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Background: The effect of lymphadenectomy around the recurrent laryngeal nerve (RLN) in open esophagectomy has been demonstrated with the efficacy index (EI). However, it remains unclear whether this effect exists for minimally invasive esophagectomy (MIE) in the prone position. The purpose of this study was to clarify whether the upper mediastinal lymphadenectomy contributed to improved prognosis in patients with esophageal squamous cell carcinoma., Study Design: This study included 339 patients with esophageal squamous cell carcinoma treated with MIE in the prone position at Kobe University or Hyogo Cancer Center, Japan, from 2010 to 2015. EIs for each station, correlations between metastatic lymph nodes around the left RLN and RLN palsy, and survival of patients with and without upper mediastinal lymphadenectomy were investigated., Results: Among 297 patients treated with upper mediastinal lymphadenectomy, Clavien- Dindo grade ≥ II left RLN palsy occurred in 59 patients (20%). Overall, EIs for the right RLN (7.4) and left RLN (6.6) were higher than EIs for other stations. For patients with upper-third or middle-third tumors, the trend was stronger. Left RLN palsy was more likely in patients with metastatic lymph nodes around the left RLN than in those without (44% vs 15%, p < 0.0001). After propensity score-matching, 42 patients were included in each group with and without upper mediastinal lymphadenectomy. In survival analyses, the 5-year overall survival rates were 55% vs 35% and cause-specific survival rates were 61% vs 43% for the patients with and without upper mediastinal lymphadenectomy respectively. Significant differences were confirmed in survival curves (overall survival: p = 0.03; cause-specific survival: p = 0.04, respectively)., Conclusions: Upper mediastinal lymphadenectomy contributes to improved prognosis with high EIs in MIE in the prone position., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The eighth edition of the American Joint Committee on Cancer (AJCC) tumor node metastasis (AJCC-TNM 8th) system adopted the newly separate post-neoadjuvant pathologic stage group (ypTNM). However, it is not compatible with the Japanese pathologic classification after neoadjuvant chemotherapy (JPN-CT-pTNM). The aim of this study is to clarify the subjects of the AJCC-ypTNM 8th and propose a unification of the AJCC and Japanese systems to create novel AJCC-CT-pTNM 8th., Methods: Participants were 304 esophageal squamous cell carcinoma (ESCC) patients who underwent neoadjuvant chemotherapy followed by 3 stage esophagectomy between 2010 and 2019. Predictive probabilities of pN, pM in AJCC-ypTNM 8th and JPN-CT-pTNM 11th systems were evaluated to propose novel system., Results: In training data from 234 patients, the overall survival rate was statistically better for ypStage IIIA than ypStage II (P = 0.040) resulting in staging inversion in AJCC-ypTNM 8th. Predictive probability of pathological N status in AJCC-ypTNM 8th (Akaike Information Criterion: AIC = 979.53) was superior to that in JPN-CT-pTNM 11th (AIC = 999.07). In AJCC-ypTNM 8th, 71% (15/21) of ypM1 diseases were supraclavicular lymph nodes (No. 104 L/N as regional in JPN-CT-pTNM 11th) metastases with considerably good prognosis. The predictive probability of the novel AJCC-CT-pTNM 8th [unification of ypStage II and IIIA, conversion of supraclavicular L/Ns metastases from ypM to ypN] (AIC = 1054.24) was superior to that of the existing AJCC-ypTNM 8th (AIC = 1070.74). The feasibility of novel system was validated using test data from 70 patients., Conclusions: Unification of the AJCC and Japanese systems yields a simpler and more precise predictive system after neoadjuvant chemotherapy., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Esophageal squamous cell cancer (ESCC) is one of the deadliest cancers in the world. Esophagectomy remains the principal treatment, and minimally invasive esophagectomy (MIE) has been performed worldwide. This study aimed to clarify whether the lymph node ratio (LNR), defined as the ratio of metastatic lymph nodes (LNs) to examined, is a prognostic factor for ESCC after MIE., Methods: This study included 327 MIEs with the patient in the prone position at two institutions from 2010 to 2015. Cox proportional hazards regression analyses using clinicopathologic characteristics and the LNR were performed for the pN1 patients and the whole cohort., Results: In the multivariate analysis for all stages, independent prognostic factors were depth of tumor invasion (P < 0.0001), LNR (P = 0.014), operative time (P = 0.003), and pneumonia (P = 0.012). In the analysis of the pN1 subgroup, the optimum LNR cutoff level for overall survival (OS) was 9 based on receiver operation characteristic analysis. The LNR was significantly associated with depth of tumor invasion (P = 0.004) and number of metastatic LNs (P < 0.0001). The OS curve for the group with an LNR of 9 or higher was significantly worse than for the group with an LNR lower than 9 (P < 0.001). Multivariate analyses demonstrated that the LNR is a unique independent prognostic factor for the pN1 subgroup (hazard ratio, 6.811; 95% confidence interval, 2.009-23.087; P = 0.002)., Conclusions: The LNR is an independent prognostic factor in ESCC after MIE. Especially for patients with pN1 status, the LNR is more useful than the number of metastatic LNs for predicting survival outcome.

Purpose: Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal squamous cell carcinoma (ESCC). Thoracic duct (TD) resection has been recommended as part of extended lymphadenectomy, although its merits are unclear. The aim of this two-institutional, matched-cohort study is to clarify whether TD resection improves prognosis in esophagectomy for ESCC., Patients and Methods: In this two-institutional, matched-cohort study of 399 patients with ESCC who underwent McKeown esophagectomy between 2010 and 2014, the primary outcomes were overall survival (OS), disease-free survival (DFS), and cause-specific survival (CSS). Secondary outcomes were perioperative results and recurrence patterns., Results: Based on a propensity score, 122 TD-resected or 122 TD-preserved patients in all stages were selected (median follow-up 4.5 years). The 5-year OS, DFS, and CSS rates in the TD-resected versus TD-preserved groups were 49% versus 60%, 53% versus 57%, and 58% versus 70%, respectively, without any significant differences. Operative time for the thoracic procedure was significantly longer and the number of retrieved mediastinal nodes was significantly higher in the TD-resected group (P = 0.009 and 0.005, respectively). The rates of chylothorax and left recurrent laryngeal nerve (RLN) palsy were significantly higher in the TD-resected group (P = 0.041 and 0.018, respectively). There were no significant differences in rates of local or distant metastases between the two groups., Conclusions: TD resection does not contribute to improve OS, DFS, or CSS in ESCC but increases incidence of chylothorax and left RLN palsy. Prophylactic TD resection should be avoided in esophagectomy for ESCC.

Background: Esophagectomy with three-field lymph node dissection is common, but the effects of cervical lymph node dissection on overall survival in patients with thoracic esophageal cancer remain controversial. Recently, we performed thoracoscopic esophagectomy and superior mediastinum and paracervical esophageal lymph nodes could have been effectively dissected from the thoracic cavity. This study assessed the risks and benefits of prophylactic supraclavicular lymph node dissection in patients who underwent thoracoscopic esophagectomy., Methods: This retrospective study included 294 patients who underwent thoracoscopic esophagectomy at Kobe University Hospital and Hyogo Cancer Center between April 2010 and December 2015. Patients in the two-field (paracervical esophageal lymph nodes were dissected from the thoracic cavity) and three-field lymph node dissection groups were matched using propensity score matching. We compared overall survival and the incidence of postoperative complications in the matched cohort and assessed the estimated efficacy of additional lymphadenectomy for supraclavicular lymph node recurrence in the entire cohort., Results: In the matched cohort, overall survival was not significantly different between the two groups, but the incidence of recurrent laryngeal nerve palsy was significantly higher in the 3FL group than in the 2FL group. In the entire cohort, 162 patients underwent a two-field lymph node dissection; 11 experienced supraclavicular nodal recurrence. We performed additional supraclavicular lymph node dissection in three patients without systemic metastasis, all of whom are alive without any other recurrence., Conclusions: Prophylactic cervical lymph nodes dissection in thoracoscopic esophagectomy does not improve long-term survival but does increase the risk of postoperative complications.

Purpose: In esophageal squamous cell carcinoma (ESCC), lymph nodes (LNs) around the subcarina and main bronchi are thought to be highly involved. Therefore, complete dissection of these LNs with preservation of the pulmonary branches of the vagus nerves, which control important pulmonary functions, is recommended. The aim of this retrospective study was to investigate the feasibility of reliable method for lymphadenectomy around the subcarina and main bronchi, named the medial approach, during thoracoscopic esophagectomy in the prone position (TEP)., Methods: This was a case-matched control study of patients who underwent TEP for ESCC. The fundamental concept in this method is to first exfoliate the LNs around the subcarina and main bronchi from the pericardium. Developing the operative field contributes to visualizing and preserving the pulmonary branches of the right vagus nerve. Twenty-three patients who underwent the medial approach and 23 patients who underwent the conventional approach were selected by the use of propensity score matching to compare the operative outcomes., Results: The medial approach significantly reduced operative time for procedure (16 ± 3 vs 30 ± 6 min, p < 0.0001) and operative blood loss (123 ± 108 vs 207 ± 162 ml, p = 0.046) comparing with conventional approach. The incidence of postoperative pneumonia was lower in the medial approach group (4%) than in the conventional approach group (15%) (p = 0.069)., Conclusions: The medial approach for lymphadenectomy around the subcarina and both main bronchi during TEP is technically safe and feasible in shorting the operative time with possibility to reduce postoperative pneumonia.

Purpose: Esophageal cancer is one of the deadliest cancers worldwide. Esophagectomy with lymphadenectomy is regarded as the only curative option for resectable esophageal cancer, but it is associated with high morbidity and mortality. Multidisciplinary team (MDT) management was recently associated with improved outcomes after surgery for esophageal cancer. The aim of this study was to investigate the effect of standardizing procedures for minimally invasive esophagectomy (MIE) in the MDT setting., Methods: This was a case-matched control study of 154 patients with esophageal cancer who underwent thoracoscopic esophagectomy in the prone position (TEP) between 2012 and 2016. Surgery was performed by two attending surgeons (surgeons A and B) who began working together in the same MDT in 2015. At that time, the following surgical procedures were standardized between surgeons A and B: mediastinal lymphadenectomy, abdominal procedures, and estimation of the blood supply of the gastric conduit. Short-term outcomes were compared between the following paired groups using propensity scores: surgeon A's pre- and post-standardization groups, surgeon B's pre- and post-standardization groups, and surgeon A's post-standardization group and surgeon B's post-standardization group., Results: Concerning surgeon A, the estimated total blood loss in the post-standardization group (142 ± 87 mL) was significantly lower than that in the pre-standardization group (376 ± 215 mL, P = 0.006). The rate of left recurrent laryngeal nerve palsy in the post-standardization group (13%) was significantly lower than that in the pre-standardization group (47%, P = 0.046). Concerning surgeon B, the rate of anastomotic leakage in the post-standardization group (0%) was significantly lower than that in the pre-standardization group (11%, P = 0.039). Comparing the post-standardization groups of surgeons A and B, there were no significant differences in operative outcomes or morbidity., Conclusions: Standardizing procedures for MIE improved and homogenized surgical short-term outcomes.

Purpose: Thoracoscopic esophagectomy with the patient in the prone position (TEP) is now being performed as minimally invasive esophagectomy for esophageal cancer. This study examines the short-term outcomes and the learning curve associated with TEP., Methods: One surgeon ("Surgeon A") performed TEP on 100 consecutive patients assigned to three periods based on treatment order. Each group consisted of 33 or 34 patients. The outcomes of the three groups were compared to define the influence of surgeon expertise., Results: Outcomes improved as Surgeon A gained experience in performing this operation, as evidenced by reduced thoracic operative times between periods 1 and 2, and then between periods 2 and 3 (p = 0.0033 and p = 0.0326, respectively); an increased number of retrieved chest nodes between periods 1 and 2 (p = 0.0070); and a decline in recurrent laryngeal nerve (RLN) palsy between periods 2 and 3 (p = 0.0450). Period 2 was the pivotal period for each learning curve., Conclusions: An individual surgeon's learning curve over the course of 100 TEP procedures had three outcomes: a shortened operative time, a higher number of retrieved chest nodes, and a decreased rate of RLN palsy. Approximately 30-60 cases were needed to reach a plateau in the TEP procedure and a reduction in the morbidity rate.

Purpose: Minimally invasive esophagectomy (MIE) has less morbidity than the open approach. In particular, thoracoscopic esophagectomy in the prone position (TEP) has been performed worldwide. Using the cumulative sum control chart (CUSUM) method, this study aimed to confirm whether a trainee surgeon who learned established standards would become skilled in TEP with a shorter learning curve than that of the mentoring surgeon., Methods: Surgeon A performed TEP in 100 patients; the first 22 patients comprised period 1. His learning curve, defined based on the operation time (OT) of the thoracic procedure, was evaluated using the CUSUM method, and short-term outcomes were assessed. Another 22 patients underwent TEP performed by surgeon B, with outcomes compared to those of surgeon A's period 1., Results: Using the CUSUM chart, the peak point of the thoracic procedure OT occurred at the 44th case in surgeon A's experience of 100 cases. With surgeon A's first 22 cases (period 1), the peak point of the thoracic procedure OT could not be confirmed and graph is expanding soaring at CUSUM chart. The CUSUM chart of surgeon B's experience of 22 cases clearly indicated that the peak point of the thoracic procedure OT occurred at the 17th case. The rate of recurrent laryngeal nerve palsy for surgeon B (9 %) was significantly lower than for surgeon A in period 1 (36 %) (p = 0.0266)., Conclusions: There is some possibility for a trainee surgeon to attain the required basic skills to perform TEP in a relatively short period of time using a standardized procedure developed by a mentoring surgeon. The CUSUM method should be useful in evaluating trainee competence during an initial series of procedures, by assessing the learning curve defined by OT.

Background: Esophagectomy with extended lymphadenectomy improves prognosis but it is associated with high morbidity and mortality. The thoracoscopic approach is associated with fewer pulmonary complications. Abdominal wall injury greatly affects pulmonary function and complication rates during the acute postoperative phase. In this study we aimed to compare the incidence of pulmonary complications and respiratory recovery after thoracoscopic esophagectomy in the prone position with hand-assisted laparoscopic surgery (HALS) versus open laparotomy (OL)., Methods: This was a case-matched control study of patients with esophageal cancer who underwent thoracoscopic esophagectomy in the prone position. Thirty-two patients in the HALS group and 32 patients in the OL group were selected by the use of propensity score matching. Operative outcomes and perioperative changes in respiratory function were compared., Results: There was no operative mortality in either group. Estimated blood loss was less in the HALS group (P < .001). The incidence of postoperative pneumonia was 6.2% (4/64) overall; it was less in the HALS group (0%) than in the OL group (12.5%) (P = .016). There were no differences in preoperative vital capacity (VC) and percent predicted vital capacity (%VC). Each parameter, including the ratio of the postoperative to preoperative %VC (%VC ratio), reached its nadir on postoperative day 7 in both groups but was greater in the HALS group (VC, 2.91 ± 0.68 L vs 2.53 ± 0.53 L, P = .018; %VC, 90.62 ± 16.92% vs 78.91 ± 16.65%, P = .007; %VC ratio, 80.90 ± 9.87% vs 72.09 ± 11.95%, P = .002). At 1 and 3 months, respiratory recovery was seen in both groups but more so in the HALS group. At 6 months, further respiratory recovery was seen in both groups, without any significant intergroup differences., Conclusion: During the acute phase after thoracoscopic esophagectomy in the prone position, HALS is associated with less-restrictive ventilatory impairment, fewer subsequent pulmonary complications, and less blood loss than OL. The combination of HALS and thoracoscopic esophagectomy in the prone position is less invasive on respiratory function., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: In esophageal cancer, lymph nodes along the recurrent laryngeal nerves (RLNs) are thought to be highly involved. Complete dissection of these lymph nodes is recommended but there is limited working space in the left upper mediastinum and advanced dissection skills are required. We present herein a new method for lymphadenectomy along the left RLN, called the Bascule method during prone esophagectomy., Methods: The fundamental concept of this new method is to draw the proximal portion of the divided esophagus and tissue that includes the left RLN and lymph nodes through a gap between the vertebral body and the right scapula. Using this technique, a two-dimensional membrane, similar to the "esophageal mesenteriolum" (lateral pedicle), will be easily recognizable. Identification and reliable cutting of the tracheoesophageal artery and distinguishing the left RLN from the lymph nodes should be easy. This technique was evaluated in 39 consecutive cases of prone esophagectomy for squamous cell cancer., Results: There were 18 patients who underwent the new method (Bascule method; Bm) and 21 patients who underwent the conventional method (Cm). The duration of the thoracic procedure and dissection along the left RLN was significantly shorter in Bm group than in Cm group (258 ± 30 vs. 291 ± 39 min; p = 0.007 and 66 ± 9 vs. 75 ± 14 min; p = 0.036, respectively). Estimated blood loss in Bm group was 20 ± 11 g compared to 38 ± 32 g in Cm group (p = 0.028). No intraoperative morbidity related to the left RLN was observed in either group. The hoarseness rate in Bm group was 28 %, which was lower than that in the Cm group (48 %)., Conclusions: The Bascule method for lymphadenectomy along the left RLN during prone esophagectomy is technically safe and feasible and reduces operative time and blood loss.

Esophagectomy with extended lymphadenectomy and gastric conduit reconstruction is a radical procedure for the treatment of esophageal cancer that is associated with a high morbidity rate. Gastric conduit necrosis is a fatal complication that occurs in 2% of patients. Conventionally, two-stage salvage surgery consisting of removal of the necrotic gastric conduit followed by reconstruction has been performed; however, this procedure has a high morbidity rate. We describe a 61-year-old man who underwent minimally invasive esophagectomy complicated by slowly progressive gastric conduit necrosis associated with complete neck drainage and a stable overall condition. There was a 2 cm gap in the anastomosis. Because there was no evidence of residual gastric conduit necrosis, a removable, covered self-expanding metal stent (SEMS) was inserted to bridge the anastomosis. The stent was fixed to the patient's ear with silk thread through the lasso on its proximal end to prevent migration. Eight weeks after insertion, the stent was removed easily without any associated complications. The anastomotic defect was completely bridged with granulation tissue, showing progressive epithelialization without leakage or stenosis. The patient was discharged home in good general health. This is the first report of the successful conservative management of esophago-gastric conduit anastomosis disruption with SEMS placement.