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Thoracolaparoscopic Dissection of Lymph Nodes Involved in the Drainage of the Esophagus Is Feasible and Safe in Human Cadavers and Swine
Hannah T. KüNzli*1,2, Mark I. Van Berge Henegouwen3, Suzanne S. Gisbertz3, Marinus J. Wiezer4, Cees a. Seldenrijk5, Jacques J. Bergman2, Bas L. Weusten1,2
1Gastroenterology, St. Antonius Hospital, Nieuwegein, Netherlands; 2Gastroenterology, Academic Medical Center Amsterdam, Amsterdam, Netherlands; 3Surgery, Academic Medical Center Amsterdam, Amsterdam, Netherlands; 4Surgery, St. Antonius Hospital, Nieuwegein, Netherlands; 5Pathology, St. Antonius Hospital, Nieuwegein, Netherlands
Background: Low-risk early esophageal cancer can safely be managed endoscopically. In case of high-risk cancer (i.e. submucosal invasion, poor tumor differentiation, or lymphovascular invasion), esophagectomy with lymph node dissection is currently advocated given the relatively high rates of lymph node (LN) metastasis in these patients. However, this procedure is associated with substantial morbidity and mortality and a reduced quality of life. Endoscopic radical (R0) local resection (by means of ESD or EMR), followed by thoracolaparoscopic lymph node dissection without concomitant esophagectomy could be an attractive alternative.
Aim: To evaluate the feasibility and safety of thoracolaparoscopic dissection of LN involved in the drainage of the esophagus in human cadavers (1) and swine (2), leaving the esophagus and cardia in situ.
Methods: (1) In fresh human cadavers, thoracolaparoscopic dissection of LN involved in drainage of the esophagus was performed. Following LN dissection, a regular esophagectomy was performed and the resection specimen was analysed for any retained LN. (2) In the animal survival study, thoracolaparoscopic dissection of LN was performed in swine. 28 days after the procedure, the swine were sacrificed and a regular esophagectomy was performed. Outcome parameters included the number of dissected LN during lymphadenectomy, and the number of retained LN in the esophagectomy specimens. In the animal survival study, outcome parameters also included the presence of ischemia and/or stenosis in the esophagectomy specimens (safety parameters). Technical success was defined as a ratio ≥ 0.9 between the number of dissected LN during lymphadenectomy and the total (resected plus retained) number of LN.
Results: In 5 fresh human cadavers (3 male, median age 83 years), a median of 26 LN (IQR 22-46) was dissected. In 2 esophagectomy specimen, 1 retained LN was found (1 high paraesophageal, 1 low paraesophageal). All procedures were considered technically successful.
In 8 female swine, a median of 11 LN (IQR 6-16) was dissected. In 4/8 esophagectomy specimens, a median of 4 retained LN (IQR 3-6) were found (paraesophageal and around the lesser curvature). One pig died because of ventricular fibrillation during the procedure, all others survived uneventfully. The esophagectomy specimens showed no signs of ischemia or stenosis.
Conclusions: Thoracolaparoscopic dissection of lymph nodes involved in the drainage of the esophagus appears to be feasible in human cadavers and swine. The animal survival study suggests that the esophageal vascularity is not severely compromised by this procedure. As anatomy is different in humans, further studies on this new algorithm consisting of radical endoscopic resection, followed by thoracolaparoscopic lymph node dissection in patients with high-risk early esophageal cancer however, are warranted.
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