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The contribution of the inferior thyroid artery to the blood supply of the human trachea. Surg Gynecol Obstet. Esophagectomy without thoracotomy:is there a risk of intramediastinal bleeding?
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In the thoracoscopic approach, however, precise dissection of this part of the anatomy is possible by the augmentation and the precision of the imaging obtained [ 18 , 25 — 27 ]. Moreover, when performing an upper mediastinal lymphadenectomy, indications for it and even its extension are still not well established; moreover, its terminology classification is not completely standardized [ 6 — 15 , 23 , 24 , 28 ]. Minimally invasive esophagectomy is increasingly performed [ 25 — 27 ], and definition of surgical anatomy is important to accomplish.
In a previous study, we have described and called meso-esophagus the fascia and structures between the aorta and the infracarinal esophagus [ 1 ].
In this retrospective and prospective study of minimally invasive esophagectomy MIE in prone position, our aim was to describe the surgical anatomy of the upper mediastinum, and the landmarks and structures that have to be divided, in order to perform an adequate esophagectomy and lymphadenectomy.
The numbers of complications recorded as a consequence of this dissection, especially palsy of the recurrent laryngeal nerves, can be considered high and may have important consequences for the numbers of respiratory infections [ 29 , 30 ]. This resulted in a technical annotation on how to perform this challenging dissection in a safe way with the purpose of decreasing the morbidity. In order to perform the MIE in prone position, first the dissection of the esophagus, periesophageal tissues and subcarinal lymph nodes is performed, which is followed by the dissection of the upper mediastinum.
Dissection starts after the opening of the pleura on both sides with division of the vascular structures necessary to free the esophagus and is followed by careful dissection of the esophagus from the pars membranacea of the trachea. After this, if indicated, extended or total lymphadenectomy on the right side is performed followed by lymphadenectomy on the left side. Bronchial arteries are considered an important vascular and nutritional supply of the esophagus, trachea, bronchi and lungs, but their anatomy shows a great variability.
Variations in arterial supply are frequent described but also its terminology for example, high on the right side arterial branches coming from the neck connects with what is called by some esophageal surgeons the tracheoesophageal artery, while by pulmonary surgeons it is called the upper bronchial artery.
It originates from the right subclavian artery, runs ventrocaudally and sends branches to trachea and esophagus.
Background of Lymph Node Dissection for Squamous Cell Carcinoma of the Esophagus
During the operation, it should be carefully observed which vessels are going to the right and which are going to the left side of the esophagus. Arterial supply of the esophagus, trachea and principal bronchi is common; therefore, it is important to know which arteries should be divided and which preserved during dissection. Important is to preserve as much as possible of the arterial supply to the trachea and bronchi.
On the left side, at least one of the two branches should be preserved, with a preference for the superior bronchial artery with only branches to the trachea and bronchus.
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If only one exists, only the branches to the esophagus should be divided. Failure to do so may result in impairment of the postoperative respiratory function [ 19 , 20 ]. In this study, we had been able to preserve at least one bronchial artery or the branch of one going to the trachea in all patients.
This is important because these bronchial arteries are not terminal arteries, having many anastomoses in front of the tracheobronchial tree. In this study, the lymphadenectomy was performed separately, upper paratracheal 2R and 2L and lower paratracheal lymph node stations 4R and 4L in all patients in the retrospective study and in two patients in the prospective study, while in three patients in the prospective study this was done en bloc. This is a new approach to perform this type of lymphadenectomy and may be performed because of the visibility obtained during thoracoscopy.
The majority of the Japanese surgeons perform a three-field lymphadenectomy for middle and high in the esophagus located SCC, whereas the common procedure in the WW is to perform a two-field LN. In Japan, surgeons initiated the intervention with bilateral neck dissection, with control of both recurrent laryngeal nerves. During lymphadenectomy, preservation of the recurrent nerves is essential and careful dissection, especially on the left side, is important in avoiding a traumatic dissection and traction.
No damage of the recurrent laryngeal nerves was seen during the operations in this series, but clinically two palsies and one temporary neuropraxia of the left nerve were observed. Moreover, the numbers of pulmonary infections and anastomotic leakages in the neck are according to the observed in the TIME trial [ 25 ]. The use of neoadjuvant chemoradiotherapy does not harm the dissection, and the lymph nodes numbers obtained in this area are considered adequate even if the neoadjuvant chemoradiotherapy is known to reduce the numbers of total lymph nodes removed, possibly having more prognostic than therapeutic value [ 22 , 31 ].
Questions arise whether the prone position of the patient will generate all these advantages in comparison with the thoracoscopy in lateral position.
Kawakubo et al. They described this position as optimal because the lateral decubitus and prone positions can be achieved by rotating the surgical table. They found that if the prone position is adequate for dissection of the middle and lower mediastinum, then the lateral position is better for the upper mediastinum, especially around the left recurrent laryngeal nerve. Moreover, to perform the thoracic phase of the robot-assisted esophageal resection RAMIE the patient is also positioned from the decubitus into this semiprone position in order to work optimally with the robot and at the same time visualize correctly the upper part of the mediastinum [ 33 ].
The pertaining comprehensive description is significant. First, it defines the anatomical structures and landmarks for the optimal esophageal resection and lymphadenectomy if indication exists for this on the upper mediastinum.
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