Surgical anatomy of the upper esophagus related to robot-assisted cervical esophagectomy.

Robot-assisted cervical esophagectomy (RACE) enables radical surgery for tumors of the middle and upper esophagus, avoiding a transthoracic approach. However, the cervical access, narrow working space, and complex topographic anatomy make this procedure particularly demanding. Our study offers a stepwise description of appropriate dissection planes and anatomical landmarks to facilitate RACE. Macroscopic dissections were performed on formaldehyde-fixed body donors (three females, three males), according to the surgical steps during RACE. The topographic anatomy and surgically relevant structures related to the cervical access route to the esophagus were described and illustrated, along with the complete mobilization of the cervical and upper thoracic segment. The carotid sheath, intercarotid fascia, and visceral fascia were identified as helpful landmarks, used as optimal dissection planes to approach the cervical esophagus and preserve the structures at risk (trachea, recurrent laryngeal nerves, thoracic duct, sympathetic trunk). While ventral dissection involved detachment of the esophagus from the tracheal cartilage and membranous part, the dorsal dissection plane comprised the prevertebral compartment harboring the thoracic duct and right intercosto-bronchial artery. On the left side, the esophagus was attached to the aortic arch by the aorto-esophageal ligament; on the right side, the esophagus was bordered by the azygos vein, right vagus nerve, and cardiac nerves. The stepwise, illustrated topographic anatomy addressed specific surgical demands and perspectives related to the left cervical approach and dissection of the esophagus, providing an anatomical basis to facilitate and safely implement the RACE procedure.

Outcome of a Step-Up Treatment Strategy for Chyle Leakage After Esophagectomy.

BACKGROUND: Thoracic chyle leakage is a major complication of esophagectomy. In this study our treatment strategy for chyle leakage was evaluated and its risk factors were identified. METHODS: According to the Esophagectomy Complications Consensus Group recommendations, chyle leakage was classified as follows: I, enteric dietary modifications; II, total parenteral nutrition (TPN); and III, interventional or surgical therapy. It was graded as A, less than 1,000 mL per day; or B, more than 1,000 mL per day. In our protocol, chyle leakage less than 500 mL per day was treated with a low-fat diet; more than 1,000 mL per day, with TPN, and 500 to 1,000 mL per day, with a low-fat diet or TPN depending on whether the chyle leakage was increasing or decreasing at diagnosis and the clinical condition. Surgery was reserved for refractory leakages. RESULTS: In total 371 patients were included. Chyle leakage incidence was 21%, consisting of 51% grade A and 49% grade B leakage. Chyle leakage severity was associated with length of stay (grade A, median 17 days versus B, 25 days; p = 0.006). Independent risk factors were a transthoracic approach (odds ratio 4.8, p = 0.002), neoadjuvant chemoradiotherapy (odds ratio 2.6, p = 0.002), and preoperative body mass index (exp(B) 0.92, p = 0.031). Treatment consisted of low-fat diet in 53%, TPN in 37%, and surgery in 10% of the patients. Low-fat diet and TPN successfully treated 87% of chyle leaks. Chyle leakages treated by TPN first were significantly more severe compared with those treated first by low-fat diet, and were significantly associated with electrolyte deficiencies, increased complication severity, and length of stay, but not with 90-day mortality. CONCLUSIONS: A step-up treatment strategy, starting with dietary modifications, solved nearly 90% of chyle leaks conservatively. A minority of chyle leaks required surgery.

New insights into the surgical anatomy of the esophagus.

Implementation of (robot assisted) minimally invasive esophagectomy and increased knowledge of the relation between the autonomic nervous system and the immune response have led to new insights regarding the surgical anatomy of the esophagus. First, two layers of connective tissue were identified; the aorto-esophageal and aorto-pleural ligaments that separate the peri-esophageal compartment, containing vagus nerves, carinal lymph nodes and trachea, from the para-aortic compartment; containing thoracic duct and azygos vein. Second the surgical anatomy of the pulmonary vagus nerve branches has been described in detail. Based on the hypothesis that sparing the vagal nerve branches may be important a method to spare the pulmonary branches of the vagus nerve during thoracoscopic esophagectomy was validated in a cadaver study. Further studies will now investigate the impact of these new insights in the surgical anatomy of the esophagus in clinical practice.