We started performing mediastinal lymph node dissection by a laparoscopic transhiatal approach (LTHA) in 2009. To date, 371 patients had undergone our method during various esophageal surgical procedures, including esophagogastric junction cancer (EGJC). Furthermore, we started performing single-port mediastinoscopic cervical approach in 2014, and developed a simple technique for transmediastinal radical esophagectomy (TMr) without thoracic approach (258 cases). Forty patients with EGJC were also treated by TMr. Methods Left single-port mediastinoscopic cervical approach was performed with pneumomediastinum. Mainly for advanced SCC, upper mediastinal lymph node dissection including recurrent laryngeal nerve LNs was performed with intraoperative monitoring using NIM system. Next, LTHA was performed for en bloc mediastinal lymph node dissection. The esophageal hiatus was opened, and working space was secured by Long Retractors. The posterior plane of the pericardium was extended. The posterior side of LNs was then separated. Finally, while lifting LNs like a membrane, they were resected from bilateral mediastinal pleura. Reconstruction with narrow gastric conduit was performed through substernal tract. Results Patients with EGJC performed TMr were analyzed (n = 40, SCC/Adeno/Others = 21/17/2). Upper mediastinal lymph node metastasis was found in 6 cases (SCC/Adeno = 3/3), middle mediastinal lymph node metastasis was found in 2 cases (SCC/Adeno = 1/1), and all of them had advanced tumors. Their perioperative outcome were compared with those performed the right thoracotomy (n = 41). The operative time and bleeding were decreased by TMr. The number of resected mediastinal lymph nodes, pR0 rate, and mediastinal recurrence in the two groups were not different. In 95.0% of patients treated by TMr, extubation was performed at 0 POD. Postoperative respiratory complications was decreased by TMr (TMr:7.5%, thoracotomy:17.1%). Conclusion This procedure, TMr, resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications in patients with EGJC.

中文翻译：

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152 食管胃结合部癌的纵隔镜根治性食管切除术的手术过程和结果

我们于 2009 年开始通过腹腔镜经裂孔入路 (LTHA) 进行纵隔淋巴结清扫术。迄今为止，371 名患者在包括食管胃结合部癌 (EGJC) 在内的各种食管外科手术中接受了我们的方法。此外，我们于 2014 年开始实施单孔纵隔镜颈椎入路，并开发了一种无需胸腔入路的经纵隔根治性食管切除术（TMr）的简单技术（258 例）。40 名 EGJC 患者也接受了 TMr 治疗。方法采用纵隔积气行左侧单孔纵隔镜颈椎入路。主要针对晚期 SCC，使用 NIM 系统在术中监测下进行包括喉返神经 LN 在内的上纵隔淋巴结清扫。接下来，对整块纵隔淋巴结清扫进行 LTHA。食管裂孔被打开，工作空间由长牵开器确保。心包后平面延长。然后分离 LN 的后侧。最后，在像膜一样提起 LN 时，将它们从双侧纵隔胸膜切除。通过胸骨下道进行狭窄胃导管的重建。结果 对进行 TMr 的 EGJC 患者进行了分析（n = 40，SCC/Adeno/Others = 21/17/2）。上纵隔淋巴结转移6例（SCC/Adeno=3/3），中纵隔淋巴结转移2例（SCC/Adeno=1/1），均为晚期肿瘤。将他们的围手术期结果与进行右侧开胸手术的结果（n = 41）进行比较。TMr减少了手术时间和出血量。切除纵隔淋巴结的数量，两组的pR0率和纵隔复发率无差异。在接受 TMr 治疗的患者中，95.0% 的患者在 0 POD 时拔管。TMr 降低了术后呼吸系统并发症（TMr：7.5%，开胸手术：17.1%）。结论 TMr 手术获得了良好的手术视野、安全的整块纵隔淋巴结清扫以及 EGJC 患者术后呼吸系统并发症的减少。