Transmediastinal approach for esophageal cancer: A new trend toward radical surgery

Abstract

Esophageal squamous cell carcinoma (ESCC), the most common histology of esophageal cancer in Japan and Asia, shows extensive mediastinal spread from an early stage. Therefore, transthoracic esophagectomy with extensive mediastinal lymphadenectomy, including in the upper mediastinum along the recurrent laryngeal nerves, is the gold standard of radical surgery for ESCC. Minimally invasive thoracoscopic esophagectomy has now become a standard option for ESCC. However, transhiatal esophagectomy is regarded as less invasive because it avoids thoracotomy. Yet, it is also considered less curative because it offers a limited surgical view and insufficient mediastinal lymphadenectomy even when conventional specialized mediastinoscopy is used. Recent clinical studies on radical esophagectomy without thoracotomy for ESCC have been reported from Japan. The introduction of novel minimally invasive techniques for the transcervical or transhiatal approach, such as single‐port or robotic surgical devices, have enabled transmediastinal radical esophagectomy for ESCC. This review focuses on the transmediastinal approach for esophageal cancer surgery, which employs minimally invasive techniques to reduce morbidity, and its application to radical surgery for ESCC.

Long-Term Trends in Respiratory Function After Esophagectomy for Esophageal Cancer

“…Recently, a novel technique called transmediastinal esophagectomy which combines mediastinoscopy-assisted transhiatal and transcervical approaches to allow extensive mediastinal LN dissection has been reported as a minimally invasive surgery for esophageal cancer. 23 Further clinical studies are warranted to reveal the clinical utility of this procedure for curability and reducing pulmonary complications.…”

Robotic esophagectomy: the evolution of open esophagectomy to current techniques and a review of the literature

“…The need for a cervical incision in transhiatal and McKeown esophagectomies can be morbid and increasingly prone to surgical site infections given that the rest of the procedure can be performed with minimally invasive or robotic fashion. In Japan, use of non-thoracic radical esophagectomy via the transcervical and transhiatal approaches with mediastinoscopic devices has attempted to address these problems resulting in feasible surgical outcomes [106][107][108][109] . This technique has been found to be especially helpful with squamous cell carcinoma of the esophagus, the most common histology of esophageal cancer in Japan and Asia, and often involving extensive mediastinal spread that can occur at an early age [107] .…”

“…In Japan, use of non-thoracic radical esophagectomy via the transcervical and transhiatal approaches with mediastinoscopic devices has attempted to address these problems resulting in feasible surgical outcomes [106][107][108][109] . This technique has been found to be especially helpful with squamous cell carcinoma of the esophagus, the most common histology of esophageal cancer in Japan and Asia, and often involving extensive mediastinal spread that can occur at an early age [107] . Additionally, esophagectomy with mediastinal lymph node dissection, including the area along the recurrent laryngeal nerves, has become the gold standard for radical surgical resection, however the view achieved with standard cervical incisions has been limited [107] .…”

“…This technique has been found to be especially helpful with squamous cell carcinoma of the esophagus, the most common histology of esophageal cancer in Japan and Asia, and often involving extensive mediastinal spread that can occur at an early age [107] . Additionally, esophagectomy with mediastinal lymph node dissection, including the area along the recurrent laryngeal nerves, has become the gold standard for radical surgical resection, however the view achieved with standard cervical incisions has been limited [107] . The introduction of other novel minimally invasive techniques for the lymph node dissection, such as the use of single port or robotic surgical devices, has expanded the options available to achieve improved dissection and, ultimately, better oncologic outcomes [107] .…”

Advances and understanding pitfalls of laparoscopic transhiatal esophagectomy with en bloc mediastinal lymph node dissection

“…By applying the same concept to middle mediastinum, we developed a new procedure for subcarinal lymph node dissection using the laparoscopic transhiatal approach [12,13] . We also started using the single-port mediastinoscopic cervical approach in 2014, and developed a simple technique for transmediastinal radical esophagectomy without a thoracic approach (more than 200 patients) [14][15][16][17] .…”