Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract · 2025
Lymphadenectomy through a triple-instrument cervical approach: a technical advance in single-port mediastinoscopic radical esophagectomy for esophageal cancer.
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Komatsu Shuhei, Konishi Tomoki, Ogawa Soichiro, Matsumoto Yoshihisa, Fujita Yuji, Matsuo Hisataka, Kuriu Yoshiaki, Ikoma Hisashi, Okamoto Kazuma, Konishi Hirotaka, Fujiwara Hitoshi, Otsuji Eigo, Shiozaki Atsushi
Аннотация
BACKGROUND: Single-port mediastinoscopic radical esophagectomy represents the least invasive form of esophagectomy that avoids thoracotomy or thoracoscopy. However, conventional double-instrument approaches are constrained by a narrow operative field, often leading to limited mediastinal lymph node dissection and a risk of recurrent laryngeal nerve (RLN) injury. Although the introduction of continuous intraoperative nerve integrity monitoring (NIM) has markedly reduced the incidence of RLN palsy, the adequacy of lymphadenectomy remains a major concern. To address this limitation, we introduced a triple-instrument cervical approach to enhance operative visibility and precision.
METHODS: Between May 2020 and April 2025, 48 consecutive patients with thoracic esophageal cancer underwent single-port mediastinoscopic radical esophagectomy with continuous NIM at our institution. Among these patient, 26 underwent a triple-instrument cervical approach, whereas 22 underwent a conventional double-instrument approach. Clinicopathological characteristics and perioperative outcomes were compared between the two groups.
RESULTS: Triple-instrument access significantly increased the number of mediastinal lymph nodes retrieved (median: 22 [IQR, 7-46] vs 16 [IQR, 2-42]; P =.048), without significant differences in blood loss (median: 123 vs 63 mL; P =.266), RLN palsy (7.7% vs 4.5%; P =.881), or hospital stay (median: 14 days in both groups; P =.883). Multivariate analysis identified the triple-instrument technique as an independent predictor of high lymph node yield (odds ratio, 5.55 [95% CI, 1.19-25.8]; P =.029).
CONCLUSION: The triple-instrument cervical approach represents a technically feasible and oncologically sound refinement of single-port mediastinoscopic esophagectomy. By combining continuous NIM and improved ergonomics, this technique enhances mediastinal lymphadenectomy without increasing morbidity.
METHODS: Between May 2020 and April 2025, 48 consecutive patients with thoracic esophageal cancer underwent single-port mediastinoscopic radical esophagectomy with continuous NIM at our institution. Among these patient, 26 underwent a triple-instrument cervical approach, whereas 22 underwent a conventional double-instrument approach. Clinicopathological characteristics and perioperative outcomes were compared between the two groups.
RESULTS: Triple-instrument access significantly increased the number of mediastinal lymph nodes retrieved (median: 22 [IQR, 7-46] vs 16 [IQR, 2-42]; P =.048), without significant differences in blood loss (median: 123 vs 63 mL; P =.266), RLN palsy (7.7% vs 4.5%; P =.881), or hospital stay (median: 14 days in both groups; P =.883). Multivariate analysis identified the triple-instrument technique as an independent predictor of high lymph node yield (odds ratio, 5.55 [95% CI, 1.19-25.8]; P =.029).
CONCLUSION: The triple-instrument cervical approach represents a technically feasible and oncologically sound refinement of single-port mediastinoscopic esophagectomy. By combining continuous NIM and improved ergonomics, this technique enhances mediastinal lymphadenectomy without increasing morbidity.