Effects of a New Traction Method for the Upper Esophagus on Mediastinal Lymph Node Dissection for Esophageal Cancer During Thoracoscopic Esophagectomy in a Prone Position

Soji Ozawa, MD, PhD, FACS, Junya Oguma, MD, PhD, Akihito Kazuno, MD, Yasushi Yamasaki, MD, Yamato Ninomiya, MD. Department of Gastroenterological Surgery, Tokai University School of Medicine

INTRODUCTION: The effects of a new traction method for the upper esophagus were examined to simplify mediastinal lymph node dissection (LND) by creating a wider operative space during thoracoscopic esophagectomy for esophageal cancer, since upper mediastinal LND can be difficult but is oncologically important.

PATIENTS AND METHODS: We retrospectively reviewed a database of 215 patients with thoracic esophageal cancer who underwent thoracoscopic esophagectomy in a prone position between September 2009 and August 2015. We attempted to improve the upper mediastinal LND method as follows: method A (no traction of the upper esophagus) during the first term, method B (esophageal traction with one thread) during the second term, and method C (esophageal traction with two tapes) during the third term. We then compared the number of dissected lymph nodes, the operative time, the blood loss, and the rate of recurrent laryngeal nerve (RLN) palsy among these three methods.

RESULTS: We selected 166 patients who were pathologically confirmed to have both more than one lymph node around the right RLN and more than one lymph node around the left RLN (method A, 33 patients; B, 83 patients; C, 50 patients). The mean age was 66 years, and there were 144 male and 22 female patients. The mean number of dissected lymph nodes around the right RLN for method C (3.7) was greater than those for methods A and B (2.3, 2.7) (ANOVA, P = 0.001; Tukey, P = 0.004). The number around the left RLN for method C (7.6) was greater than those for methods A and B (4.1, 5.4) (P < 0.001, P = 0.002). The mean number in the upper mediastinum for method C (13.7) was greater than those for methods A and B (7.9, 10.1) (P < 0.001, P < 0.001). The mean thoracoscopic time for method C (259 min) was only longer than that for method B (226 min) (Grames-Howell, P = 0.03). No differences in the mean thoracoscopic blood loss were observed among three methods. No differences in the rate of RLNP were observed among methods A (24%), B (35%), and C (38%) (Chi-square, P = 0.551). No operative deaths occurred in this series.

CONCLUSIONS: This new traction method for the upper esophagus using two tapes was effective for thoracoscopic surgery for esophageal cancer in terms of the number of dissected lymph nodes and the rate of RLNP. Further reductions in the operative time will be necessary.

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