Extensive mediastinal lymphadenectomy during minimally invasive esophagectomy: optimal results from a single center

Recent advances in thoracoscopic surgery have made it possible to perform esophagectomy with conventional lymphadenectomy (paraesophageal and subcarinal lymph node dissection) using minimally invasive techniques. However, minimally invasive esophagectomy (MIE) combined with extensive lymphadenectomy along the recurrent laryngeal nerves (RLN) has remained technically challenging for thoracic surgeons. The aim of this study was to examine the safety and efficacy of extensive lymphadenectomy when compared to conventional lymphadenectomy during MIE.

We retrospectively reviewed data from a cohort of 147 consecutive patients who underwent MIE for esophageal cancer (EC) over a 3-year period at our institution. During thoracoscopic esophagectomy, extensive lymphadenectomy along the RLN was performed on 76 patients from June 2009 to December 2010 (group A), while 71 patients underwent conventional lymphadenectomy from June 2008 to May 2009 (group B) and were enrolled as historical controls. Clinical characteristics including patient demographics, operation features, and the rate and type of complications were recorded for both groups. The number of dissected lymph nodes and the number of patients with nodes positive for cancer on histological examination were determined for both groups. Statistical analysis was used to identify differences between the two groups.

All patients underwent thoracoscopic esophagectomy without conversion to open thoracotomy. Patient demographics and operation features were similar between the two groups. Of the 76 patients that underwent extensive lymphadenectomy there were 13 patients (17.11%) who were RLN positive, which resulted in upstaging of TNM in 5 patients (6.58%). The overall incidence of postoperative complications (42.10% versus 39.47%, p = 0.742) and permanent recurrent laryngeal nerve palsy (1.32% versus 0%, p = 0.517) was similar between the two groups.

Extensive mediastinal lymphadenectomy during minimally invasive esophagectomy is a feasible procedure for EC patients. It is technically safe and oncologically adequate in experienced hands, and improves the accuracy of tumor staging. Further study is required to discuss its long-term prognostic value for esophagus cancer patients.