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Minimmaly Invasive Esophagectomy. Lymph Nodes Removal and Complications. a Retrospective Study
Jaime Otero De Pablos^*, Esther Sanchez Lopez, AndréS SáNchez-Pernaute
Digestive Surgical Department, Hospital Clinico San Carlos, Madrid, Spain

Background: Esophageal cancer (EC) has one of the highest malignant potentials of any type of tumor. Recent studies have shown that Minimally Invasive Esophagectomy ( MIE ) reduces blood loss, respiratory complications, the total morbidity rate and hospitalization duration. Current recommendations suggest that at least 15 lymph nodes should be examined after esophagectomy. The number of lymph nodes examined during surgical resection therefore considerably affects staging accuracy. Because of that, staging is clearly an important prognostic factor for patients.
Despite aggressive treatment, locoregional recurrence figures are around 25-30%.
Although data suggest that operative mortality is not significantly different between open and Minimally Invasive Esophagectomy ( MIE ), from our knowledge, patient survival has not been studied.
The aim of this study is to evaluate the total number of resected lymph nodes after MIE and classic approach, as well as their complications.
Method: From 2004 to2012, 40 patients went through Ivor Lewis esophagectomy, including 7 of whom under went thoracoscopic and laparoscopic approach, 12 patients under went thoracotomy and laparoscopic approach, and 21 patients under went thoracotomy and laparotomy approach. In any case, laparoscopic and open approach, abdominal lymphadenectomy used was D2 dissection. Whereas in the thorax, conventional two-field dissection was performed.
Results: There were no differences between the TNM between different groups.
When we compare the number of lymph nodes removed at the abdomen by laparoscopy (mean:16.95 Metastatic Lymph Node Ratio(MLNR):0,16) compared to laparotomy (mean:17.4 MLNR:0,30) no statistically significant differences were observed ( p = 0.87 ).
When analyzing the thoracic lymph nodes removed by thoracoscopy (mean:10.29 MLNR:0,05) versus thoracotomy (mean:15.36 MLNR:0,31) less dissection of metastasic lymph nodes and total lymph nodes were observed, although this differences were not statistically significant( p = 0, 754 )
Based on Clavien scale, decrease in complications type III and IV were seen when minimally invasive approach was accomplished. However, these differences were not statistically significant ( p > 0,05 ).
The reported hospital stay average were reduced when both, laparoscopic and thoracoscopic approach was the elected procedure, but this reduction was not seen when only one of the endoscopic procedure was elected. ( p > 0,05 )
Discussion: The MIE has shown a decrease in postoperative complications, as has been shown in the literature. Since a decrease in the number of lymph nodes removed by MIE has not been demonstrated, minimally invasive surgery may be approach of choice. However, more studies comparing long-term survival in these patients are needed.

Resected abdominal lymph node depending on their location and technique.

LAPAROSCOPY	LAPAROSCOPY	N	Mean	Standard deviation	Standard error	p
Right Paracardial	YES	19	2,47	2,568	0,589	0,270
Right Paracardial	NO	21	2,29	3,690	0,805
Left Paracardial	YES	19	2,47	2,756	0,632	0,027
Left Paracardial	NO	21	1,24	2,827	0,617
Lesser Curvature	YES	19	5,68	7,227	1,658	0,652
Lesser Curvature	NO	21	3,95	3,775	0,824
Left Gastric Artery	YES	19	1,95	1,840	0,422	0,751
Left Gastric Artery	NO	21	3,52	3,572	0,780
Celiac Trunk	YES	19	1,95	1,840	0,422	0,751
Celiac Trunk	NO	21	2,43	2,580	0,563
Hepatic artery	YES	19	2,28	2,081	0,490	0,885
Hepatic artery	NO	21	2,29	2,283	0,498
Greater Curvature	YES	19	0,26	0,806	0,185	0,534
Greater Curvature	NO	21	0,19	0,873	0,190
Retroportal vein	YES	19	0,0	0,0	0,0	0,048
Retroportal vein	NO	21	0,33	0,796	0,174

Resected thoracic lymph node depending on their location and technique.

THORACOSCOPY	THORACOSCOPY	N	Mean	Standard deviation	Standard error	p
Recurrent chain	YES	7	0,43	1,134	0,429	0,651
Recurrent chain	NO	33	0,91	2,156	0,375
Paratracheal	YES	7	0,57	1,134	0,429	0,463
Paratracheal	NO	33	1,27	2,125	0,37
Subcarinal	YES	7	5,29	4,499	1,700	0,463
Subcarinal	NO	33	2,36	2,356	0,410
Para Aortic	YES	7	0	0	0	0,553
Para Aortic	NO	33	0,45	1,543	0,269
Paraesophageal	YES	7	3,86	3,716	1,405	0,095
Paraesophageal	NO	33	10,15	17,532	3,052
Diaphragm	YES	7	0,14	0,378	0,143	0,972
Diaphragm	NO	33	0,18	0,528	0,092

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