Can mediastinoscopic esophagectomy be a choice of curative surgery? From the viewpoint of the short term outcomes: a clinical practice review
Introduction
Esophagectomy has been the mainstay of treatment modalities for esophageal cancer. The optimal surgical approach has been discussed so far; which of the two, the non-transthoracic or transthoracic approach, is superior has been the point of the discussion (1-3). The former approach is associated with reduced pulmonary complications and mainly favored by American surgeons (4). However, the conventional non-transthoracic esophagectomy is performed mainly by transhiatal approach and omits mediastinal lymph node dissection. Therefore, non-transthoracic esophagectomy has been regarded as an insufficient surgical procedure especially for esophageal squamous cell carcinoma (3,5).
Nowadays, the emergence and the prevalence of the video-assisted surgical procedure have greatly altered the above-mentioned discussion. Minimally invasive transthoracic esophagectomy using video assisted and/or surgical robot has greatly reduced the surgical mortality of esophageal cancer (6,7). As for non-transthoracic esophagectomy, a video-assisted approach via a cervical skin incision enabled the retrieval of the upper mediastinal regional lymph nodes adjacent to the bilateral recurrent laryngeal nerves (8-10). It also enables the retrieval of subcarinal lymph nodes in the middle mediastinum. The non-transthoracic esophagectomy, combining the transcervical and transhiatal approaches, has been referred as mediastinoscopic esophagectomy. The mediastinoscopic esophagectomy retrieves the whole regional lymph nodes in the mediastinum and can be equally radical to the transthoracic McKeown’s esophagectomy (11-13). The mediastinoscopic esophagectomy is free from manipulations on the lungs or the thoracic wall and may have several advantages over the transthoracic esophagectomy. However, the narrow operative field of the mediastinoscopic esophagectomy may restrict the assistance from a second surgeon and, therefore, possible intraoperative injury on the adjacent vital organs such as great vessels or the bronchus cannot be easily managed.
Although the oncologic non-inferiority compared to the transthoracic surgery has been yet to be reported, studies on the safety and feasibility of the mediastinoscopic esophagectomy has been accumulated (9-13). The aim of this review is to highlight the short term outcomes of the mediastinoscopic esophagectomy.
Methods
Procedural outline of the mediastinoscopic esophagectomy
Earlier to 2010, mediastinoscopic upper mediastinal dissection using rigid endoscope combined with micro instruments has been reported (14,15). This kind of mediastinoscopic technique should be considered as non-radical esophagectomy without systemic dissection of the mediastinal regional lymph nodes. The first study introducing the use of single-incision laparoscopic surgery (SILS) port access device for cervical skin incision was reported by Parker et al. in 2011 and the majority of mediastinoscopic esophagectomy performed nowadays follow their method (8). Cervical approach is established via the SILS device placed on the left sided collar incision. While several surgeons use an additional right sided incision (16,17), most of the clinical studies introduced surgery with SILS device in the left. The mediastinum is inflated with 8 to 10 mmHg of carbon dioxide and a strongly magnified view, especially along the left recurrent laryngeal nerve, is provided by the mediastinoscope. Using two or three surgical ports in addition to the one for camera, the surgical dissections along the esophagus together with regional lymph nodes are performed in the upper and middle mediastinum. The surgical dissection in the cervical field is performed without video assisted approach. Subsequently or simultaneously, the transhiatal surgery is performed by laparoscopy and the dissection fields of the two approaches, namely transcervical and transhiatal, are reached to each other in the middle mediastinal field. In this way, the whole length of the esophageal and the three-field regional lymph nodes were dissected and the specimen was retrieved via a cervical incision or a mini-laparotomy.
Surgical indication
Considering the technical issues described afterwards, most previous studies excluded cases of clinical T4 and cases after definitive chemoradiotherapy. Meanwhile, patients with low pulmonary function regarded as border-line indication of one lung ventilation can be candidates of mediastinoscopic surgery.
Technical issues
Due to a narrow operative field, surgeons at starting-up phase can be confused by an unfamiliar surgical view. This would be the first and biggest issue in starting up mediastinoscopic esophagectomy. Great vessels, especially the azygos and the left pulmonary vein, are unexpectedly close to the esophagus and the regional lymph nodes. These structures as well as the membranous portion of the trachea and the bronchi can be severely injured if the operative field is stained with blood. However, if the operative field is maintained bloodless and clean, the dissections close to these adjacent vital structures can be guided by the view of the loose tissue space spontaneously exposed by the positive pressure inflation. To avoid hemorrhage, even a small one, leading to such intraoperative adverse events, surgeons should be familiar to the mediastinoscopic view of the field in detail, especially the location and the course of the tracheal arteries which gives numeral small branches to the esophagus and the regional lymph nodes (18,19).
Another issue is the susceptibility of the left recurrent nerve to mechanical injury. Its injury can be resulted from the unrecognizable compression or retraction of the nerve outside the narrow vision range of the mediastinoscope. To avoid this “unrecognizable” injury, a continuous intraoperative nerve monitoring system would be an effective device (20).
Possibly due to the publication bias, lethal intraoperative adverse events have been rarely reported in literature. Theoretically, non-transthoracic approach would be advantageous in reducing pulmonary complications due to its minimal invasiveness to the lungs or the thoracic wall. Our main concern would be whether or not the pulmonary complications can be minimized in the postoperative course of mediastinoscopic esophagectomy despite the above-mentioned technical issues.
Method of the literature review
In this review article, the safety of the mediastinoscopic esophagectomy is reviewed and discussed (estimated intraoperative blood loss, operative time and perioperative adverse events). Literature search was performed using PubMed with keywords “Mediastinoscope AND Esophagectomy” or “Transmediastinal AND Esophagectomy”. Excluded were the literatures on non-malignant esophageal disease, other fields of malignancy (e.g., lung cancer), case reports and non-clinical study (e.g., animal model, cadaver surgery). Studies on apparently non-radical esophagectomy such that nothing about the mediastinal lymph node retrieval was discussed were also excluded.
Results
Surgical outcomes
The search hit fourteen studies from twelve institutes reporting perioperative outcomes and four review articles. There were two author groups [Zhu et al. (21) and Gan et al. (22)] reporting two studies. Only newer one of the two from the same author group was included in this review of surgical outcomes. Tables 1,2 list literatures from the twelve author groups together with their perioperative outcomes (8,11-13,17,21-27).
Table 1
| First author (Ref.) | Year | Country | Number | PMID | Estimated blood loss (mL) | Operation time (min) | Conversion (%) |
|---|---|---|---|---|---|---|---|
| Wu (13) | 2021 | China | 29 | 34364369 | 114.2±17.5; 111.7±16.0 | 192.9±13.0; 246.8±6.9 | 0 |
| Zhu (21) | 2021 | China | 39 | 34659820 | NA | NA | 0 |
| Gan (22) | 2020 | China | 28 | 32035045 | NA | NA | 0 |
| Yamagata (23) | 2020 | Japan | 16 | 32962718 | 180 (30 to 665) | 489 (430 to 616) | 6.3 |
| Daiko (17) | 2020 | Japan | 16 | 32989533 | 50 (11 to 920) | 231 (157 to 429) | 6.3 |
| Egberts (24) | 2019 | Germany | 5 | 31039586 | 322† | NA | 0 |
| Nakauchi (26) | 2019 | Japan | 6 | 30074105 | 179 (118 to 409) | 805.5 (563 to 1,145) | 0 |
| Fujiwara (11) | 2017 | Japan | 60 | 28859387 | 235 (IQR, 120–375) | 363 (IQR, 331–412) | 3.3 |
| Okumura (27) | 2015 | Japan | 63 | 26252999 | 643±310 | 403±140 | 1.6 |
| Mori (12) | 2015 | Japan | 22 | 25809390 | 385 (30 to 890) | 524 (445 to 724) | 0 |
| Parker (8) | 2011 | USA | 8 | 21701920 | 119† (25 to 400) | 292† (194 to 375) | 0 |
| Bumm (25) | 1997 | Germany | 47 | 9327673 | NA | NA | 0 |
Studies by Zhu et al. (21) and Gan et al. (22) reported the perioperative outcome in individual two cohorts of patients undergoing mediastinoscopic esophagectomy. Estimated blood loss and operation time is described in mean ± standard deviation, median (range), or median (IQR). †, mean. NA, not available; IQR, interquartile range.
Table 2
| First author (Ref.) | Year | Number | Hospital stay (days) | Pulmonary complications, % | Laryngeal nerve palsy, % | Anastomotic failure, % | Chyle leak, % | In-hospital mortality, % |
|---|---|---|---|---|---|---|---|---|
| Wu (13) | 2021 | 29 | 7.6±1.3; 6.9±1.2 | 0 | 3.4 | 0 | 3.4 | – |
| Zhu (21) | 2021 | 39 | 12.00 (IQR, 11.00); 12.00 (IQR, 5.00) | 5.1 | 21 | 10 | 0 | – |
| Gan (22) | 2020 | 28 | NA | 0 | 14 | 11 | 0 | – |
| Yamagata (23) | 2020 | 16 | 16 (12 to 67) | 0 | 6.3 | 0 | 19 | – |
| Daiko (17) | 2020 | 16 | 15 (11 to 75) | 23 | 38 | 6.3 | 0 | – |
| Egberts (24) | 2019 | 5 | NA | 0 | 20 | 20 | 20 | – |
| Nakauchi (26) | 2019 | 6 | 17.5 (15 to 26) | 17 | 0 | 17 | 0 | – |
| Fujiwara (11) | 2017 | 60 | 31 (IQR, 25–48) | 6.7 | 33 | 15 | 0 | – |
| Okumura (27) | 2015 | 63 | NA | 9.5 | 12 | 22 | 0 | 1.6 |
| Mori (12) | 2015 | 22 | 18 (11 to 41) | 0 | 4.5 | 18 | 4.5 | – |
| Parker (8) | 2011 | 8 | 7 (5 to 16) | 13 | 25 | 13 | – | – |
| Bumm (25) | 1997 | 47 | NA | 19 | 13 | 34 | – | 4.3 |
Tracheal injury was reported in three studies with a frequency of 3.3–6.3% and no other type of intraoperative adverse event was reported. Conversion to transthoracic surgery was reported in four studies including the three cases with airway injury and one with cancer invasion to the adjacent vital organs. Median (or mean in several studies) estimated blood loss and operation time (median or mean) ranged 50 to 643 mL and 192.9 to 805.5 minutes, respectively. Compared to the historical data from the cohort of the patients undergoing transthoracic esophagectomy in Japan, the mediastinoscopic surgery seemed to be associated with reduced blood loss and equivalent operation time (7).
Postoperative course
The reported median length of postoperative stay ranged 6.9 to 31 days and recent studies rarely reported in-hospital mortality (Tables 1,2). High frequency (over 20%) of recurrent nerve palsy was reported in five institutes. However, a majority of the recent studies with sufficient number of patients reported the frequency of pulmonary complications as less than 10%. Although no convincing evidence has been obtained yet, this review study suggested a possible superiority of the mediastinoscopic esophagectomy in the reduction of pulmonary complications despite the high frequency of laryngeal nerve palsy in several institutes. Three studies reported that all cases of the laryngeal palsy in their series were temporary while only one case (6.7%) reported by Fujiwara et al. was persistent (11). As for anastomotic leakage and chyle leakage, there were no remarkable findings in this review.
Superiority in quality of life (QOL)
The QOL after mediastinoscopic esophagectomy was validated by Sugawara et al. using two European Organization for Research and Treatment of Cancer (EORTC) questionnaire module, namely QLQ-C30 and QLQ-OES18 (28). In the comparison with open transthoracic esophagectomy, mediastinoscopic esophagectomy provided significantly higher scores of QOL and also resulted in significantly fewer problems such as fatigue, general pain, insomnia and dry mouth. Moreover, the respiratory function was better maintained after mediastinoscopic esophagectomy compared to the open esophagectomy (29).
However, these studies were reported from the same single center and the comparison was the one with open transthoracic esophagectomy. To confirm QOL superiority of mediastinoscopic esophagectomy, a prospective study should provide a comparison to the transthoracic minimally invasive esophagectomy.
Strength and limitations
In this paper, no statistical analyses were performed. All of the reviewed studies were retrospective studies or non randomized prospective studies.
Conclusions
The mediastinoscopic radical esophagectomy has been demonstrated as safe and feasible. It is associated with less frequent postoperative pneumonia and improved postoperative quality of life when compared with the conventional transthoracic surgery. However, a prospective clinical trial providing the comparison of the two types of minimally invasive esophagectomy, thoracoscopic and mediastinoscopic, is needed to conclude the superiority of the mediastinoscopic esophagectomy.
Acknowledgments
Funding: None.
Footnote
Peer Review File: Available at https://dmr.amegroups.com/article/view/10.21037/dmr-22-63/prf
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://dmr.amegroups.com/article/view/10.21037/dmr-22-63/coif). The author has no conflicts of interest to declare.
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Cite this article as: Mori K. Can mediastinoscopic esophagectomy be a choice of curative surgery? From the viewpoint of the short term outcomes: a clinical practice review. Dig Med Res 2024;7:3.
