Preoperative prediction of preferable approach to the mediastinum during minimally invasive esophagectomy by CT scan

Kei Sakamoto, MD, Yosuke Izumi, MD, PhD, Tairo Ryotokuji, MD, Akinori Miura, MD, PhD, Tsuyoshi Kato, MD, Michiyo Tokura, MD

Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital

INTRODUCTION:The first randomized trial has provided evidence for reduced pulmonary infection of minimally invasive esophagectomy(MIE) compared with open esophagectomy. Debate still exists about benefits of MIE probably because of technical difficulty.

This technical difficulty is based on obscured view by lung and pooled blood in the middle and lower mediastinum.Prone position addressed this problem and reduced time of thoracoscopic procedure. However prone position has disadvantage of unfamiliality and difficulty in conversion to open surgery. We performed laparoscopic transhiatal approach to the lower mediastinum to address the problem of obscured view by the lung. Laparoscopic transhiatal approach to the lower mediastinum required neither one-lung ventilation nor retraction of the lung. Thoracoscopic procedure was only performed for dissection of lymph nodes and mobilization of the esophagus in the upper mediastinum. Depending on the shape of thorax of the patients, preferable approach, thoracoscopic or laparoscopic, is different to the lower mediastinum. It is important to determine the range of thoracoscopic procedure and laparoscopic procedure in the mediastinum for reduction of the time for thoracoscopic procedure and all operative time.

AIM:To establish the method to predict the preferable approach, thoracoscopic or laparoscopic, to the lower mediastinum by preoperative CT scan.

METHODS: Between June 2007 and June 2009, MIE was performed in 57 patients, while laparoscopic transhiatal approach was intended to dissect up to the level of subcarinal lymph nodes, and gastric reconstruction via retrosternal route, thoracosopic dissection in the paratracheal lymph nodes and bilateral neck dissection were performed. 35 out of 57 patients underwent laparoscopic dissection of the subcarinal lymph nodes. The others underwent laparoscopic mediastinal dissection up to the level of lower pulmonary vein. We measured the thorax size on CT scan, which are thought to be related to difficulty of the procedure.

RESULTS:
Deviation of the esophagus to the left from the midline
Mean operative time of thoracoscopic procedure were 130 minutes in 8cases with deviation<20mm, 185 minutes in 9cases with deviation 25-30mm and 130minutes in 9cases with deviation >35mm, respectively. Mean operative time of thoracoscopic procedure was significantly shorter in patients with deviation <20mm or >35mm, compared with patients with deviation 25-30mm(p=0.024, 0.015 respectively)

Length between vertebra and sternum
Mean operative time of laparoscopic procedure up to the level of subcarinal lymph nodes were 268 minutes in 14 cases (58% of 22 cases) with the length<10cm and 267minutes in 21cases (66% of 33cases) with the length >10cm. They were not different. Rate of dissection up to the level of subcarinal lymph nodes was higher in patients with the length >10cm, not significantly different.

CONCLUSION:
1. Laparoscopic transhiatal procedure might be limited to the level of lower pulmonary vein in patients with the length between vertebra and sternum <10cm and deviation of the esophagus to the left from the midline <20mm.
2. Laparoscopic transhiatal procedure would be better to be done up to the level of subcarinal lymph nodes or upper in patients with the length between vertebra and sternum >10cm and deviation of the esophagus to the left from the midline 25-30mm.


Session: Poster Presentation

Program Number: P242

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