Transhiatal esophagectomy (THE), popularized by Orringer and Sloan,1Orringer M.B. Sloan H. Esophagectomy without thoracotomy.J Thorac Cardiovasc Surg. 1978; 76: 643-654PubMed Google Scholar was proposed to decrease postoperative morbidity and mortality. The major inconvenience is the mediastinal lymphadenectomy that guarantees radical oncologic surgery. Recently, Bumm and associates2Bumm R. Hölscher A.H. Feussner H. Tachibana M. Bartels H. Siewert J.R. Endodissection of the thoracic esophagus: technique and clinical results in transhiatal esophagectomy.Ann Surg. 1993; 218: 97-104Crossref PubMed Scopus (86) Google Scholar used an endodissector that eliminated the “blind” mediastinal dissection. Furthermore, the advent of video-assisted technology provided increasing visualization and allowed bimanual maneuvers.3Hürtgen M. Friedel G. Toomes H. Fritz P. Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA)—technique and first results.Eur J Cardiothorac Surg. 2002; 21: 348-351Crossref PubMed Scopus (115) Google Scholar, 4Pop D. Venissac N. Leo F. Mouroux J. Video-assisted mediastinoscopy: a useful technique for paratracheal mesothelial cysts.J Thorac Cardiovasc Surg. 2005; 129: 690-691Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar This is our preliminary report using video-assisted mediastinoscopy (VAM) during THE, including technical details. Between October 1, 2001 and January 31, 2003 (a 15-month period), we operated on our first 5 patients. The usual pretherapeutic staging and preoperative assessment were done. One patient had neoadjuvant chemoradiotherapy. All 5 patients’ characteristics are noted in Table 1.TABLE 1Patients’ characteristicsNo. (age [y], sex)IT/length (cm)uTN/pTNFEV1 (L/%)Surgery (min)Survival (mo)1 (73, F)29/2T1 N1/T1 N02.2 (130)22042 - AWD2 (70, M)25/5T3 N0/T3 N01.5 (54)33037 - AWD3 (51, M)27/6T3 N1/T3 N12.7 (91)48017 - DWD4 (76, F)31/2T2 N1/T2 N10.6 (33)25551 - AWD5 (63, M)32/7Barrett/Tis3.2 (106)32536 - AWDIT, Distance from incisors in flexible esophagoscopy; u, endoscopic ultrasound; p, postoperative; Barrett, Barrett esophagus; Tis, carcinoma in situ; FEV1, forced expiratory volume in 1 second (liter and %); AWD, alive without disease; DWD, dead without disease. Open table in a new tab IT, Distance from incisors in flexible esophagoscopy; u, endoscopic ultrasound; p, postoperative; Barrett, Barrett esophagus; Tis, carcinoma in situ; FEV1, forced expiratory volume in 1 second (liter and %); AWD, alive without disease; DWD, dead without disease. The surgical procedures were done by the same team (surgeon with two assistants). The patients were supine with one roll beneath the scapulae (for maximal cervical extension). The abdominal and cervical phases were done by the standard technique.1Orringer M.B. Sloan H. Esophagectomy without thoracotomy.J Thorac Cardiovasc Surg. 1978; 76: 643-654PubMed Google Scholar Care must be taken to avoid arrhythmia or hypotension because of cardiac displacement during abdominal upward dissection of the esophagus. The mediastinal phase is done by VAM only through a cervicotomy (Figure 1). The equipment and the instruments have been previously described.4Pop D. Venissac N. Leo F. Mouroux J. Video-assisted mediastinoscopy: a useful technique for paratracheal mesothelial cysts.J Thorac Cardiovasc Surg. 2005; 129: 690-691Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar First, along the left side of the esophagus, the video-mediastinoscope allows clear visualization of the left recurrent nerve to the aortopulmonary window level. With bimanual blunt dissection and hemostatic clips, the lymph nodes situated next to the nerve can be easily separated without hurting the nerve. The video-mediastinoscope can be pushed farther into the mediastinum until the full length is reached. Next the anterior side is dissected. The back surface of the trachea, the carina, and the lymph nodes can be safely detached. Then the posterior side of the esophagus can be easily dissected from the prevertebral fascia. The thoracic duct can be identified and endoclips can be used generously for lymphostasis. Finally, the right side of the esophagus can be dissected by passing behind or in front of the esophagus, avoiding injury to the azygos system. Normally, the mediastinal pleurae are not opened. When the superior mediastinal phase is accomplished, the video-mediastinoscope provides the light to reach the upward abdominal dissection of the esophagus. We prefer a gastric substitute. One patient needed a left colon graft because of total gastrectomy for synchronous antral cancer, which lengthened the intervention. The mean operative time for the remainder was about 280 minutes. The mean hospital stay was 21 days. There was no 30-day mortality. Two major complications arose: myocardial ischemia in a patient with known coronary stenosis and pneumonia in a patient with acute respiratory distress syndrome that required ventilatory support. The living patients had no recurrences; one patient died of a myocardial infarction, but was free of cancer. Use of a vein stripper to avulse the esophagus from the posterior mediastinum was first described by Denk (1913) in cadavers and experimental animals.1Orringer M.B. Sloan H. Esophagectomy without thoracotomy.J Thorac Cardiovasc Surg. 1978; 76: 643-654PubMed Google Scholar After several attempts by different teams, Orringer and Sloan1Orringer M.B. Sloan H. Esophagectomy without thoracotomy.J Thorac Cardiovasc Surg. 1978; 76: 643-654PubMed Google Scholar (1978) reported on 26 patients with THE with gastric or colonic replacement in the same operative stage. The anticipated benefit was to avoid the morbidity of thoracotomy and to lessen the disastrous effect of an anastomotic fistula. Critics of this approach have warned of inadequate hemostasis and oncologic surgery. Recently, a meta-analysis5Hulscher J.B.F. Tijssen J.G.P. Obertop H. van Lanschot J.J.B. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis.Ann Thorac Surg. 2001; 72: 306-313Abstract Full Text Full Text PDF PubMed Scopus (470) Google Scholar showed that perioperative blood loss was significantly higher after transthoracic esophagectomy (TTE) but that THE resulted in more severe bleeding. The postoperative outlook gave potential benefits for THE in terms of pulmonary complications, chylous leakage, and in-hospital mortality. To the contrary, THE resulted in more cardiac complications, vocal cord paralysis, and anastomotic leakage. The use of mediastinoscopy2Bumm R. Hölscher A.H. Feussner H. Tachibana M. Bartels H. Siewert J.R. Endodissection of the thoracic esophagus: technique and clinical results in transhiatal esophagectomy.Ann Surg. 1993; 218: 97-104Crossref PubMed Scopus (86) Google Scholar helps dissection at or above the trachea and reduces the postoperative complications of standard THE. The advent of the video camera substantially improves visualization. We4Pop D. Venissac N. Leo F. Mouroux J. Video-assisted mediastinoscopy: a useful technique for paratracheal mesothelial cysts.J Thorac Cardiovasc Surg. 2005; 129: 690-691Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar have proved the benefit in resecting paratracheal mesothelial cysts. None of our patients treated by THE had significant bleeding or recurrent nerve injury. The primary goal of cancer surgery remains radical resection. Partial esophagectomy and 2-field lymphadenectomy done by TTE is the most currently used technique. Theoretically, it offers a better, but not significantly better, 5-year survival.5Hulscher J.B.F. Tijssen J.G.P. Obertop H. van Lanschot J.J.B. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis.Ann Thorac Surg. 2001; 72: 306-313Abstract Full Text Full Text PDF PubMed Scopus (470) Google Scholar The new VAM technique and the possibility of bimanual handling allow true lymphadenectomy.3Hürtgen M. Friedel G. Toomes H. Fritz P. Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA)—technique and first results.Eur J Cardiothorac Surg. 2002; 21: 348-351Crossref PubMed Scopus (115) Google Scholar For our patients, the mean number of lymph nodes was 7 (limits 2-22). This technique enables a truly en bloc esophagectomy and lymphadenectomy. Despite our limited experience with THE and VAM, the results are promising. With careful handling, VAM is superior to standard mediastinoscopy and it reduces the complications linked to the surgical maneuvers (inadequate hemostasis and recurrent nerve injury). In our opinion, VAM allows not only controlled lymph node biopsy in the mediastinum but true lymphadenectomy around the esophagus.

The focus of the thesis is on the relationship between the long-term benefits of public infrastructure investment and economic growth under conditions of political transition and trade liberalization in Romania. We hypothesize that in contrast with a smooth transformation, sudden structural shift to open economy impacts negatively on the expected long-term returns on the public infrastructure that already existed at the start of the transition. Under these conditions, the existing infrastructure becomes oversized and/or misplaced. At the same time, however, in the longer run the systematic under- or misinvestment in infrastructure becomes a hindering factor of local firms' productivity under conditions of competitive markets. In this excerpt, we present the formal model designed to interpret the interaction between structural change and policy reactions in terms of infrastructure provision. The proposed political economy model was built by estimating the aggregate production function of the economy, calculating public infrastructure productivity and by assuming different objective functions of policy makers when deciding upon infrastructure investments. The novelty of the model is that it considers public sector augmenting technological change and it estimates the inter- and intra-elasticity of substitution of inputs in the specified production function.

During mediastinoscopy, the definition of the limit between station 2 and station 4 is arbitrary. We describe a simple technique based on computed tomographic scan evaluation to precisely define it. The technique is based on calculating the distance between the sternal notch and the upper aortic arch on computed tomographic scan (radiological station 2 lower limit), and subtracting a constant factor (at our institution, 20 mm) to compensate for modifications of mediastinal structures due to neck hyperextension during mediastinoscopy. This corrected distance (surgical station 2 lower limit) is labeled on the mediastinoscope. When the mediastinoscope is inserted to this distance with a lateral deviation of about 45 degrees, the point of contact with the mediastinum of the biopsy forceps is the limit between station 2 and station 4. We applied this technique in 15 consecutive patients submitted to video-assisted mediastinoscopy for lung cancer. The R2 lower limit was identified by positioning 2 surgical clips during mediastinoscopy. The position of the clips, verified by a chest roentgenogram, was excellent (on the upper aortic arch line) in 7 patients, good (at less than 5 mm from the line) in 6 patients, and acceptable (at 7 mm from the line) in 1 patient. In one case clips were not visible. The proposed technique is simple and precise. Due to the possible differences in patient positioning during mediastinoscopy in other institutions, this correcting factor (-20 mm) should be verified before using this technique to define the lower limit of station 2.

Explanations dealing with the ethnic composition of local labour markets focus on the role community and the political choices have in minority policy rather than that of economic factors. The article proposes to contribute to the literature by inquiring about the effects of income differentials driven voluntary labour migration has on minority groups. The cases are Hungary, Romania and Transylvania (the north-western province of Romania). The study finds that large enough wage differentials produce unidirectional migration to the region with higher wages. To evaluate the effects of such type of migration, a three-level hierarchical CGE model is applied. The findings indicate that, under conditions of sufficiently large interregional wage differentials, linguistic match between the receiving region and a segment of labour in the source region might lead to the selection of migrant labour speaking the local language. The general conclusion is that labour liberalisation under conditions of significantly large wage differentials and language preferences on the host market produces language homogenization in formerly mixed regions.