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J Thorac Cardiovasc Surg 2007;133:267-268
© 2007 The American Association for Thoracic Surgery
Brief Communication |
Thoracic Surgery Department, Pasteur Hospital, Nice, France.
Received for publication June 24, 2006; revisions received August 10, 2006; accepted for publication August 25, 2006. * Address for reprints: Daniel Pop, MD, Thoracic Surgery Department, Pasteur Hospital—Building H1, 30 Avenue de la Voie Romaine, 06002 Nice, France. (Email: danielpopch{at}yahoo.com).
Transhiatal esophagectomy (THE), popularized by Orringer and Sloan,1
was proposed to decrease postoperative morbidity and mortality. The major inconvenience is the mediastinal lymphadenectomy that guarantees radical oncologic surgery. Recently, Bumm and associates2 used an endodissector that eliminated the "blind" mediastinal dissection. Furthermore, the advent of video-assisted technology provided increasing visualization and allowed bimanual maneuvers.3,4 This is our preliminary report using video-assisted mediastinoscopy (VAM) during THE, including technical details.
Between October 1, 2001 and January 31, 2003 (a 15-month period), we operated on our first 5 patients. The usual pretherapeutic staging and preoperative assessment were done. One patient had neoadjuvant chemoradiotherapy. All 5 patients’ characteristics are noted in Table 1.
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Care must be taken to avoid arrhythmia or hypotension because of cardiac displacement during abdominal upward dissection of the esophagus. The mediastinal phase is done by VAM only through a cervicotomy (Figure 1). The equipment and the instruments have been previously described.4 First, along the left side of the esophagus, the video-mediastinoscope allows clear visualization of the left recurrent nerve to the aortopulmonary window level. With bimanual blunt dissection and hemostatic clips, the lymph nodes situated next to the nerve can be easily separated without hurting the nerve. The video-mediastinoscope can be pushed farther into the mediastinum until the full length is reached. Next the anterior side is dissected. The back surface of the trachea, the carina, and the lymph nodes can be safely detached. Then the posterior side of the esophagus can be easily dissected from the prevertebral fascia. The thoracic duct can be identified and endoclips can be used generously for lymphostasis. Finally, the right side of the esophagus can be dissected by passing behind or in front of the esophagus, avoiding injury to the azygos system. Normally, the mediastinal pleurae are not opened. When the superior mediastinal phase is accomplished, the video-mediastinoscope provides the light to reach the upward abdominal dissection of the esophagus. We prefer a gastric substitute. One patient needed a left colon graft because of total gastrectomy for synchronous antral cancer, which lengthened the intervention. The mean operative time for the remainder was about 280 minutes. The mean hospital stay was 21 days. There was no 30-day mortality. Two major complications arose: myocardial ischemia in a patient with known coronary stenosis and pneumonia in a patient with acute respiratory distress syndrome that required ventilatory support. The living patients had no recurrences; one patient died of a myocardial infarction, but was free of cancer.
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Use of a vein stripper to avulse the esophagus from the posterior mediastinum was first described by Denk (1913) in cadavers and experimental animals.1 After several attempts by different teams, Orringer and Sloan1 (1978) reported on 26 patients with THE with gastric or colonic replacement in the same operative stage. The anticipated benefit was to avoid the morbidity of thoracotomy and to lessen the disastrous effect of an anastomotic fistula. Critics of this approach have warned of inadequate hemostasis and oncologic surgery.
Recently, a meta-analysis5 showed that perioperative blood loss was significantly higher after transthoracic esophagectomy (TTE) but that THE resulted in more severe bleeding. The postoperative outlook gave potential benefits for THE in terms of pulmonary complications, chylous leakage, and in-hospital mortality. To the contrary, THE resulted in more cardiac complications, vocal cord paralysis, and anastomotic leakage. The use of mediastinoscopy2 helps dissection at or above the trachea and reduces the postoperative complications of standard THE. The advent of the video camera substantially improves visualization. We4 have proved the benefit in resecting paratracheal mesothelial cysts. None of our patients treated by THE had significant bleeding or recurrent nerve injury.
The primary goal of cancer surgery remains radical resection. Partial esophagectomy and 2-field lymphadenectomy done by TTE is the most currently used technique. Theoretically, it offers a better, but not significantly better, 5-year survival.5 The new VAM technique and the possibility of bimanual handling allow true lymphadenectomy.3 For our patients, the mean number of lymph nodes was 7 (limits 2-22). This technique enables a truly en bloc esophagectomy and lymphadenectomy.
Despite our limited experience with THE and VAM, the results are promising. With careful handling, VAM is superior to standard mediastinoscopy and it reduces the complications linked to the surgical maneuvers (inadequate hemostasis and recurrent nerve injury). In our opinion, VAM allows not only controlled lymph node biopsy in the mediastinum but true lymphadenectomy around the esophagus.
References
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