Surgical anatomy of the supracarinal esophagus based on a minimally invasive approach: vascular and nervous anatomy and technical steps to resection and lymphadenectomy

Evaluation of indocyanine green tracheobronchial fluorescence (ICG-TBF) via nebulization during minimally invasive esophagectomy

Surgical manipulation of the tracheobronchial complex is a contributing factor in pulmonary morbidity of esophagectomy. Accurate dissection between membranous trachea and bronchi with esophagus is essential. This study tests the feasibility of delivering indocyanine green (ICG) in an aerosol form to achieve tracheobronchial fluorescence (ICG-TBF). Patients with esophageal and esophagogastric junction carcinoma (N = 37) undergoing minimally invasive esophagectomy (McKeown type) were included. ICG was aerosolized by nebulization in supine position before thoracoscopy. ICG-TBF was observed with real-time fluorescence-enabled camera. Intra- and postoperative complications related to ICG were the primary focus. ICG-TBF was identified in 94.6% (35/37) of patients with median time to fluorescence identification of 15 minutes (range 1-43). There were no airway injuries in the study. The ICU median stay was 2 (range 2-21) days. No intra- or postoperative complications attributable to ICG were observed. Grade 3 or 4 pulmonary complications were seen in total 8.1% patients. No 90-day postoperative mortality was seen. ICG delivered in aerosol form was found to be safe and effective in achieving ICG-TBF. It aided in accurate dissection of esophagus from the tracheobronchial complex. Further studies on effect of ICG-TBF in decreasing pulmonary complications of esophagectomy are needed.

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

BACKGROUND

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).

METHODS

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.

RESULTS

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.

CONCLUSION

RE with the outermost layer-oriented approach can provide safe short-term outcomes.

A novel anatomical description of the esophagus: the supracarinal mesoesophagus

BACKGROUND

During thoracoscopic esophageal resection, while performing the supracarinal lymphadenectomy along the left recurrent laryngeal nerve (LRLN) from the aortic arch to the thoracic apex, we observed a not previously described bilayered fascia-like structure, serving as prolongation of the already known mesoesophagus.

METHODS

We retrospectively evaluated 70 consecutively unedited videos of thoracoscopic interventions on esophageal resections for cancer, in order to determine the validity of this finding and to describe its utility for performing a systematic and more accurate dissection of the LRLN and its adequate lymphadenectomy.

RESULTS

After mobilization of the upper esophagus from the trachea and tilting the esophagus by means of two ribbons, a bilayered fascia was observed between the esophagus and the left subclavian artery in 63 of the 70 patients included in this study. By opening the right layer, the left recurrent nerve became visualized and could be dissected free in its whole trajectory. Vessels and branches of the LRLN were divided between miniclips. Mobilizing the esophagus to the right, the base of this fascia could be found at the left subclavian artery. After dissecting and clipping the thoracic duct, complete lymphadenectomy of 2 and 4L stations could be performed. Mobilizing the esophagus in distal direction, the fascia continued at the level of the aortic arch, where it had to be divided in order to mobilize the esophagus from the left bronchus. Here, a lymphadenectomy of the aorta-pulmonary window lymph nodes (station 8) can be performed. It seems that from there the fascia continued without interruption with the previously described mesoesophagus between the thoracic aorta and the esophagus.

CONCLUSIONS

Here we described the concept of the supracarinal mesoesophagus on the left side. Applying the description of the mesoesophagus will create a better understanding of the supracarinal anatomy, leading to a more adequate and reproducible surgery.

A revamped MIC-McKeown operation without removing azygos vein arch, bronchial artery and vagus nerve trunk

BACKGROUND

The purpose of this study was to investigate the effect of our revamped MIE-McKeown operation on postoperative gastrointestinal function recovery.

METHODS

This revamped MIE-McKeown operation without removing azygos vein arch, bronchial artery and vagus nerve trunk and with the tubular stomach buried throughout esophageal bed and azygos arch, has been implemented from July 2020 to July 2021 by the same medical team of Gaozhou People's Hospital thoracic surgery for 13 times. Preoperative clinical data, main intraoperative indicators and postoperative complications were observed.

RESULTS

All patients had esophageal malignant tumors at the level of middle and lower thoracic non-azygous venous arch, with preoperative clinical stage CT1-2N0M0 stage i-ii. V-vst test was performed on the 7th postoperative day, and 10 patients were found to have no loss of safety/efficacy. There were 2 cases with impaired efficacy and no impaired safety, 1 case with impaired safety. There were 1 cases of pulmonary infection, 1 cases of anastomotic fistula combined with pleural and gastric fistula, 2 cases of hoarseness, 2 cases of arrhythmia, 10 cases of swallowing function were grade i, 2 cases of swallowing function were grade iii, 1 case of swallowing function was grade iv in watian drinking water test one month after operation.

CONCLUSIONS

Merit of this revamped MIE-McKeown operation is well preserving the integrity of azygos arch of vagus nerve and bronchial artery, and it is technically safe and feasible. No postoperative mechanical obstruction of thoracostomach, huge thoracostomach and gastrointestinal dysfunction occurs.

The surgical anatomy of a (robot-assisted) minimally invasive transcervical esophagectomy

BACKGROUND

Transcervical esophagectomy allows for esophagectomy through transcervical access and bypasses the thoracic cavity, thereby eliminating single lung ventilation. A challenging surgical approach demands thorough understanding of the encountered anatomy. This study aims to provide a comprehensive overview of surgical anatomy encountered during the (robot-assisted) minimally invasive transcervical esophagectomy (RACE and MICE).

METHODS

To assess the surgical anatomy of the lower neck and mediastinum, MR images were made of a body donor after, which it was sliced at 24-μm intervals with a cryomacrotome. Images were made every 3 slices resulting in 3.200 images of which a digital 3D multiplanar reconstruction was made. For macroscopic verification, microscopic slices were made and stained every 5 mm (Mallory-Cason). Schematic drawings were made of the 3D reconstruction to demonstrate the course of essential anatomical structures in the operation field and identify anatomical landmarks.

RESULTS

Surgical anatomy 'boxes' of three levels (superior thoracic aperture, upper mediastinum, subcarinal) were created. Four landmarks were identified: (i) the course of the thoracic duct in the mediastinum; (ii) the course of the left recurrent laryngeal nerve; (iii) the crossing of the azygos vein right and dorsal of the esophagus; and (iv) the position of the aortic arch, the pulmonary arteries, and veins.

CONCLUSIONS

The presented 3D reconstruction of unmanipulated human anatomy and schematic 3D 'boxes' provide a comprehensive overview of the surgical anatomy during the RACE or MICE. Our findings provide a useful tool to aid surgeons in learning the complex anatomy of the mediastinum and the exploration of new surgical approaches such as the RACE or MICE.

Surgical anatomy of the upper esophagus related to robot-assisted cervical esophagectomy

Robot-assisted cervical esophagectomy (RACE) enables radical surgery for tumors of the middle and upper esophagus, avoiding a transthoracic approach. However, the cervical access, narrow working space, and complex topographic anatomy make this procedure particularly demanding. Our study offers a stepwise description of appropriate dissection planes and anatomical landmarks to facilitate RACE. Macroscopic dissections were performed on formaldehyde-fixed body donors (three females, three males), according to the surgical steps during RACE. The topographic anatomy and surgically relevant structures related to the cervical access route to the esophagus were described and illustrated, along with the complete mobilization of the cervical and upper thoracic segment. The carotid sheath, intercarotid fascia, and visceral fascia were identified as helpful landmarks, used as optimal dissection planes to approach the cervical esophagus and preserve the structures at risk (trachea, recurrent laryngeal nerves, thoracic duct, sympathetic trunk). While ventral dissection involved detachment of the esophagus from the tracheal cartilage and membranous part, the dorsal dissection plane comprised the prevertebral compartment harboring the thoracic duct and right intercosto-bronchial artery. On the left side, the esophagus was attached to the aortic arch by the aorto-esophageal ligament; on the right side, the esophagus was bordered by the azygos vein, right vagus nerve, and cardiac nerves. The stepwise, illustrated topographic anatomy addressed specific surgical demands and perspectives related to the left cervical approach and dissection of the esophagus, providing an anatomical basis to facilitate and safely implement the RACE procedure.

The Value of Paratracheal Lymphadenectomy in Esophagectomy for Adenocarcinoma of the Esophagus or Gastroesophageal Junction: A Systematic Review of the Literature

Background

The role of upper mediastinal lymphadenectomy for distal esophageal or gastroesophageal junction (GEJ) adenocarcinomas remains a matter of debate. This systematic review aims to provide a comprehensive overview of evidence on the incidence of nodal metastases in the upper mediastinum following transthoracic esophagectomy for distal esophageal or GEJ adenocarcinoma.

Methods

A literature search was performed using Medline, Embase and Cochrane databases up to November 2020 to include studies on patients who underwent transthoracic esophagectomy with upper mediastinal lymphadenectomy for distal esophageal and/or GEJ adenocarcinoma. The primary endpoint was the incidence of metastatic nodes in the upper mediastinum based on pathological examination. Secondary endpoints were the definition of upper mediastinal lymphadenectomy, recurrent laryngeal nerve (RLN) palsy rate and survival.

Results

A total of 17 studies were included and the sample sizes ranged from 10-634 patients. Overall, the median incidence of upper mediastinal lymph node metastases was 10.0% (IQR 4.7-16.7). The incidences of upper mediastinal lymph node metastases were 8.3% in the 7 studies that included patients undergoing primary resection (IQR 2.0-16.6), 4,4% in the 1 study that provided neoadjuvant therapy to the full cohort, and 10.6% in the 9 studies that included patients undergoing esophagectomy either with or without neoadjuvant therapy (IQR 8.9-15.8%). Data on survival and RLN palsy rates were scarce and inconclusive.

Conclusions

The incidence of upper mediastinal lymph node metastases in distal esophageal adenocarcinoma is up to 10%. Morbidity should be weighed against potential impact on survival.

Mediastinal anatomical landmarks, their variants and tips for video-assisted thoracoscopic navigation during oesophageal extirpation

Purpose

There is no systematic description of primary anatomical landmarks that allow a surgeon to reliably and safely navigate the superior and posterior mediastinum’s fat tissue spaces near large vessels and nerves during video-assisted endothoracoscopic interventions in the prone position of a patient. Our aim was to develop an algorithm of sequential visual navigation during thoracoscopic extirpation of the esophagus and determine the most permanent topographic and anatomical landmarks allowing safe thoracoscopic dissection of the esophagus in the prone position.

Methods

The anatomical study of the mediastinal structural features was carried out on 30 human cadavers before and after opening the right pleural cavity.

Results

For thoracoscopic extirpation of the esophagus in the prone position, anatomical landmarks are defined, their variants are assessed, and an algorithm for their selection is developed, allowing their direct visualization before and after opening the mediastinal pleura.

Conclusion

The proposed algorithm for topographic and anatomical navigation based on the key anatomical landmarks in the posterior mediastinum provides safe performance of the video-assisted thoracoscopic extirpation of the esophagus in the prone position.

Minimally Invasive Esophagectomy for Achieving R0

Background:

Minimally invasive esophagectomy (MIE) is becoming increasing popular. Since it was introduced, there has been debate about its safety and efficacy when compared with open esophagectomies (OE). We sought to compare the oncologic outcomes of MIE and OE in this study specifically with regards to margin status and nodal retrieval.

Methods:

Ninety-three patients that underwent MIE (76/93) or OE (17/93) for esophageal cancer at out institution between January 2013 and September 2018 were retrospectively reviewed. Histological type, pathological tumor grading, clinical tumor staging (cTNM), pathological tumor staging (pTNM), post-neoadjuvant tumor staging (ypTNM), and lymph node retrieval were obtained and compared.

Results:

The results show a statistically significant improvement in resection margins (R0) in the MIE group when compared with the OE group. Other oncologic parameters including clinical staging, pathologic staging, tumor grade, neoadjuvant therapy (NAT), and nodal retrieval were not statistically significantly different between the open and MIE groups.

Conclusion:

The improvement in short-term surgical outcomes in MIE is well established. This study demonstrates that MIE can have superior surgical oncologic outcomes compared to OE, this was specifically an improved R0 margin rate with MIE compared to OE. These results further support the use of MIE in the treatment of esophageal cancer.

Three-dimensional visualization system is one of the factors that improve short-term outcomes after minimally invasive esophagectomy

PURPOSE

Minimally invasive esophagectomy (MIE) has been increasingly used, but many reports have stated that recurrent laryngeal nerve (RLN) palsy after MIE is a major complication associated with postoperative pneumonia. Prevention of RLN palsy clearly has been a challenging task. The study aim was to determine if a three-dimensional (3-D) stereoscopic vision system can reduce the RLN palsy rate after MIE.

METHODS

This was a retrospective study of MIE (McKeown esophagectomy) using a 3-D or 2-D stereoscopic vision system to treat 358 patients in the prone position between April 2010 and March 2019. The patients who underwent 3-D MIE (3-D group) or 2-D MIE (2-D group) were matched by using propensity score matching. After matching, the perioperative outcomes were compared between the groups.

RESULTS

After propensity score matching, 154 patients were analyzed (77 patients, 3-D group; 77 patients, 2-D group). There were no significant differences in the patients' baseline characteristics in the matched cohort. There were no significant differences in the rates of pneumonia (Clavien-Dindo (C-D) grade ≥ II, 3-D vs. 2-D, 11 (14%) vs. 12 (16%)), anastomotic leakage (C-D grade ≥ II, 10 (13%) vs. 18 (23%)) and mortality. The rates of left RLN palsy (C-D grade ≥ IIIa, 1 (1.3%) vs. 7 (9.1%), P = 0.029), right RLN palsy (C-D grade ≥ I, 2 (3%) vs. 8 (10%), P = 0.049), comprehensive complication index (CCI®) (8.5 vs. 14.3, P = 0.011), and postoperative hospital stay period (median: 25 vs. 30 days, P = 0.034) were significantly lower in the 3-D group than in the 2-D group, respectively.

CONCLUSIONS

In MIE, the 3-D viewing system was one of the factors that reduced postoperative morbidities such as the rates of each RLN palsy and CCI®, leading to shorter postoperative hospital stay.

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.

Minimally invasive mesoesophageal resection

Based in the anatomical concept of the mesoesophagus, that at subcarinal level all the vessels come through a by-layer connective tissue plane from the aorta to the esophagus whereas supracarinally these structures will come from both sides, with vagal and recurrent laryngeal nerves, a minimally invasive mesoesophageal (MIME) resection model may be described. Based on this surgical plane concept, dissection of esophagus and mediastinal lymphadenectomy can be performed along these structures establishing clear anatomical modules for an adequate oncological resection.

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.

Mesenteric excision for esophageal cancer surgery: based on the concept of mesotracheoesophagus

The fundamental principle of surgery for intestinal cancer is mesenteric excision. It has been widely accepted as radical surgery for colorectal cancer, and it comprises procedures such as complete mesocolic excision for colon cancer and total mesorectal excision for rectal cancer. So far, the concept of mesenteric excision of the esophagus has not been well documented, but our surgical experience with a magnified view using a thoracoscope and understanding of the surgical anatomy based on embryologic foregut development has led us to introduce the concept of mesotracheoesophagus. Using this concept, our technique is reproducible, effective, and safe for lymph node dissection along the left recurrent laryngeal nerve. Here we report our concept, procedure, and results of thoracoscopic esophageal cancer surgery.

New insights into the surgical anatomy of the esophagus

Implementation of (robot assisted) minimally invasive esophagectomy and increased knowledge of the relation between the autonomic nervous system and the immune response have led to new insights regarding the surgical anatomy of the esophagus. First, two layers of connective tissue were identified; the aorto-esophageal and aorto-pleural ligaments that separate the peri-esophageal compartment, containing vagus nerves, carinal lymph nodes and trachea, from the para-aortic compartment; containing thoracic duct and azygos vein. Second the surgical anatomy of the pulmonary vagus nerve branches has been described in detail. Based on the hypothesis that sparing the vagal nerve branches may be important a method to spare the pulmonary branches of the vagus nerve during thoracoscopic esophagectomy was validated in a cadaver study. Further studies will now investigate the impact of these new insights in the surgical anatomy of the esophagus in clinical practice.