When could bilateral thoracotomy be envisaged in lower esophageal cancer?
K. Iwase, W. Kamiike, T. Kido, T. Takao, H. Matsuda (Osaka)
Metastatic lymph nodes from the lower esophageal cancer are observed most frequently in the superior gastric region and more frequently in the lower mediastinal region than in the middle or upper mediastinal region . Therefore, particular attention should be paid to the superior gastric and lower mediastinal regions as well as the upper and the middle mediastinal regions in the case of lower esophageal cancer. Radical operation for thoracic esophageal cancer, including aggressive mediastinal lymph node dissection, is usually performed through a right posterolateral thoracotomy, a laparotomy and a cervical approach [1, 2]. For better exposure of the whole posterior mediastinum, a right posterolateral thoracotomy should be chosen. However, a satisfactory surgical view of the lower posterior mediastinum and complete exposure of the left lower pulmonary vein could not be obtained by a right posterolateral thoracotomy. A satisfactory surgical view from the left lower pulmonary vein to the celiac axis is consecutively obtained by a left oblique thoracolaparotomy.
We have envisaged thoracic esophagectomy for lower esophageal cancer through a left oblique thoracolaparotomy and a right posterolateral thoracotomy in cases without preoperative respiratory dysfunctions for the purposes as described below:
-to perform the dissection of regional lymph nodes and the surrounding tissues as completely as possible for curative operation, or
- to obtain a satisfactory surgical view from the lower pulmonary vein to the celiac axis for easy and safe removal of huge tumor revealing predicted tight adhesion to the left atrium or large vessels.
Materials and methods
Seven patients with squamous cell carcinoma of the lower esophagus were operated through the approach described previously . Preoperative respiratory, renal and liver function tests were normal in all cases.
A left oblique abdomino-thoracotomy is made above the 8th intercostal space on a half right lateral position. The diaphragm is divided, and the left parietal pleura is incised from the lung hilus to the esophagogastric junction. The left lower pulmonary vein, pericardium and aorta are completely exposed. The esophagus is transected on the oral side of the tumor invasion. The posterior mediastinal, the lower thoracic paraesophageal and the diaphragmatic lymph nodes are dissected en bloc. The esophageal hiatus is circularly incised, keeping 1 cm away from the esophagus. The right parietal pleura is largely incised through the esophageal hiatus. The upper abdominal aorta, celiac artery and common hepatic artery are completely exposed. The left subphrenic artery and the left gastric artery and vein are ligated and cut at the root. The cardiac, celiac arterial, left gastric arterial and common hepatic arterial lymph nodes are dissected en bloc. The gastric tube or jejunum is put into the right thoracic cavity through the esophageal hiatus.
After closure of the left oblique abdominothoracic incision, a right posterolateral thoracotomy is performed through the 5th intercostal space on a complete left lateral position. The azygos vein is divided. The right bronchial artery and vagus nerve are carefully isolated. The lymph nodes around the trachea are dissected, and the highest mediastinal lymph nodes situated behind the right subclavian artery are evaluated with careful attention paid to the right recurrent nerve. The upper thoracic esophagus is transected, and the dissection of the right hilar and subcarinal lymph nodes is carried out. The esophageal branches of the right vagus nerve are transected, while the pulmonary branches are carefully preserved. The aorta, the inferior vena cava, the right lower pulmonary vein and pericardium are exposed, and the middle and lower thoracic esophagus and the surrounding lymph nodes are removed en bloc. An intrathoracic anastomosis between the upper thoracic esophagus and the gastric tube or jejunum is performed using the EEA stapling devices. The anastomotic region is consequently placed on the posterior wall of the intrathoracic trachea 5 to 7 cm above the carina.
Operating time was 372 ± 65 (mean ± SD) min, and intraoperative blood loss was 663 ± 172 ml. Transfusion was not required in 4 of the 7 cases. Extubation of the tracheal tube was possible within 3 days after operation in all cases. Additional oxygen gas administration was required 2-4 days after extubation of the tracheal tube (Table I). Supplemental aspiration of sputum using a bronchofiberscope was required after extubation of the tracheal tube in 2 of the 7 patients. No postoperative major pulmonary complication or anastomotic leakage was noted in any of the 7 cases.
Pulmonary complications continue to be a major cause of postoperative morbidity and mortality after surgery for carcinoma of the esophagus . However, it is still unknown whether thoracotomy during operation plays an important role in postoperative respiratory insufficiency. An exprimental study using dogs suggested that bilateral thoracotomy itself did not always cause more critical respiratory insufficiency as compared with right thoracotomy . Some recent advances in operative technique, such as careful preservation of the right bronchial artery and pulmonary branches of the right vagus nerve, decreased the incidence of severe respiratory complications . In the present study, extubation of the tracheal tube was possible within 3 days after operation in all patients.
Metastatic lymph nodes are frequently observed particularly in the lower mediastinal and superior gastric regions . Consecutive surgical view from the lower mediastinal region to the superior gastric region through additional left oblique thoracolaparotomy was quite useful for en bloc lymph node dissection as compared with the traditional approach through a right posterolateral thoracotomy and an upper abdominal laparotomy. Furthermore, removal of the tumor and the regional lymph nodes could be performed easily and safely in spite of the existence of a tight adhesion between the huge tumor and the left lower pulmonary vein in two of the 7 cases (cases 5 and 7) in our present report. It is considered that this new approach through a left oblique thoracolaparotomy and a right posterolateral thoracotomy might be applied not only for the purpose of the complete removal of the regional lymph nodes in case of curative operation but also for the purpose of the safe and easy removal of huge tumor of the lower esophagus.
6. Fujita H, Kawahara H, Yamana H, et al. Mediastinal lymph node dissection procedure during esophageal cancer operation: careful consideration for preserving respiratory function. Jpn J Surg 1988;18:31-34.