Left-primary & right-auxiliary operation mode in mediastinoscope-assisted radical esophagectomy.

BACKGROUND: Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is the most minimally invasive esophagectomy procedure. It is a more challenging procedure and more difficult to be popularized than thoracoscopic surgery. We developed a new MATHE operation mode that provides a clearer visual field and makes the procedures simpler. METHODS: A total of 80 patients with esophageal cancer were divided into a control group (n = 29) and a study group (n = 51). The control group underwent classic MATHE, while the study group received modified MATHE. We compared the two groups on operation time; intraoperative blood loss; blood transfusion amount; incidence rate of lung infection, recurrent laryngeal nerves (RLNs) injury, chylothorax, and anastomotic leakage; and upper mediastinal lymph node dissection. RESULTS: The study group was significantly better than the control group in operation time (271.78 min vs. 322.90 min, p < 0.05), intraoperative blood loss (48.63 mL vs. 68.97 mL, p < 0.05), and left paratracheal lymph node (No. 4L) dissection rate (88.24% vs. 24.14%, p < 0.01). No significant differences were identified in the incidence rate of anastomotic leakage, lung complications, or RLNs injury between the two groups. CONCLUSION: The modified MATHE is easier to perform. Modified MATHE is significantly superior to classic MATHE in operation time, intraoperative blood loss, and upper mediastinal lymph node dissection rate.

Novel Mediastinoscope-Assisted Minimally Invasive Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis.

BACKGROUND: Minimally invasive surgery is an expanding field of surgery that has replaced many open surgical techniques. Surgery remains a cornerstone in the treatment of esophageal cancer, yet it is still associated with significant morbidity and technical difficulties. Mediastinoscope-assisted esophagectomy is a promising technique that aims to decrease the surgical burden and enhance recovery. METHODS: PubMed, MEDLINE, and EMBASE databases were searched for publications on mediastinoscope-assisted esophagectomies for esophageal cancer. The primary endpoint was a postoperative anastomotic leak, while secondary endpoints were assessment of harvested lymph nodes (LNs), blood loss, chyle leak, hospital length of stay (LOS), operative (OR) time, pneumonia, wound infection, mortality, and microscopic positive margin (R1). The pooled event rate (PER) and pooled mean were calculated for binary and continuous outcomes respectively. RESULTS: Twenty-six out of the 2274 searched studies were included. The pooled event rate (PER) for anastomotic leak was 0.145 (0.1144; 0.1828). The PERs for chyle leak, recurrent laryngeal nerve injury/hoarseness, postoperative pneumonia, wound infection, early mortality, postoperative morbidity, and microscopically positive (R1) resection margins were 0.027, 0.185, 0.09, 0.083, 0.020, 0.378, and 0.037 respectively. The pooled means for blood loss, hospital stay, operative time, number of total harvested LNs, and number of harvested thoracic LNs were 159.209, 15.187, 311.116, 23.379, and 15.458 respectively. CONCLUSIONS: Mediastinoscopic esophagectomy is a promising minimally invasive technique, avoiding thoracotomy, patient repositioning, and lung manipulation; thus allowing for shorter surgery, decreased blood loss, and decreased postoperative morbidity. It can also be reliable in terms of oncological safety and LN dissection.

Subxiphoid Mediastinoscopic Autonomous Double Fenestration.

The coexistence of pleural and pericardial effusions in frail patients with or without confirmed neoplasia necessitates the use of a minimally invasive technique that has a minor impact on the patient's general status and allows for fast fluid evacuation and biopsy sampling if necessary. We present a subxiphoid mediastinoscopic autonomous (simultaneous noncommunicating) double fenestration approach for these patients with both diagnostic and therapeutic advantages in selected cases. Using the mediastinoscope alone through the subxiphoid incision can considerably reduce the duration of operation, allow for fluid evacuation, and significantly alleviate the patient's symptoms. This method enables the sampling of pleural and pericardial fluids and targeted tissue, if necessary.

Transhiatal chest drainage in mediastinoscope and laparoscope-assisted esophagectomy for esophageal cancer: a retrospective study.

BACKGROUND: Mediastinoscope and laparoscope-assisted esophagectomy for esophageal cancer occasionally causes postoperative accumulation of pleural effusion despite the preservation of the mediastinal pleura. Transhiatal chest drainage has been reported to be useful for thoracic esophagectomy; however, its use in mediastinoscope and laparoscope-assisted esophagectomy remains unelucidated. This study aimed to evaluate the effectiveness and safety of transhiatal chest drainage in mediastinoscope and laparoscope-assisted esophagectomy. METHODS: This retrospective study included patients who underwent mediastinoscope and laparoscope-assisted esophagectomy for esophageal cancer from 2018 to 2021. Transhiatal chest drainage involved the insertion of a 19-Fr Blake® drain from the abdomen to the left thoracic cavity through the hiatus. We assessed its effectiveness and safety by the daily drainage output, accumulation of postoperative pleural effusion, frequency of postoperative thoracentesis, and other complications. The drainage group comprising 24 patients was compared with the non-drainage group comprising 13 patients, in whom a transhiatal chest drainage tube was not placed during mediastinoscope and laparoscope-assisted esophagectomy. RESULTS: The median daily output of the transhiatal chest drainage was 230 mL on day 1, 385 mL on day 2, and 313 mL on day 3. The number of patients with postoperative pleural effusion was significantly reduced from 10/13 (76.9%) in the non-drainage group to 4/24 (16.7%) in the drainage group (p = 0.001). The frequency of thoracentesis in the drainage group was significantly lower than that in the non-drainage group (p = 0.002). There were no significant differences in the occurrence of other postoperative complications. CONCLUSIONS: Transhiatal chest drainage could evacuate pleural effusion effectively and safely after mediastinoscope and laparoscope-assisted esophagectomy.

[Mediastinoscope-Assisted Transhiatal Esophagectomy for Esophageal Gastrointestinal Stromal Tumor(GIST)-A Case Report].

A 71-year-old woman was referred to our hospital because of an esophageal submucosal tumor. Esophagogastroduodenoscopy revealed a submucosal tumor of 40×25 mm with ulceration in the lower thoracic esophagus and endoscopic ultrasonographic fine needle aspiration histology showed KIT(+), CD34(+), DOG-1(+), desmin(-), S-100 protein(-). We diagnosed esophageal GIST and performed mediastinoscope-assisted transhiatal esophagectomy with gastric tube reconstruction. Histopathological findings showed c-kit(+), Ki-67 index of 8%, and middle-risk GIST by the modified- Fletcher classification. Mediastinoscope-assisted transhiatal esophagectomy is useful in terms of shortening total operative time and preventing respiratory complications because it does not require thoracic operation, one-lung ventilation, or repositioning. Subtotal esophagectomy under a mediastinal approach could secure a margin for resection, which may reduce the risk of recurrence, and could be one of the surgical procedures for esophageal GIST.

[Mediastinoscopic Radical Esophagectomy for Esophageal Cancer in a Patient with Chronic Pulmonary Infection].

Mediastinoscopic esophagectomy(ME)is a minimally invasive approach without thoracotomy and pulmonary atelectasis during surgery. Here, we report the case of a 67-year-old patient who was successfully treated with thoracic esophageal cancer and severe chronic pulmonary infection using ME and home enteral nutrition therapy. Esophageal cancer patients with severe lung dysfunction have a risk of postoperative pneumoniae. ME could be a promising procedure for patients with severe lung dysfunction. We highlight the usefulness of ME as a safe approach to avoid pulmonary complications.

A Case-Control Study on the Therapeutic Effect of Mediastinoscope-Assisted and Thoracoscope-Assisted Esophagectomy.

Objective. To compare the clinical efficacies of mediastinoscope-assisted and thoracoscope-assisted esophagectomy. Materials and Methods. Seventy-six patients with esophageal cancer who underwent minimally invasive esophagectomy at the General Hospital of Ningxia Medical University between June 2015 and January 2019 were retrospectively evaluated. Among them, 28 patients underwent mediastinoscope-assisted transhiatal esophagectomy (MATHE), and 48 received thoracoscope-assisted transthoracic esophagectomy (TATTE). The perioperative clinical data and follow-up data of the 2 groups were compared. Results. All operations were successful in both groups. MATHE was favorable in terms of operation time, intraoperative blood loss, drainage volume 3 days after surgery, postoperative hospital stay, and hypoproteinemia (P < .05). Lymph node dissections were less than those in the TATTE (P < .05). No significant differences in long-term postoperative complications and survival rate were found between the 2 groups (P > .05). Conclusion. MATHE has the advantages of minimal trauma, shorter operation time, less intraoperative blood loss, and faster recovery. More adequate tumor clearance in terms of lymph node dissection can be achieved with TATTE. However, the comparison of survival rates between the 2 groups is similar.

Comparison of transhiatal esophagectomy using a mediastinoscope with transhiatal esophagectomy by the classic method.

BACKGROUND: This study aimed to evaluate the results of transhiatal esophagectomy using a mediastinoscope in comparison with conventional transhiatal esophagectomy. METHODS: Sixty-two esophageal cancer patients who were referred to our thoracic surgery clinic between April 2015 and March 2017, and met the inclusion criteria, were randomly divided into two groups of 31 each. In the first group, patients were operated on by conventional transhiatal esophagectomy. In the second group, only release of the thoracic esophagus through a neck incision (mediastinal esophagolysis) was performed using a mediastinoscope. The other surgical procedures were similar to those in the first group. RESULTS: The mean age of the patients was almost the same in both groups (57.7 years in the first group versus 56.7 years in the second group). There was no significant difference in sex ratio. The mean volume of blood loss during the operation, mean operative time, and intensive care unit stay as well as cardiopulmonary complications and early postoperative complications were lower in the group that had esophagectomy using a mediastinoscope, and the number of resected mediastinal lymph nodes was greater. CONCLUSION: Based on the results of this study, it can be expected that use of a video mediastinoscope for esophagolysis of the thoracic esophagus in a transhiatal esophagectomy procedure is safe and it will reduce the morbidity and mortality in these patients.

[Clinical study of cervical necrotizing fasciitis accompanied with descending necrotizing mediastinitis treated with cervical double parallel incision combined with mediastinoscope or thoracoscope].

Objective: To summarize the experience of applying cervical double parallel incision combined with mediastinoscope or thoracoscope in the treatment of cervical necrotizing fasciitis (CNF) accompanied with descending necrotizing mediastinitis (DNM), so as to provide a reference for clinical practice. Methods: The clinical data of six patients with CNF accompanied with DNM who were admitted to the Department of Stomatology and the Department of Otolaryngology Head and Neck Surgery, The First People's Hospital of Changzhou from September 2014 to September 2018 were retrospectively analyzed. All of the six patients were confirmed by CT of neck and chest, among whom there were two males and four females aged from 48 to 73. Three patients were treated with cervical double parallel incision combined with mediastinoscope to be combined with cervical and thoracic drainage under general anesthesia while the other three with cervical double parallel incision combined with thoracoscope to be combined cervical and thoracic drainage under general anesthesia. The CT of neck and chest as well as infectious indicators including hematology, C-reactive protein (CRP) and procalcitonin (PCT) were reexamined during the postoperative period. Results: The cervical and thoracic combined drainage was unobstructed in all of the six patients, no secondary surgery was performed, and the infectious indicators gradually decreased. All patients had off-bed activities on the first day after the operation, were all cured and discharged after an average of 21 days (16 to 36 days) in hospital and followed up for an average of 18 months (4 to 30 months) after the operation. None of them experienced infection relapse, and they were all satisfied with the appearance of the cervical incision. Conclusions: Cervical double parallel incision combined with mediastinoscope or thoracoscope for the treatment of CNF accompanied with DNM has the advantages of complete drainage, small trauma, excellent efficacy and aesthetic operative area, thus being deserved to be clinically popularized.

[A Case of Esophageal Gastrointestinal Stromal Tumor Resected by Mediastinoscope-Assisted Transhiatal Esophagectomy].

A 58-year-old man was followed up for esophageal submucosal tumor at our hospital. Esophagogastroduodenoscopy showed the tumor was located on the left side of the thoracic esophagus and had gradually increased in size. Endoscopic ultrasonography revealed an 18×11.5mm hypoechoic tumor connected to the fourth layer of the esophagus and fine needle biopsy revealed c-kit(+), desmin(-)and a-SMA(-). Double-contrast barium study detected a tumor of diameter 20 mm in the middle-lower thoracic esophagus. We diagnosed an esophageal gastrointestinal stromal tumor(GIST)and performed mediastinoscope-assisted transhiatal esophagectomy with gastric tube reconstruction. The maximum tumor diameter was 25mm and pathological evaluation showed c-kit(+), Ki-67 index of less than 5%, and low-risk GIST by the Fletcher classification. Mediastinoscope-assisted transhiatal esophagectomy might be a useful approach for esophageal GIST, because dissection along the esophagus can be performed without thoracotomy.

Perioperative outcomes of single-port mediastinoscope-assisted transhiatal esophagectomy for thoracic esophageal cancer.

We developed an en bloc lymphadenectomy method in the upper mediastinum with a single-port mediastinoscopic cervical approach. This study was designed to evaluate the safety and efficacy of single-port mediastinoscope-assisted transhiatal esophagectomy for thoracic esophageal cancer. The perioperative outcomes of 60 patients with thoracic esophageal cancer who underwent this operation between March 2014 and June 2016 were retrospectively analyzed. The upper mediastinal dissection including lymphadenectomy along the left recurrent laryngeal nerve, using a left cervical approach, was performed with a single-port mediastinoscopic technique, which was used to improve the visibility and handling in the deep mediastinum around the aortic arch. The lymphadenectomy along the right recurrent laryngeal nerve was performed under direct vision using a right cervical approach. Bilateral cervical approaches were followed by hand-assisted laparoscopic transhiatal esophagectomy with en bloc lymphadenectomy in the middle and lower mediastinum. Tumors were mainly located in the middle thoracic esophagus (n = 33), and most tumors were squamous cell carcinoma (n = 58). Pretreatment diagnoses were stage I, 19; II, 13; III, 24; IV, 4. Preoperative chemotherapy was performed for 40 patients. The median operation time and blood loss were 363 minutes and 235 mL, respectively. There were two patients who underwent conversion to thoracotomy. Perioperative complications were evaluated and graded according to the Clavien-Dindo (CD) and the Esophagectomy Complications Consensus Group (ECCG) classifications. Postoperatively, pneumonia was observed in four patients (CD, Grade II, 2; Grade IIIb, 2), although vocal cord palsy was more frequent (ECCG, Type I, 12; Type III, 8). The median number of thoracic lymph nodes resected was 21, and the R0 resection rate was 95%. Single-port mediastinoscope-assisted transhiatal esophagectomy is feasible, in terms of perioperative outcomes, for a radical surgery for thoracic esophageal cancer, although its safety needs to be further demonstrated.

Single-Port Mediastinoscopic Lymphadenectomy Along the Left Recurrent Laryngeal Nerve.

We herein describe a single-port mediastinoscopic method for upper mediastinal dissection in esophageal cancer surgery. After the left cervical incision and lymphadenectomy, a Lap-Protector (Hakko, Tokyo, Japan) was inserted into the wound and an EZ Access port (Hakko) was attached. Esophageal mobilization with en bloc lymphadenectomy along the left recurrent laryngeal nerve was then performed using a port-in-port technique with conventional flexible laparoscopy. Carbon dioxide insufflation expanded the intramediastinal space, and minute structures in the deep mediastinum around the aortic arch, such as nerves, bronchial arteries, and lymphatic vessels, were clearly visualized, allowing lymphadenectomy to be safely and carefully performed along the nerve.

Clinical significance of mediastinoscope-assisted transhiatal esophagectomy in patients with esophageal cancer.

PURPOSE: Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is a useful surgical procedure in esophageal cancer patients who have limited indications for transthoracic operations due to preoperative complications. METHODS: In the last 10 years, 63 patients underwent MATHE at our department. We examined the clinical data of these patients and assessed the indications, postoperative outcomes, and prognostic factors of MATHE. RESULTS: The 5-year overall survival (OS) rate was 53.4 %, and disease-free survival (DFS) rate was 66.0 %. Postoperative complications were observed in 22 cases (34.9 %), and recurrent disease occurred in 17 cases (27.0 %). On univariate analyses of OS, location of the tumor, tumor depth, lymph node metastasis, clinical stage, simultaneous resection of other organs, postoperative pneumonia, and blood loss were significant prognostic factors. On multivariate analyses, location of the tumor and lymph node metastasis were independent prognostic factors of OS. On univariate analyses, location of the tumor, tumor depth, lymph node metastasis, clinical stage, and blood loss were significant prognostic factors of DFS, while on multivariate analyses of DFS, lymph node metastasis and blood loss were independent prognostic factors. CONCLUSION: MATHE is a useful procedure for the middle to lower thoracic esophageal cancer patients without clinical lymph node metastasis with serious complications who were unable to undergo thoracotomy.

Endoscopic transesophageal biopsy in the posterior mediastinum using submucosal tunneling technology and novel homemade instruments.

BACKGROUND/AIMS: This animal study was performed to evaluate the feasibility and safety of endoscopic transesophageal biopsy by using submucosal tunneling technology novel homemade instruments in the posterior mediastinum. METHODOLOGY: In six survival pigs, a mid-esophageal mucosal incision and a 10-cm submucosal tunnel was created. The endoscope attached to homemade decompression tube was passed through the muscular layers into the posterior mediastinal space. The mediastinal compartment, lung, descending thoracic aorta, vertebra, and exterior surface of the esophagus will be identified, and mediastinal living tissue as lymph node biopsy will also be accomplished. During two survival weeks, blood test and temperature monitoring and chest radiograph and endoscopic examination were performed. RESULTS: The procedure was successfully completed in all six pigs. Mediastinal structures could be identified without difficulty by the transesophageal tunneling approach. Tissue as lymph nodes and pleural biopsy under direct visualization were easily accomplished. One pig died after operation due to an unexplained pneumothorax. At necropsy, apparent atelectasis was noted in the right lobe. After applying homemade drainage tube attached to the syringe, one pig with pneumothorax soon had restoration. There were no apparent ill effects in the survival pigs. CONCLUSIONS: Endoscopic transesophageal biopsy in the posterior mediastinum using a novel tunneling technology can provide excellent visualization of mediastinal structures. These procedures could be performed safely in pigs with short-term survival. Further study about immediate complications will be needed with a larger sample size and longer survival time.

Cervical and retrosternal approach to the left thoracic cavity using a flexible endoscope.

OBJECTIVES: Mediastinoscopy remains the gold standard for surgical exploration of the mediastinum. The use of this approach to access the left thoracic cavity could be complicated by vascular or neurological lesion. The aim of this experimental work was to describe a new approach to the left thoracic cavity through a cervical incision and retrosternal space using a flexible endoscope as a unique instrument. METHODS: We conducted an experimental work on 12 refrigerated and non-embalmed cadavers. Through a cervical incision, we dissected the retrosternal space to the level of Louis angle and then opened the left mediastinal pleura. We introduced the flexible endoscope through this pleural window into the left thoracic cavity. We defined three distances between the borders of the endoscope entry point, the phrenic nerve and the mammary artery: Distance 1: between the medial edge of the endoscope entrance point and the medial edge of the left mammary artery, Distance 2: between the top of the endoscope entrance point and the penetration of phrenic nerve in the left thoracic cavity and Distance 3: between the lateral edge of the entrance point of the endoscope and the medial edge of the phrenic nerve. To measure these distances, we performed a left postero-lateral thoracotomy. RESULTS: Procedure was successfully executed in 10 of the 12 studied subjects. The mean distances 1, 2 and 3 were 17.1 (range 2-40), 39.5 (17-80) and 19.1 mm (10-40), respectively. The minimal Distance 1 was in two subjects 0.2 and 0.5 mm. CONCLUSIONS: This approach avoids the para-aortic and supra-aortic zone; this access could be less dangerous than already described access techniques. Despite the limits of our work on cadavers, and the two failures in the application of the access, the mean distances we calculated show the potential safety of our approach concerning the phrenic nerve and the mammary artery. An experimental protocol on living animals is currently underway with the aim of confirming the safety of our approach.

Endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of intrathoracic lymphadenopathy in patients with extrathoracic malignancy: A study in a tuberculosis-endemic country.

BACKGROUND: Mediastinal lymphadenopathy in patients with malignancy is a common clinical problem in tuberculosis-endemic countries. The recently developed endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) procedure enables direct and real-time aspiration of mediastinal and hilar lymph nodes. The aim of the study was to determine the efficacy of EBUS-TBNA results in the evaluation of mediastinal lymph nodes in patients with extrathoracic malignancy. MATERIALS AND METHODS: Retrospective analysis was performed in 40 patients with proven (n = 38) or suspected metastasis of unknown origin (n = 2) who underwent EBUS-TBNA between July 2007 and August 2011. RESULTS: All 40 patients successfully underwent EBUS-TBNA and no complications were observed. EBUS-TBNA diagnosed metastasis from extrathoracic malignancy in 16 (40%) patients, new lung cancer in 2 (5%), reactive lymph node in 9 (22.5%), sarcoidosis in 5 (12.5%), anthracosis in 5 (12.5%) and tuberculosis in 3 (7.5%). The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of EBUS-TBNA based on the number of patients were 90.0%, 100%, 100%, 90.9% and 95.0%, respectively. In 33 patients with available data of fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) scans, the diagnostic sensitivity, specificity, PPV, NPV and accuracy of PET/CT scan based on the number of patients were 94.7%, 35.7%, 66.6%, 83.3%, and 69.6%, respectively. The association between larger lymph node size on EBUS and malignancy of lymph node sample on pathological examination was statistically significant (P = 0.018). CONCLUSIONS: EBUS-TBNA is a sensitive, specific, minimally invasive and a safe procedure for the diagnosis of mediastinal and hilar metastasis from extrapulmonary malignancy in a tuberculosis-endemic country.

Video-axillaroscopy: a new mini-invasive technique for surgical exploration of the axillary region.

Subclavicular lymph nodes are one of the deeper lymph node groups of the lymphatic network located in the axillary region. As its location is surrounded by vessels and nerves, biopsy of subclavicular lymph nodes is not possible without eye control. We describe a new, mini-invasive technique for accessing the thoracic outlet region. Video-axillaroscopy is a reliable mini-invasive technique for targeting biopsies of lymph nodes in the axillary region. It is safer and more accurate than radio-guided techniques. Exploration of this region might benefit treatment of lymphoma and breast cancer and applications might emerge for thoracic outlet syndromes.