278. mediastinoscopic esophagectomy with intraoperative nerve monitoring for esophagogastric junction adenocarcinoma; a single-center initial experience

Abstract Background In recent years, adenocarcinoma of esophagogastric junction (EGJ) has been on the increase in Japan. Although laparoscopic resection by the transhiatal approach is commonly used, patients often have difficulty with mediastinal lymph node dissection and reconstruction after resection. Since 2020, we have been performing mediastinoscopic esophagectomy for EGJ adenocarcinoma patients with esophageal invasion exceeding 3 cm in length or with a large tumor diameter. We report on the short-term results of the surgery performed. Methods Of 15 patients with adenocarcinoma of the esophagogastric junction who underwent radical esophagectomy at our hospital during a 36-month period from January 2020 to December 2022, 5 patients underwent mediastinoscopic esophagectomy without thoracic incisions. Surgery consisted of mediastinoscopic and laparoscopic subtotal esophagectomy, mediastinal lymph node dissection, and posterior mediastinal gastric tube reconstruction with cervical anastomosis. In all cases, continuous left recurrent nerve monitoring was performed intraoperatively. Short-term surgical outcomes were evaluated in terms of age, gender, TNM classification, stage, preoperative complications, operation time, blood loss, tumor diameter, length of esophageal invasion, postoperative complications, and postoperative hospital stay. Results All five patients were male, with a mean age of 67.8 years. 4 of the 5 patients had preoperative complications. Tumor localization was Siewert classification type I in 4 patients and type II in 1. The average tumor length and esophageal invasion length was 44 ± 26 mm and 38 ± 11 mm respectively. The average operation time was 395 ± 29 minutes and blood loss was 38 ± 39 mL. Lymph node metastases was revealed in three patients. No postoperative anastomotic leakage or recurrent nerve palsy was observed. One patient developed postoperative aspiration pneumonia but was cured without reintubation. Conclusion Mediastinoscopic esophagectomy for EGJ adenocarcinoma was performed safely. RCTs conducted in Western countries reported that esophagectomy with cervical anastmosis is associated with higher rates of recurrent nerve palsy than esophagectomy by the transhiatal approach. The use of a mediastinoscope to visualize the recurrent nerve and the use of intraoperative nerve monitoring devices might reduce the frequency of recurrent nerve palsy.