Skip to main content

Advertisement

SpringerLink
Log in

Mesenteric excision of upper esophagus: a concept for rational anatomical lymphadenectomy of the recurrent laryngeal nodes in thoracoscopic esophagectomy

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

The recurrent laryngeal nerve (RLN) lymph nodes are among the most frequently involved lymph nodes in esophageal cancer. Surgical removal of these lymph nodes is considered beneficial for postoperative prognosis, especially in patients with squamous cell carcinoma. Unfortunately, the precise surgical anatomy of the upper mediastinum is not well understood and no distinct high-resolution images are currently available.

Methods

In this article, we provide a simple intuitive concept of upper mediastinal surgical anatomy that could facilitate rational anatomical lymphadenectomy of the RLN lymph nodes. The essential concept of this mesenteric excision is to mobilize mesoesophagus including RLN in an en bloc fashion and to save RLN laterally by incising visceral sheath. This is applicable identically to both right and left upper mediastinum.

Results

Between January 2009 and December 2017, thoracoscopic esophagectomy with upper mediastinal lymphadenectomy for primary esophageal cancer was performed in 189 patients. Median thoracoscopic procedure time was 297 (range 205–568) min and median intraoperative blood loss was 70 ml (range unmeasurable up to 2545 ml). Median number of harvested upper mediastinal lymph nodes was 12. Postoperative complication of Clavien–Dindo classification grade III or higher events was observed in 14% of patients. RLN palsy of grade II or higher occurred in 20 patients (11%).

Conclusion

The mesoesophagus in the upper mediastinum is an anatomical unit surrounded by fibrous connective tissue containing the esophagus, trachea, tracheoesophageal vessels, lymphatic tissue, and RLNs. Thus, mesenteric excision of esophagus is defined to resect this area by sparing trachea and RLNs for rational anatomical lymphadenectomy. We believe that this concept makes upper mediastinal lymphadenectomy safer and more appropriate.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Abbreviations

RLN:

Recurrent laryngeal nerve

AV:

Azygos vein

TD:

Thoracic duct

SCA:

Subclavian artery

BA:

Bronchial artery

VN:

Vagus nerve

SN:

Sympathetic nerve

References

  1. Udagawa H, Ueno M, Shinohara H, Haruta S, Kaida S, Nakagawa M, Tsurumaru M (2012) The importance of grouping of lymph node stations and rationale of three-field lymphoadenectomy for thoracic esophageal cancer. J Surg Oncol 106:742–747

    Article  Google Scholar 

  2. Tachimori Y, Ozawa S, Numasaki H, Matsubara H, Shinoda M, Toh Y, Udagawa H, Fujishiro M, Oyama T, Uno T, The Registration Committee for Esophageal Cancer of the Japan Esophageal Society (2016) Efficacy of lymph node dissection by node zones according to tumor location for esophageal squamous cell carcinoma. Esophagus 13:1–7

    Article  Google Scholar 

  3. Itami A, Watanabe G, Tanaka E, Nakayama S, Fujimoto A, Kondo M, Nakau M, Okabe H, Satoh S, Sakai Y (2008) Multimedia article. Upper mediastinal lymph node dissection for esophageal cancer through a thoracoscopic approach. Surg Endosc 22:2741

    Article  Google Scholar 

  4. Kinjo Y, Kurita N, Nakamura F, Okabe H, Tanaka E, Kataoka Y, Itami A, Sakai Y, Fukuhara S (2012) Effectiveness of combined thoracoscopic-laparoscopic esophagectomy: comparison of postoperative complications and midterm oncological outcomes in patients with esophageal cancer. Surg Endosc 26:381–390

    Article  Google Scholar 

  5. Tanaka E, Okabe H, Kinjo Y, Tsunoda S, Obama K, Hisamori S, Sakai Y (2015) Advantages of the prone position for minimally invasive esophagectomy in comparison to the left decubitus position: better oxygenation after minimally invasive esophagectomy. Surg Today 45:819–825

    Article  CAS  Google Scholar 

  6. Tanaka E, Okabe H, Tsunoda S, Obama K, Kan T, Kadokawa Y, Akagami M, Sakai Y (2012) Feasibility of thoracoscopic esophagectomy after neoadjuvant chemotherapy. Asian J Endosc Surg 5:111–117

    Article  CAS  Google Scholar 

  7. Sakai Y, Hasegawa S, Shinohara H, Yamada M, Michiaki O (2016) Laparoscopic total mesorectal excision (TME) for rectal cancer. In: Sakai Y (ed) Laparoscopic surgery for colorectal cancer. Springer, Tokyo, pp 109–135

    Chapter  Google Scholar 

  8. Sarrazin R, Voog R (1971) Anatomical background to mediastinoscopy. In: Jepsen O, Sørensen HR (eds) Mediastinoscopy. Odense University Press, Odense, pp 1–6

    Google Scholar 

  9. Sadler TW (2014) Langman’s medical embryology, 13th edn. LWW, Philadelphia

    Google Scholar 

  10. Salassa JR, Pearson BW, Payne WS (1977) Gross and microscopical blood supply of the trachea. Ann Thorac Surg 24:100–107

    Article  CAS  Google Scholar 

  11. Noshiro H, Urata M, Ikeda O, Iwasaki H, Nabae T, Uchiyama A, Nagai E, Tanaka M (2013) Triangulating stapling technique for esophagogastrostomy after minimally invasive esophagectomy. Surgery 154:604–610

    Article  Google Scholar 

  12. Japan Esophageal Society (2017) Japanese Classification of Esophageal Cancer, 11th edition: part I. Esophagus 14:1–36

    Article  Google Scholar 

  13. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

    Article  Google Scholar 

  14. Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616

    Article  CAS  Google Scholar 

  15. Heald RJ (1988) The ‘Holy Plane’ of rectal surgery. J R Soc Med 81:503–508

    Article  CAS  Google Scholar 

  16. Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S (2009) Standardized surgery for colonic cancer: complete mesocolic excision and central ligation—technical notes and outcome. Colorectal Dis 11:354–364 (discussion 364–355)

    Article  CAS  Google Scholar 

  17. Tufano A, Tufano G, Brusciano L, del Genio G, Rossetti G, Di Stazio C, Grillo M, del Genio A (2007) Mesorectum, is it an appropriate term? Int J Colorectal Dis 22:1127–1128

    Article  CAS  Google Scholar 

  18. Havenga K, Grossmann I, DeRuiter M, Wiggers T (2007) Definition of total mesorectal excision, including the perineal phase: technical considerations. Dig Dis 25:44–50

    Article  Google Scholar 

  19. Matsubara T, Ueda M, Nagao N, Takahashi T, Nakajima T, Nishi M (1998) Cervicothoracic approach for total mesoesophageal dissection in cancer of the thoracic esophagus. J Am Coll Surg 187:238–245

    Article  CAS  Google Scholar 

  20. Tokairin Y, Nakajima Y, Kawada K, Hoshino A, Okada T, Ryotokuji T, Okuda M, Kume Y, Kawamura Y, Yamaguchi K, Nagai K, Akita K, Kinugasa Y (2018) Histological study of the thin membranous structure made of dense connective tissue around the esophagus in the upper mediastinum. Esophagus 15:272–280

    Article  Google Scholar 

  21. Cuesta MA, Weijs TJ, Bleys RL, van Hillegersberg R, van Berge Henegouwen MI, Gisbertz SS, Ruurda JP, Straatman J, Osugi H, van der Peet DL (2015) A new concept of the anatomy of the thoracic oesophagus: the meso-oesophagus. Observational study during thoracoscopic esophagectomy. Surg Endosc 29:2576–2582

    Article  Google Scholar 

  22. Akiyama Y, Iwaya T, Endo F, Nikai H, Sato K, Baba S, Chiba T, Kimura T, Takahara T, Otsuka K, Nitta H, Mizuno M, Kimura Y, Koeda K, Sasaki A (2018) Thoracoscopic esophagectomy with total meso-esophageal excision reduces regional lymph node recurrence. Langenbecks Arch Surg. https://doi.org/10.1007/s00423-018-1727-5

    Article  PubMed  Google Scholar 

  23. Tachimori Y (2014) Total mesoesophageal esophagectomy. Chin Med J (Engl) 127:574–579

    Google Scholar 

  24. Lin J, Kang M, Chen S, Deng F, Han Z (2016) Feasibility and strategy for left tracheobronchial lymph node dissection in thoracolaparoscopic esophageal cancer surgery. Thorac Cancer 7:199–206

    Article  Google Scholar 

  25. Kang M, Huang S, Lin J, Chen S, Han W (2016) Video-assisted thoracoscopy the total mesoesophageal excision and systematic en bloc mediastinal lymph node dissection. J Vis Surg 2:102

    Article  Google Scholar 

  26. Akiyama H, Tsurumaru M, Udagawa H, Kajiyama Y (1994) Radical lymph node dissection for cancer of the thoracic esophagus. Ann Surg 220:364–372 (discussion 372–363)

    Article  CAS  Google Scholar 

  27. Nishihira T, Hirayama K, Mori S (1998) A prospective randomized trial of extended cervical and superior mediastinal lymphadenectomy for carcinoma of the thoracic esophagus. Am J Surg 175:47–51

    Article  CAS  Google Scholar 

  28. Fujita H, Sueyoshi S, Tanaka T, Fujii T, Toh U, Mine T, Sasahara H, Sudo T, Matono S, Yamana H, Shirouzu K (2003) Optimal lymphadenectomy for squamous cell carcinoma in the thoracic esophagus: comparing the short- and long-term outcome among the four types of lymphadenectomy. World J Surg 27:571–579

    Article  Google Scholar 

  29. Igaki H, Tachimori Y, Kato H (2004) Improved survival for patients with upper and/or middle mediastinal lymph node metastasis of squamous cell carcinoma of the lower thoracic esophagus treated with 3-field dissection. Ann Surg 239:483–490

    Article  Google Scholar 

  30. Kato H, Watanabe H, Tachimori Y, Iizuka T (1991) Evaluation of neck lymph node dissection for thoracic esophageal carcinoma. Ann Thorac Surg 51:931–935

    Article  CAS  Google Scholar 

  31. Fang WT, Chen WH, Chen Y, Jiang Y (2007) Selective three-field lymphadenectomy for thoracic esophageal squamous carcinoma. Dis Esophagus 20:206–211

    Article  Google Scholar 

  32. Gilchrist RK, David VC (1938) Lymphatic spread of carcinoma of the rectum. Ann Surg 108:621–642

    Article  CAS  Google Scholar 

  33. Coller FA, Kay EB, Macintyre RS (1941) Regional lymphatic metastases of carcinoma of the colon. Ann Surg 114:56–67

    Article  CAS  Google Scholar 

  34. Shinohara H, Kurahashi Y, Kanaya S, Haruta S, Ueno M, Udagawa H, Sakai Y (2013) Topographic anatomy and laparoscopic technique for dissection of no. 6 infrapyloric lymph nodes in gastric cancer surgery. Gastric Cancer 16:615–620

    Article  CAS  Google Scholar 

  35. Shinohara H, Haruta S, Ohkura Y, Udagawa H, Sakai Y (2015) Tracing dissectable layers of mesenteries overcomes embryologic restrictions when performing infrapyloric lymphadenectomy in laparoscopic gastric cancer surgery. J Am Coll Surg 220:e81–e87

    Article  Google Scholar 

  36. Shinohara H, Kurahashi Y, Haruta S, Ishida Y, Sasako M (2018) Universalization of the operative strategy by systematic mesogastric excision for stomach cancer with that for total mesorectal excision and complete mesocolic excision colorectal counterparts. Ann Gastroenterol Surg 2:28–36

    Article  Google Scholar 

  37. Zaheer S, Pemberton JH, Farouk R, Dozois RR, Wolff BG, Ilstrup D (1998) Surgical treatment of adenocarcinoma of the rectum. Ann Surg 227:800–811

    Article  CAS  Google Scholar 

  38. Oshikiri T, Nakamura T, Hasegawa H, Yamamoto M, Kanaji S, Yamashita K, Matsuda T, Sumi Y, Fujino Y, Tominaga M, Suzuki S, Kakeji Y (2018) Standardizing procedures improves and homogenizes short-term outcomes after minimally invasive esophagectomy. Langenbecks Arch Surg 403:221–234

    Article  Google Scholar 

  39. Saito Y, Takeuchi H, Fukuda K, Suda K, Nakamura R, Wada N, Kawakubo H, Kitagawa Y (2018) Size of recurrent laryngeal nerve as a new risk factor for postoperative vocal cord paralysis. Dis Esophagus https://doi.org/10.1093/dote/dox162

    Article  PubMed  Google Scholar 

  40. Motoyama S, Maeda E, Yano M, Yasuda T, Ohira M, Doki Y, Toh Y, Higashi T, Matsubara H, Society JE (2018) Appropriateness of the institute certification system for esophageal surgeries by the Japan Esophageal Society: evaluation of survival outcomes using data from the National Database of Hospital-Based Cancer Registries in Japan. Esophagus. https://doi.org/10.1007/s10388-018-0646-4

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

This work was supported in part by JSPS KAKENHI Grant Number 16H05399.

Author information

Authors and Affiliations

  1. Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan

    Shigeru Tsunoda, Hisashi Shinohara, Seiichiro Kanaya, Hiroshi Okabe, Eiji Tanaka, Kazutaka Obama, Hisahiro Hosogi, Shigeo Hisamori & Yoshiharu Sakai

  2. Department of Surgery, Hyogo College of Medicine, Hyogo, Japan

    Hisashi Shinohara

  3. Department of Surgery, Osaka Red Cross Hospital, Osaka, Japan

    Seiichiro Kanaya

Authors
  1. Shigeru Tsunoda
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hisashi Shinohara
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Seiichiro Kanaya
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hiroshi Okabe
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Eiji Tanaka
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kazutaka Obama
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Hisahiro Hosogi
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shigeo Hisamori
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Yoshiharu Sakai
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Shigeru Tsunoda.

Ethics declarations

Disclosures

Shigeru Tsunoda, Hisashi Shinohara, Seiichiro Kanaya, Hiroshi Okabe, Eiji Tanaka, Kazutaka Obama, Hisahiro Hosogi, Shigeo Hisamori, and Yoshiharu Sakai have no conflict of interest or financial ties to disclose.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (ZIP 2007 MB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tsunoda, S., Shinohara, H., Kanaya, S. et al. Mesenteric excision of upper esophagus: a concept for rational anatomical lymphadenectomy of the recurrent laryngeal nodes in thoracoscopic esophagectomy. Surg Endosc 34, 133–141 (2020). https://doi.org/10.1007/s00464-019-06741-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-019-06741-x

Keywords

Search

Navigation