Mediastinoscopic salvage esophagectomy for recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy in a previously pneumonectomized patient

Sternal lifting increases the operating space in esophagectomy via mediastinoscopy: a prospective cohort study

Background

Esophagectomy with combined single-port inflatable mediastinoscopy and laparoscopy reduces the risk of postoperative respiratory complications as it obviates the need to pass through the pleural space. However, it has strict indications owing to the narrow space for operation. Therefore, we adopted a sternal lifting method using a retractor that enables the expansion of the operating space, a technique which has not been previously reported. We describe our experience and report the results of an evaluation of this new approach.

Methods

Thirty-nine patients with esophageal squamous cell carcinomas underwent esophagectomy using combined single-port inflatable mediastinoscopy and laparoscopy from March 2019 to August 2021. Among them, 20 cases received sternal suspension [sternal suspension group (SS group)], and 19 cases did not receive sternal suspension [non-sternal suspension group (NSS group)]. The short-term efficacy of the two groups was observed.

Results

Patients in the SS group had a shorter intramediastinal operation time (82.50 vs. 110.00 minutes; P<0.001), more dissected chest lymph nodes (14 vs. 12; P=0.036), and a lower incidence of postoperative hoarseness (2 vs. 6; P=0.235) than did those in the NSS group. There were no significant differences between the SS group and NSS group in terms of intraoperative blood loss, postoperative hospital stay, post-surgical pathologic TNM classification (pTNM), post-surgical pathologic tumor classification (pT), post-surgical pathologic extent of lymph node involvement (pN), and total number of dissected lymph nodes. There were no statistical differences in the incidence of anastomotic fistula, respiratory complications, arrhythmia, or chylothorax between the two groups. There was no mortality during hospitalization in the two groups.

Conclusions

Sternal lifting increases the working space in esophagectomy via mediastinoscopy. It can make video-assisted radical esophagectomy by a transmediastinal approach with total pneumomediastinum assistance (VARETT) easier to perform, and sternal suspension in VARETT is safe and effective.

Salvage treatment after definitive chemoradiotherapy for esophageal squamous cell carcinoma

Definitive chemoradiotherapy (dCRT) for the esophageal squamous cell carcinoma (ESCC) is performed for patients with cT4 disease without distant metastasis and also for those with cStage I-III who are unable to tolerate or who refuse surgery. The rates of clinical complete response (cCR) after dCRT differ depending on the cStage, and patients who once achieved cCR frequently experience tumor recurrence. For those with residual tumor or with recurrence, salvage treatment is performed to achieve a cure. Several procedures have been reported as salvage treatments. Salvage esophagectomy is associated with high rates of morbidity and mortality, but can offer long-term survival. With R0 resection, with cCR to dCRT, pulmonary complications appear to be important prognostic factors affecting overall survival (OS). Lymphadenectomy is performed for the patients with lymph node metastasis without recurrence of primary lesions or distant metastasis, but the contribution to long-term OS is unclear. Metastasectomy is performed when distant metastasis is limited to the lung and there are few lesions, possibly contributing to long-term OS. Endoscopic resection and photodynamic therapy are indicated for cT1a and cT1-2 residual or recurrent tumors, respectively, and can yield favorable outcomes. Re-CRT and re-radiotherapy are performed for the patients with contraindications for surgery, but neither appears to contribute to long-term OS despite high incidences of esophageal fistula and perforation.