Hand‐assisted laparoscopic transhiatal esophagectomy with a systematic procedure for en bloc infracarinal lymph node dissection

Laparoscopic transhiatal esophagectomy is a minimally invasive approach for esophageal cancer. However, a transhiatal procedure has not yet been established for en bloc mediastinal dissection. The purpose of this study was to present our novel procedure, hand‐assisted laparoscopic transhiatal esophagectomy, with a systematic procedure for en bloc mediastinal dissection. The perioperative outcomes of patients who underwent this procedure were retrospectively analyzed. Transhiatal subtotal mobilization of the thoracic esophagus with en bloc lymph node dissection distally from the carina was performed according to a standardized procedure using a hand‐assisted laparoscopic technique, in which the operator used a long sealing device under appropriate expansion of the operative field by hand assistance and long retractors. The thoracoscopic procedure was performed for upper mediastinal dissection following esophageal resection and retrosternal stomach roll reconstruction, and was avoided based on the nodal status and operative risk. A total of 57 patients underwent surgery between January 2012 and June 2013, and the transthoracic procedure was performed on 34 of these patients. In groups with and without the transthoracic procedure, total operation times were 370 and 216 minutes, blood losses were 238 and 139 mL, and the numbers of retrieved nodes were 39 and 24, respectively. R0 resection rates were similar between the groups. The incidence of recurrent laryngeal nerve palsy was significantly higher in the group with the transthoracic procedure, whereas no significant differences were observed in that of pneumonia between these groups. The hand‐assisted laparoscopic transhiatal method, which is characterized by a systematic procedure for en bloc mediastinal dissection supported by hand and long device use, was safe and feasible for minimally invasive esophagectomy.     

Efficacy of mediastinal lymphadenectomy in transhiatal esophagectomy with and without diaphragm opening: a cadaveric study

Transhiatal esophagectomy (THE) is believed to induce a lower morbidity and mortality compared with transthoracic esophagectomy, but to be inefficient in performing mediastinal lymphadenectomy. Some surgeons are convinced that lymphadenectomy of the lower mediastinum in THE and transthoracic esophagectomy are equivalent. To test this, the authors performed THE in 20 cadavers (10 with and 10 without diaphragm opening). The number of lymph nodes resected with the esophagus and dissected through the hiatus was counted. After THE, the thorax was opened and the number of residual lymph nodes was evaluated. Complications were also assessed. The results show that lymphadenectomy in THE is incomplete in the lower mediastinum and not possible in the upper mediastinum; comparing THE with and without diaphragm opening, the first permits resection of a superior number of lymph nodes with the esophagus and dissection of a higher number of nodes through the hiatus. It is concluded that THE does not provide an effective mediastinal lymphadenectomy.     

Robotic lung segmentectomy for malignant and benign lesions

Objective

Surgical use of robots has evolved over the last 10 years. However, the academic experience with robotic lung segmentectomy remains limited. We aimed to analyze our lung segmentectomy experience with robot-assisted thoracoscopic surgery.

Methods

Prospectively recorded clinical data of 21 patients who underwent robotic lung anatomic segmentectomy with robot-assisted thoracoscopic surgery were retrospectively reviewed. All cases were done using the da Vinci System. A three incision portal technique with a 3 cm utility incision in the posterior 10^th to 11^th intercostal space was performed. Individual dissection, ligation and division of the hilar structures were performed. Systematic mediastinal lymph node dissection or sampling was performed in 15 patients either with primary or secondary metastatic cancers.

Results

Fifteen patients (75%) were operated on for malignant lung diseases. Conversion to open surgery was not necessary. Postoperative complications occurred in four patients. Mean console robotic operating time was 84±26 (range, 40-150) minutes. Mean duration of chest tube drainage and mean postoperative hospital stay were 3±2.1 (range, 1-10) and 4±1.4 (range, 2-7) days respectively. The mean number of mediastinal stations and number of dissected lymph nodes were 4.2 and 14.3 (range, 2-21) from mediastinal and 8.1 (range, 2-19) nodes from hilar and interlobar stations respectively.

Conclusions

Robot-assisted thoracoscopic segmentectomy for malignant and benign lesions appears to be practical, safe, and associated with few complications and short postoperative hospitalization. Lymph node removal also appears oncologically acceptable for early lung cancer patients. Benefits in terms of postoperative pain, respiratory function, and quality of life needs a comparative, prospective series particularly with video-assisted thoracoscopic surgery.     

The pattern of lymphatic metastases in superficial squamous cell carcinoma of the esophagus

BACKGROUND/AIMS: Lymphatic spread patterns in relation to the location of primary tumors of the superficial thoracic esophageal squamous cell carcinoma have not been well established. We therefore analyzed patterns of lymph node metastasis in these patients. METHODOLOGY: We reviewed medical records of 65 patients who underwent systematic three-field dissection for superficial squamous carcinoma of the thoracic esophagus from 1993 through 2000. RESULTS: Lymph node involvement was found in 0% (0/13) and 44% (23/52) of patients whose tumor invaded the muscularis mucosa and submucosal layer, respectively. The 5-year survival rate was 77% in the node-negative group and 59% in the node-positive group (P<0.05). None of the patients with upper thoracic esophageal cancer had metastasis to the mediastinal and abdominal nodes. Patients with lower thoracic esophageal tumors (Lt) had no metastasis to the cervical nodes. Patients with middle thoracic esophageal tumors (Mt) and Lt patients rarely had metastasis (2-5%) in the lower mediasinal nodes (Nos. 108-112). No patient with superficial thoracic esophageal cancer had metastasis to the subcarinal nodes in this study. CONCLUSIONS: In our series, no patient with intramucosal carcinoma had lymphatic metastases. Some patients with submucosal cancers metastasized beyond regional lymph nodes. However, this study suggests that subcarinal nodes might not need to be sampled or dissected in patients with superficial carcinoma of the thoracic esophagus. In Mt and Lt patients, metastases to the mediastinal nodes were infrequent (2-7%). Mediastinal nodes other than #107 can easily be sampled through cervical and abdominal incisions. Therefore, combined with lymph node sampling in cervical, mediasinal and abdominal stations through cervical and abdominal incisions, esophagectomy without thoracotomy might be acceptable in Mt and Lt patients with superficial squamous cell carcinoma of the esophagus.     

Evaluation of subcarinal lymph node dissection and metastasis in transmediastinal radical esophagectomy

Background

The aim of the present study was to evaluate subcarinal lymph node dissection in transmediastinal radical esophagectomy and subcarinal lymph node metastasis in patients with esophageal cancer.

Methods

Three hundred and twenty-three patients with primary esophageal cancer who underwent transmediastinal or transthoracic esophagectomy with radical two- or three-field lymph node dissection were retrospectively investigated. The clinicopathological characteristics of patients with subcarinal lymph node metastasis were analyzed in detail.

Results

The median of dissected subcarinal lymph nodes in transmediastinal and transthoracic esophagectomy groups was 6 and 7, respectively, and there was no significant difference between the two groups (p?=?0.12). Of all patients, 26 (8.0%) were pathologically diagnosed as positive for subcarinal lymph node metastasis, whereas only 7 (26.9%) of those with metastasis were preoperatively diagnosed as positive. In addition, all patients with subcarinal lymph node metastasis had other non-subcarinal lymph node metastasis. By univariate analysis, subcarinal lymph node metastasis was found in larger (≥?30 mm) and deeper (T3/T4a) primary lesions (p?=?0.02 and 0.02, respectively), but it was not found in 49 patients with the primary lesion located in the upper thoracic esophagus.

Conclusions

Subcarinal lymph nodes can be dissected in transmediastinal esophagectomy, almost equivalent to transthoracic esophagectomy. The tumor size, depth, and location may be predictive factors for subcarinal lymph node metastasis.

     

Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomsis

We retrospectively analyzed the clinical data of 112 patients who underwent esophagectomy for esophageal carcinoma and gastro-esophageal anastomosis in right thoracic cavity from October 2011 to June 2013. First, the gastric tube was created with the aid of linear stapling device by removing the stomach and dissecting lymph nodes under laparoscopy and making a 3-4 cm incision through the subxiphoid area in the upper abdomen. Second, the thoracic esophagus and lymph nodes were dissected during thoracoscopic procedure. Gastric tube was inserted into the chest cavity and placed in the posterior mediastinum. The thoracic gastro-esophageal anastomosis was stapled with a circular stapler. Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis is technically feasible and safe, with minimized trauma, less operative blood loss and quick recovery.KEYWORDS : Laparoscopic, thoracoscopic, esophagectomy, esophagogastric anastomosis, esophageal carcinoma     

Should lymph nodes along the thoracic duct be dissected routinely in radical esophagectomy?

Background

Although dissection of mediastinal lymph nodes along the thoracic duct is included in standard radical esophagectomy, it is not routinely performed because of the undesirable hemodynamic effects. This study aims to investigate whether dissection of the nodes along the thoracic duct has prognostic benefits.

Methods

A total of 778 consecutive patients who underwent radical esophagectomy with three-field lymph node dissection for squamous cell carcinoma of the thoracic esophagus from 1984 to 2011 were included. The incidence of metastasis in thoracic duct nodes and that in nodes within #112 station excluding thoracic duct nodes were studied in relation to the depth of the main tumor. The survival curves of lymph node-positive patients were compared.

Results

The metastatic incidence was 2.2 % in T1b/T2, whereas it was 10.0 % in T3/T4. The survival curves in patients with metastasis in the thoracic duct nodes and in the #112 station were not statistically different.

Conclusion

The dissection of the nodes along the thoracic duct along with thoracic duct resection should be performed routinely; however, reliable indicator of the necessity of its dissection is awaited in T1b/T2 tumors because of the low metastatic rate and the potential risk associated with resection of the thoracic duct.     

Re-evaluation of the role of thoracoscopic esophagectomy as a Japanese-style radical surgery

Purpose

To investigate the value of thoracoscopic surgery in radical esophagectomy with three-field lymphadenectomy.

Materials and method

The subjects were 329 consecutive patients who, without preoperative chemoradiotherapy, underwent R0 radical esophagectomy with three-field lymphadenectomy for thoracic squamous cell esophageal cancers during 1998–2013. Open thoracotomy was applied in 212 (O), and thoracoscopic surgery in 117 (V). Survivals according to TNM Stages and Efficacy index (EI) were analyzed.

Results

Hospital death rates of O/V were 1.9/0%. The survivals of V according to TNM Stages had significantly better prognosis in TNM6th cStage III and showed not worse prognosis in general. In the analysis using Cox proportional hazards model, “V or O” was a significant prognostic factor indicating better prognosis of V. More bilateral paratracheal lymph nodes along the recurrent laryngeal nerves tended to be classified as mediastinal instead of cervical in V. Efficacy index of mediastinal paratracheal nodes was higher in V than in O, while cervical lymphadenectomy maintained high EI.

Discussion and conclusion

Though our series have limitations of retrospective study and substantial bias, the feasibility and safety of thoracoscopic esophagectomy with three-field lymphadenectomy was shown. Higher paratracheal lymph nodes along the recurrent laryngeal nerves could be dissected from the mediastinal side in V group. Thoracoscopic esophagectomy, which is regarded as minimally invasive surgery in other countries, is being accepted in Japan mainly in the expectation of more thorough and meticulous lymphadenectomy. At the same time, the dissection range is continuously re-evaluated for safer surgery maintaining radicality.

     

Posterior mediastinal lymph node dissection using the pneumomediastinum method for esophageal cancer

Although posterior mediastinal lymph node metastases are often observed in patients with esophageal cancer, their complete resection via a right thoracic approach is difficult and carries a risk of complications. We have developed a novel procedure for en-bloc dissection of the posterior mediastinal lymph nodes using the pneumomediastinum method. The patient was a 48-year-old female with middle thoracic esophageal cancer. A computed tomography scan showed a posterior mediastinal lymph node 1?cm in diameter. After division of the gastrosplenic ligament by hand-assisted laparoscopic surgery, the esophageal hiatus was opened, and carbon dioxide was introduced into the mediastinum. The anterior and left sides of the distal esophagus were separated, and a swollen posterior mediastinal lymph node was detected. Subsequently, the adventitia of the thoracic aorta was exposed, and the posterior side of the lymph node was separated. While lifting these nodes like a membrane, we cut them along the border of the left mediastinal pleura. Histopathological examination revealed a single squamous cell carcinoma metastasis in the resected lymph node. A good surgical view was obtained in our surgical procedure, and en-bloc dissection of the posterior mediastinal lymph nodes was safely performed.     

Survival outcomes of 220 consecutive patients with three‐staged thoracoscopic esophagectomy

Patients with thoracic esophageal cancer are often treated by minimally invasive esophagectomy. However, the long‐term survival benefits of minimally invasive esophagectomy remain unclear. Two approaches are available for thoracoscopic surgery: one with the patient in the left lateral decubitus position (LLDP), and the other with the patient in the prone position (PP). We investigated the survival benefit of thoracoscopic esophagectomy according to the tumor stage and patient position during the thoracoscopic procedure. We reviewed the records of 220 consecutive patients with esophageal cancer treated from 1998 to 2012. In total, 146 and 74 patients were treated with thoracoscopic esophagectomy in the LLDP and PP, respectively. No patients were initially proposed to be candidates for esophagectomy by thoracotomy during the study period. Data collection was performed with a focus on survival and recurrent disease. Among all the 220 patients, the overall 5‐year survival rates were 83.7%, 74.1%, 45.5%, 78.6%, 44.2%, 29.4% and 24.3% in the patients with pStage IA, IB, IIA, IIB, IIIA, IIIB and IIIC disease, respectively. Despite the greater number of dissected mediastinal lymph nodes in the PP procedure, there were no significant differences in the survival curves between the LLDP and PP procedures. The long‐term results of thoracoscopic esophagectomy are comparable and acceptable. The PP procedure was not confirmed to offer a superior survival benefit to the LLDP procedure in this retrospective study.     

Thoracoscopic purse string technique for minimally invasive Ivor Lewis esophagectomy

Objective

Thoracolaparoscopic esophagectomy with chest anastomosis (TLE-chest) is increasingly performed for middle and lower esophageal cancer; however, gastroesophageal anastomosis for this surgery remains both challenging and inefficient. To address this issue, we previously reported our MIE technique with Ivor-Lewis anastomosis. Here we present the video to introduce our TLE-chest operation procedures.

Methods

TLE-chest with a combined thoracoscopic and laparoscopic technique was performed by one group of surgeons. From October 2011 to September 2013, 80 esophageal cancer patients were treated with TLE-chest using this improved anastomotic technique.

Results

The surgery was successful for all patients, although the anastomosis in one patient required intraoperative manual repair. No patients required open conversion. In this video, dissociation of stomach, and dissection of lymph nodes, creation of gastric tube and staple line embedding, jejunostomy were carried out by laparoscopic surgery. Dissection of esophageal cancer and mediastinal lymph nodes were done through rib 3 or 4 by a 3-4 cm video-assisted right anterior minithoracotomy, then esophago-gastric anastomosis was performed in right thoracic cavity This video shows the R0 resection of T3N0M0 esophageal cancer. Totally, 36 lymph nodes were dissected, including 21 mediastinal lymph nodes and 15 abdominal lymph nodes. The patient recovered well and was discharged on day 8 after the surgery, with good short term outcomes.

Conclusions

A safe, cost effective purse string stapled anastomotic technique has been presented for TLE-chest in our video. It is consistent with the oncology principles.     

Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer

This study was designed to determine the efficacy of esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) with regard to the perioperative outcomes of esophageal cancer. The esophageal hiatus was opened by hand‐assisted laparoscopic surgery, and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using LTHA. Next, cervical lymphadenectomy, reconstruction via a retrosternal route with a gastric tube and anastomosis from a cervical approach were performed. Finally, a small thoracotomy (around 10 cm in size) was made to extract the thoracic esophagus and allow upper mediastinal lymphadenectomy to be performed. The treatment outcomes of 27 esophageal cancer patients who underwent LTHA‐preceding esophagectomy were compared with those of 33 patients who underwent the transthoracic approach preceding esophagectomy without LTHA (thoracotomy; around 20 cm in size). The intrathoracic operative time and operative bleeding were significantly decreased by LTHA. The total operative time did not differ between the two groups, suggesting that the abdominal procedure was longer in the LTHA group. The number of resected lymph nodes did not differ between the two groups. Postoperative respiratory complications occurred in 18.5% of patients treated with LTHA and 30.3% of those treated without it. The increase in the number of peripheral white blood cells and the duration of thoracic drainage were significantly decreased by this method. Our surgical procedure provides a good surgical view of the posterior mediastinum, markedly shortens the intrathoracic operative time, and decreases the operative bleeding without increasing major postoperative complications.     

Omentoplasty for cervical esophagogastrostomy following radical esophagectomy with three-field dissection

BACKGROUND/AIMS: Anastomotic leakage is the main cause of postoperative mortality and incidence of which, following three-field lymph node dissection, is around 30%. The study was undertaken to investigate the role of omentoplasty to reinforce cervical esophagogastrostomy with the expectation of lowering the rate of anastomotic leakage after radical esophagectomy with three-field lymph node dissection. METHODOLOGY: Between July 1995 and Dec 1997, a total of 32 patients underwent total thoracic esophagectomy with three-field lymph node dissection and cervical esophagogastrostomy. Eleven patients were stage IIA, 3 stage IIB, 5 stage III and 13 stage IV. After radical esophagectomy and lymph node dissection, several omental branches of the gastroepiploic vessels remained to supply a gastric tube. An end-to-side cervical esophagogastrostomy was performed on the posterior wall of the gastric tube using a circular stapler. The omentoplasty--wrapping the esophagogastrostomy--was performed. A retrosternal route for reconstruction was used in 23 patients and a posterior mediastinal route in 9 patients. RESULTS: Esophageal anastomotic leakage occurred in only 1 patient, 3.1% overall. There was neither pyothorax nor mediastinitis. There was no lethal anastomotic leakage. Later, 2 patients (6.2%) developed an anastomotic stricture that required balloon dilatation. CONCLUSIONS: Omentoplasty to reinforce cervical esophagogastrostomy decreases anastomotic failure following radical esophagectomy with three-field lymph node dissection.     

Thoracoscopic esophagectomy with extended lymph node dissection in the left lateral position: technical feasibility and oncologic outcomes

The aim of this study was to estimate the technical and oncologic feasibility of video‐assisted thoracoscopic radical esophagectomy (VATS) in the left lateral position. From January 2003 to December 2011, 132 patients with esophageal cancer underwent VATS. The mean duration of the thoracic procedure and the entire procedure was 294 ± 88 and 623 ± 123 minutes, respectively. Mean blood loss during the thoracic procedure and the entire procedure was 313 ± 577 and 657 ± 719 g, respectively. The mean number of dissected thoracic lymph nodes was 32.6 ± 12.9. There were four in‐hospital deaths (3.0%); two patients (1.5%) died of acute respiratory distress syndrome and two patients (1.5%) died of tumor progression. Postoperative unilateral or bilateral recurrent laryngeal nerve (RLN) palsy, or pneumonia was found in 33 (25.0%), 21 (15.9%), and 27(20.5%) patients, respectively. The patients were divided into the first 66 patients who underwent VATS (Group 1) and the subsequent 66 patients (Group 2). The numbers of cases who underwent neoadjuvant or induction chemotherapy for T4 tumor and intrathoracic anastomosis were higher in Group 2 than in Group 1. The duration of the procedure, amount of blood loss, and the number of dissected thoracic lymph nodes were not different between the two groups. The total number of dissected lymph nodes was higher in Group 2 than in Group 1 (72.6 ± 27.8 vs. 62.6 ± 21.6, P = 0.023). The rate of bilateral RLN palsy was less in Group 2 than in Group 1 (7.6% vs. 24.2%, P = 0.042). The mean follow‐up period was 38.7 months. Primary recurrence consisted of hematogenous, lymphatic, peritoneal dissemination, pleural dissemination, and locoregional in 15 (11.3%), 20 (15.1%), 3 (2.3%), 4 (3.0%), and 5 patients (3.8%), respectively. The rate of regional lymph node recurrence within the dissection field was only 4.5%. The prognosis of patients with lymph node metastasis was significantly poorer than that of patients without lymph node metastasis. However, the prognosis of the 11 cases that had metastasis only around RLNs was similar to that of node‐negative cases. Thirteen patients with pathological remnant tumor (R1 or R2) did not survive longer than 5 years at present. The overall 5‐year survival rate of stage I, II, and III disease after curative VATS was 82.2%, 77.0%, and 52.3%, respectively. Expansion of VATS criteria for patients after induction chemotherapy for T4 tumor or thoracoscopic anastomosis did not adversely affect the surgical results by experience. Although the VATS procedure is accompanied by a certain degree of morbidity including RLN palsy and pulmonary complications, VATS has an excellent locoregional control effect. In addition, the favorable survival after VATS shows that the procedure is oncologically feasible.     

Thoracoscopic and laparoscopic radical esophagectomy with lateral-prone position

With 20 years of development, minimally-invasive treatment for esophageal cancer has been widely spread. However, surgeons have not reached consensus about the optimal minimally-invasive operation method, or whether the effect of radical lymph nodes dissection is comparable to the traditional open procedure. Thoracoscopic esophagectomy with lateral-prone position combines the advantages of both lateral position (allowing quick conversion to open procedure) and prone position (good visual area and complete lymphadenectomy). Together with laparoscopic abdominal lymphadenectomy, gastric tube formation and jejunostomy, this approach provides an easier way for minimally-invasive radical esophagectomy. In this article, approaches for thoracoscopic esophagectomy with lateral-prone position and total mediastinal lymphadenectomy, combined with totally laparoscopic gastric mobilization, abdominal lymphadenectomy, gastric tube formation and jejunostomy, will be presented by video instructions. All the procedures were under the rule of radical lymphadenectomy. Cervical lymph nodes dissection and esophago-gastrostomy were the same as those in open procedure, which will not be discussed here.     

Validity of intraoperative pathological diagnosis of paratracheal lymph node as a strategy for selection of patients for cervical lymph node dissection during esophagectomy

The aim of this paper is to examine whether intraoperative examination of paratracheal nodes can indicate cervical node dissection and whether this approach is valid. From 1988 to 1997, 76 patients with thoracic esophageal squamous cell carcinoma received esophagectomies with and without cervical lymph node (LN) dissection based on the results of intraoperative pathological diagnosis from selective checking of paratracheal LN. We retrospectively examined the outcomes for the patients and the micro metastasis in the dissected lymph node using cytokeratin staining. Three of the seven patients with cervical LN dissection were detected as having cervical LN metastasis by postoperative hematoxylin-eosin or cytokeratin staining. Five (7%) of the 69 patients without cervical LN dissection had cervical LN recurrence after the operation. Four of the seven patients who were diagnosed as having metastasis or micro metastasis in paratracheal LN by postoperative examination had cervical LN recurrence after the operation. In conclusion, the esophagectomy with and without cervical LN dissection for thoracic esophageal squamous cell carcinoma based on the results of intraoperative pathological diagnosis from selective checking of paratracheal LN was not fully acceptable. The reliability of intraoperative pathological diagnosis of selective checking may improve by increasing the number of checked LN and the detection of micro metastasis.     

Mediastinoscopic esophagectomy for patients with early esophageal cancer

Objective

The purpose of this study was to detect the feasibility, safety, and effectiveness of mediastinoscopic esophagectomy for early esophageal cancer.

Methods

The clinical data of 194 patients who underwent mediastinoscopic esophagectomy for early esophageal cancer in our center from December 2005 to October 2014 were retrospectively analyzed.

Results

All the surgery was performed successfully. The average duration of thoracic surgery was 48.2±7.8 min and the average intra-operative blood loss was 128.1±34.5 mL. An average of 3.1±1.6 lymph node stations were dissected, with an average number of dissected lymph nodes being 9.38±6.2, among which 4.2±5.4 were mediastinal lymph nodes. No peri-operative mortality was noted, and the rate of peri-operative morbidity was 13.4%. The median duration of follow-up was 39 [3-108] months, and the overall survival was 72.73%. The overall survival rates significantly differed among different T stages; more specifically, the 5-year survival was 95.23% in patients with stage T_1a esophageal cancer, 70.15% for T_1b, and 55.56% for T₂ (P<0.001). The overall survival was significantly better in patients with negative lymph nodes than those with lymph nodes metastasis (P=0.003); more specifically, the 5-year survival rate was 84.9% for N₀, 62.5% for N₁, and 50.0% for N₂ + N₃.

Conclusions

The mediastinoscopic esophagectomy can achieve a similar effectiveness as the conventional thoracoscopic surgery for patients with early stage esophageal cancer.     

Azygos lymph node enlargement as initial manifestation of underlying disease

Azygos lymph node enlargement is usually an indication of advanced bronchogenic carcinoma, although it may occur in benign pulmonary disease. Often it is found in conjunction with enlargement of hilar and other mediastinal lymph nodes. Isolated azygos lymph node enlargement is unusual and demands tissue diagnosis. Four patients without other evidence of underlying disease were evaluated because of roentgenographic finding of azygos lymph node enlargement. Three had malignant disease and one reactive lymphoid hyperplasia. Current concepts of mediastinal lymphatic drainage are presented. Because of the likelihood of underlying malignancy, biopsy examination of an enlarged azygos node by cervical mediastinoscopy is indicated.     

Completely thoracoscopic right upper lobectomy and mediastinal lymph node dissection

Video-assisted thoracoscopic surgery (VATS) has been constantly used in the diagnosis and treatment of intrathoracic disease. The focus of VATS is primarily concerned with the completeness of mediastinal lymph node dissection for lung cancer and the safety of surgery. Here we discuss the feasibility of VATS right upper lobectomy and systematic lymph node dissection, for a 60-year-old woman who was admitted for tumor of the right upper lobe, and describe this treatment method and the major indications. The technique of single-direction lobectomy and mediastinal lymph node dissection is a safe and feasible completely thoracoscopic lobectomy in minimally invasive approach. Single-direction lobectomy can shorten the operation time and reduce the difficulty and complexity of the procedure. The video demonstrates the manipulation of arterial and venous bleeding in thoracoscopic surgery and the skill of single-direction operation.KEYWORDS : Video-assisted thoracoscopic surgery (VATS), right upper lobectomy, systematic lymph node dissection     

改良式左胸腹联合左颈二切口在食管癌根治术中的应用(附21例临床分析)

目的探讨改良式左胸腹联合左颈二切口在食管下段癌根治术中的应用. 方法对2002年2月至2003年6月采用了改良式左胸腹联合左颈二切口根治术的21例食管下段癌患者的手术时间、手术并发症、上腹部淋巴结清扫范围进行回顾性分析. 结果改良式左胸腹联合左颈二切口根治术能有效的简化了手术操作步骤,减少了手术创伤及并发症,扩大了腹内淋巴结清扫范围. 结论改良式左胸腹联合左颈二切口根治术是食管下段癌患者的较理想的术式.