoperative complications between the two groups. Compared with other LN metastases, the metastatic rate of the left tracheobronchial LNs was relatively lower. Based on multivariate analysis of six factors, lymphatic invasion and subcarinal node metastasis were shown to be strong independent predictors of left tracheobronchial metastasis.ConclusionRoutine thoracoscopic extensive lymphadenectomy, including the left tracheobronchial LN, was technically feasible and safe in patients with esophageal cancer. Using a mesoesophagus suspension technique, we performed a meticulous LN dissection in the upper mediastinal space.

Feasibility and strategy of common hepatic artery lymph node dissection in thoracolaparoscopic esophagectomy for thoracic esophageal squamous cell cancer

“…These complications included the following: pneumonia, anastomotic leakage, vocal cord palsy, gastrointestinal dysfunction, cardiovascular disease, and chylothorax. [8] There was no statistically significant difference in the incidence of major complications.…”

Comparative study of three types of lymphadenectomy along the left recurrent laryngeal nerve by minimally invasive esophagectomy

“…Recent studies from Japan have shown the benefits of MIE in the prone position in terms of better surgical exposure, a larger number of dissected lymph nodes and less blood loss compared to MIE in the left lateral decubitus position. However, most cases undergo MIE in the left lateral decubitus or semi‐prone position in China . It is difficult to obtain better operative exposure around the left RLN in this position because the collapsed right lung and mediastinal organs and structures move to the left side, which deepens the location of the left RLN.…”

“…It is essential following lymphadenectomy along the RLN during esophagectomy for accurate pathological staging and prognostic evaluation, but does require more advanced and reliable dissection skills . Although thoracoscopic lymphadenectomy, particularly along the left RLN, is thought to be a burdensome step, with potential difficulties arising during operative exploration in the left lateral decubitus position, which may also lead to a potential increase in the risk of RLN damage, however, it is considered reliable and feasible in experienced hands …”

Minimally invasive esophagectomy

“…Авторы [15,16,18] демонстрируют противоречивые результаты по частоте его повреждения, но статистически значимые различия между двумя группами отсутствуют. При этом применение оригинальных методик лимфоаденэктомии позволяет улучшить данные показатели как в группе LD [9], так и в группе PP [19].…”

“…[8], которые провели сравнительный анализ эзофагэктомий у 447 пациентов, 324 из них прооперированы традиционным способом, а 123 -из МИД. Авторы отметили, что количество удаляемых лимфатических узлов при МИЭ и ОЭ существенно не различалось (20,4±3,8 и 21,1±4,3 соответственно; p=0,0944), однако при ОЭ, выполняемой из правостороннего доступа, количество лимфатических узлов, удаляемых в зоне левого возвратного гортанного нерва, было больше, чем при МИЭ (80,2 и 43,9%; р<0,001), что, очевидно, связано с выбором позиции больного во время грудного этапа удаления пищевода (lateral decubitus и prone position) и техники выполнения лимфодиссекции [9,10].…”