A novel anatomical description of the esophagus: the supracarinal mesoesophagus.

BACKGROUND: During thoracoscopic esophageal resection, while performing the supracarinal lymphadenectomy along the left recurrent laryngeal nerve (LRLN) from the aortic arch to the thoracic apex, we observed a not previously described bilayered fascia-like structure, serving as prolongation of the already known mesoesophagus. METHODS: We retrospectively evaluated 70 consecutively unedited videos of thoracoscopic interventions on esophageal resections for cancer, in order to determine the validity of this finding and to describe its utility for performing a systematic and more accurate dissection of the LRLN and its adequate lymphadenectomy. RESULTS: After mobilization of the upper esophagus from the trachea and tilting the esophagus by means of two ribbons, a bilayered fascia was observed between the esophagus and the left subclavian artery in 63 of the 70 patients included in this study. By opening the right layer, the left recurrent nerve became visualized and could be dissected free in its whole trajectory. Vessels and branches of the LRLN were divided between miniclips. Mobilizing the esophagus to the right, the base of this fascia could be found at the left subclavian artery. After dissecting and clipping the thoracic duct, complete lymphadenectomy of 2 and 4L stations could be performed. Mobilizing the esophagus in distal direction, the fascia continued at the level of the aortic arch, where it had to be divided in order to mobilize the esophagus from the left bronchus. Here, a lymphadenectomy of the aorta-pulmonary window lymph nodes (station 8) can be performed. It seems that from there the fascia continued without interruption with the previously described mesoesophagus between the thoracic aorta and the esophagus. CONCLUSIONS: Here we described the concept of the supracarinal mesoesophagus on the left side. Applying the description of the mesoesophagus will create a better understanding of the supracarinal anatomy, leading to a more adequate and reproducible surgery.

En bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy based on the mesoesophageal theory.

PURPOSE: To investigate the effectiveness and clinical significance of thoracolaparoscopic esophagectomy with mesoesophagus excision. MATERIALS AND METHODS: Patients who underwent en bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy were retrospectively enrolled. Carbon nanoparticles were used in some patients to label the esophageal drainage lymph nodes. The clinical data were analyzed. RESULTS: En bloc mesoesophageal esophagectomy was successfully performed in 135 patients (100%). The carbon nanoparticles were used in 10 patients, among which the left gastric arterial lymph nodes were labeled in all patients and excised together with the left gastric mesentery, mesoesophagus, esophageal cancer, lymph nodes, vessels, nerves, and adipose tissues as one intact package. The mean operation time was 182.5 ± 26.4 min, intraoperative blood loss 45.9 ± 17.6 ml, mean number of lymph nodes dissected 20.9 ± 8.12, extubation time of drainage tubes 7.5 ± 3.8 days, first oral feeding time 7.5 ± 1.8 days, and postoperative hospital stay 13 ± 5.11 days. Postoperatively, anastomotic leakage occurred in six patients (4.4%), anastomotic stenosis in eight (5.9%), hoarseness in seven (5.2%), and inflammation of the remnant stomach in four (3.0%), with a complication rate of 18.5%. Patients were followed up for 13-34 months (median 23). Eighteen patients presented with organ metastasis. No local recurrence or death during follow-up. CONCLUSION: Based on the membrane anatomy or mesoesophagus theory, thoracolaparoscopic en bloc mesoesophageal esophagectomy is safe, with decreased blood loss, and it is necessary to resect the left gastric artery lymph nodes together with the left gastric mesentery and its contents to completely remove the cancer.

Outcomes of minimally invasive total mesoesophageal excision: a propensity score-matched analysis.

BACKGROUND: This study aimed to investigate the safety and efficacy of minimally invasive total mesoesophageal excision (TME) for esophageal cancer. METHODS: We retrospectively collected data from patients with esophageal cancer who underwent esophagectomy at our center between January 2011 and June 2017. Among 611 eligible patients, 302 underwent minimally invasive total mesoesophageal excision (the TME group) and 309 underwent non-total mesoesophageal excision (the NME group). Outcomes were compared after 1-to-1 propensity score matching, and subgroup analyses were performed for cases involving pT1-2 or pT3-4a disease. RESULTS: The propensity score matching produced 249 pairs of patients. The TME group had a shorter operative time (P < 0.001), lower intraoperative bleeding (P < 0.001), and a shorter postoperative hospital stay (P < 0.001). There were no significant differences between the two groups in the number of removed lymph nodes, 30-day mortality, or postoperative complications. In addition, both groups had similar 3-year rates of overall survival (OS) and disease-free survival (DFS). However, the 3-year recurrence rate in the esophageal bed was significantly lower in the TME group (P = 0.033). Furthermore, among patients with pT3-4a disease, the TME group had better 3-year rates of OS, DFS, and recurrence. CONCLUSION: Minimally invasive total mesoesophageal excision appears to be a safe technique that can reduce tumor recurrence in the esophageal bed. Furthermore, this technique provided survival benefits for patients with pT3-4a disease.

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

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.

Minimally invasive mesoesophageal resection.

Based in the anatomical concept of the mesoesophagus, that at subcarinal level all the vessels come through a by-layer connective tissue plane from the aorta to the esophagus whereas supracarinally these structures will come from both sides, with vagal and recurrent laryngeal nerves, a minimally invasive mesoesophageal (MIME) resection model may be described. Based on this surgical plane concept, dissection of esophagus and mediastinal lymphadenectomy can be performed along these structures establishing clear anatomical modules for an adequate oncological resection.

Thoracoscopic esophagectomy with total meso-esophageal excision reduces regional lymph node recurrence.

PURPOSE: We investigated the operative outcomes of thoracoscopic esophagectomy (TE) in the prone position, using the concept of total meso-esophageal excision for esophageal cancer. METHODS: The medical records of 140 consecutive patients with esophageal cancer who underwent radical esophagectomy by TE were reviewed retrospectively, and operative outcomes were compared between patients treated before (non-meso-esophagus; non-ME group) and after (ME group) the introduction of total meso-esophageal excision (ME). RESULTS: There were no significant differences between the groups in postoperative morbidity (non-ME group vs. ME group, 28.3% vs. 41.4%, p = 0.119), 30-day mortality (non-ME group vs. ME group, 0% vs. 1.1%; p = 0.433), and in-hospital mortality (non-ME group vs. ME group, 1.9% vs. 0%, p = 0.199). Although overall survival and relapse-free survival did not differ significantly between the groups, the overall recurrence rate was significantly lower in the ME group than the non-ME group (non-ME group vs. ME group, 43.4% vs. 23%, p = 0.011). In particular, the rate of regional lymph node recurrence in the mediastinum was lower in the ME group (non-ME group vs. ME group, 11.3% vs. 2.3%; p = 0.026). CONCLUSIONS: Our results suggest that the ME procedure might be one of the procedures that reduce regional lymph node recurrence in the mediastinum without any deterioration in short-term outcomes.

Technique and surgical outcomes of mesenterization and intra-operative neural monitoring to reduce recurrent laryngeal nerve paralysis after thoracoscopic esophagectomy: A cohort study.

BACKGROUND: Because the thoracic esophageal carcinoma has a high metastatic rate to the upper mediastinal lymph nodes, especially along the recurrent laryngeal nerves (RLN), it is crucial to perform a complete lymphadenectomy along the RLN without complications. Although intraoperative neural monitoring (IONM) during thyroid surgery has gained widespread acceptance as a useful tool for visual nerve identification, utilization of IONM during esophageal surgery has not become common. Here, we describe our procedures, focusing on a lymphadenectomy along the RLN utilizing the IONM. METHODS: Eighty-seven patients who underwent prone esophagectomy between December 2009 and September 2017 were included in this study. We divided patients into two groups: neural monitoring group (Nm, n = 31) and conventional method group without IONM (Cm, n = 56). We first dissect around the esophagus, preserving the membranous structure; mesoesophagus, which contains tracheoesophageal artery; RLN; and lymph nodes (mesenterization). In Nm group, we next identify the location of the RLN, which runs in the mesoesophagus using IONM before visual contact. Next, we perform lymphadenectomy around the RLN, preserving the nerve itself. Early surgical outcomes were retrospectively compared between two groups. RESULTS: In all 31 cases in the Nm group, we detected the location of the RLN before the visual contact. The sensitivity and specificity of the IONM to detect the RLN paralysis were 67% and 96%, respectively. Postoperative RLN paralysis was observed in 3 cases in the Nm group (9.7%), which was lower than that in the Cm group (32.1%, p = 0.03). Clavien-Dindo grade 2 and over aspiration were seen in 2 (Nm, 6.5%) and 16 (Cm, 28.6%) cases (p = 0.01), respectively. The postoperative hospital stay was shorter in the Nm group (22 days, median) than in the Cm group (39 days, median, p = 0.0002). The number of dissected mediastinal lymph nodes was similar in both groups (25 vs. 20, median, p = 0.12). CONCLUSIONS: The combination of IONM and the concept of the mesoesophagus have substantial advantages in allowing accurate and safe mediastinal lymphadenectomy during prone esophagectomy.

A case of schwannoma of the mesoesophagus displaced from the left to the right of the posterior mediastinum.

Although schwannomas are the most common neurogenic tumors found in the thorax, schwannomas of the mesoesophagus are extremely rare. We report a case of an 80-year-old man having a tumor in contact with the esophagus in the left posterior mediastinum. A preoperative follow-up computed tomography scan showed tumor displacement from the left to the right of the posterior mediastinum. The patient underwent surgery, and the tumor was diagnosed as a schwannoma of the mesoesophagus. The tumor might have been displaced from the left to the right of the posterior mediastinum because it was located in the mesoesophagus.

Evaluation of total mesoesophageal excision by thoracoscopy combined with laparoscopy in radical resection ;of esophageal carcinoma / 中国基层医药

Objective To explore the feasibility,necessity and the skill of total mesoesophageal excision (TME ) during thoracoscopy combined with laparoscopy in radical resection of esophageal carcinoma.Methods 69 patients with esophageal carcinoma were divided into the TME group(40 cases)and the thoracotomy with triple incisions group(29 cases)according to the admission sequence.The operation time,intraoperative blood loss,total lymph nodes removed,postoperative complication rate and disease -free survival were compared between the two groups.Results The operation time of TME group was (182.85 ±26.73)min,which was significantly shorter than (295.71 ±19.50)min of the thoracotomy group (t=-19.301,P0.05 ).The disease-free survival period in TME group was (14.78 ±2.14)months,which in the thoracotomy group was (13.10 ±4.09)months,the difference was significant (t=2.200,P<0.05).Conclusion TME is safe and feasible during thoracoscopy combined with laparos-copy in radical resection of esophageal carcinoma.TME is better in improving the regional control in esophageal carci-noma.

Mesoesophagus and other fascial structures of the abdominal and lower thoracic esophagus: a histological study using human embryos and fetuses.

A term "mesoesophagus" has been often used by surgeons, but the morphology was not described well. To better understand the structures attaching the human abdominal and lower thoracic esophagus to the body wall, we examined serial or semiserial sections from 10 embryos and 9 fetuses. The esophagus was initially embedded in a large posterior mesenchymal tissue, which included the vertebral column and aorta. Below the tracheal bifurcation at the fifth week, the esophagus formed a mesentery-like structure, which we call the "mesoesophagus," that was sculpted by the enlarging lungs and pleural cavity. The pneumatoenteric recess of the pleuroperitoneal canal was observed in the lowest part of the mesoesophagus. At the seventh week, the mesoesophagus was divided into the upper long and lower short parts by the diaphragm. Near the esophageal hiatus, the pleural cavity provided 1 or 2 recesses in the upper side, while the fetal adrenal gland in the left side was attached to the lower side of the mesoesophagus. At the 10th and 18th week, the mesoesophagus remained along the lower thoracic esophagus, but the abdominal esophagus attached to the diaphragm instead of to the left adrenal. The mesoesophagus did not contain any blood vessels from the aorta and to the azygos vein. The posterior attachment of the abdominal esophagus seemed to develop to the major part of the phrenoesophageal membrane with modification from the increased mass of the left fetal adrenal. After postnatal degeneration of the fetal adrenal, the abdominal esophagus might again obtain a mesentery. Consequently, the mesoesophagus seemed to correspond to a small area containing the pulmonary ligament and aorta in adults.

Mesoesophagus and other fascial structures of the abdominal and lower thoracic esophagus: a histological study using human embryos and fetuses / 대한해부학회지

A term "mesoesophagus" has been often used by surgeons, but the morphology was not described well. To better understand the structures attaching the human abdominal and lower thoracic esophagus to the body wall, we examined serial or semiserial sections from 10 embryos and 9 fetuses. The esophagus was initially embedded in a large posterior mesenchymal tissue, which included the vertebral column and aorta. Below the tracheal bifurcation at the fifth week, the esophagus formed a mesentery-like structure, which we call the "mesoesophagus," that was sculpted by the enlarging lungs and pleural cavity. The pneumatoenteric recess of the pleuroperitoneal canal was observed in the lowest part of the mesoesophagus. At the seventh week, the mesoesophagus was divided into the upper long and lower short parts by the diaphragm. Near the esophageal hiatus, the pleural cavity provided 1 or 2 recesses in the upper side, while the fetal adrenal gland in the left side was attached to the lower side of the mesoesophagus. At the 10th and 18th week, the mesoesophagus remained along the lower thoracic esophagus, but the abdominal esophagus attached to the diaphragm instead of to the left adrenal. The mesoesophagus did not contain any blood vessels from the aorta and to the azygos vein. The posterior attachment of the abdominal esophagus seemed to develop to the major part of the phrenoesophageal membrane with modification from the increased mass of the left fetal adrenal. After postnatal degeneration of the fetal adrenal, the abdominal esophagus might again obtain a mesentery. Consequently, the mesoesophagus seemed to correspond to a small area containing the pulmonary ligament and aorta in adults.