145 ADVANTAGES OF MINIMALLY INVASIVE TRANSMEDIASTINAL ESOPHAGECTOMY IN ELDERLY PATIENTS WITH ESOPHAGEAL CANCER

Esophagectomy for esophageal cancer (EC) is one of the most invasive surgical procedures and, especially for elderly patients, postoperative respiratory complication (PRC) is still frequent and life-threatening. We started esophagectomy by a laparoscopic transhiatal approach in 2009, and single-port mediastinoscopic cervical approach in 2014. Nowadays, we have performed total mediastinal lymph node dissection without thoracic approach. The purpose of this study was to evaluate transmediastinal esophagectomy (TME) for the prevention of PRC in elderly patients. Methods 1) Patients with EC performed TME (n = 238) were compared with those performed the right thoracotomy (n = 185). 2) Outcomes of TME for elderly patients (75 years and older, n = 48) was evaluated by comparing with non-elderly patients (n = 190). 3) Elderly patients performed subtotal esophagectomy were divided into 2 groups according to the presence (n = 12) or absence (n = 51) of PRC. The two groups were compared about clinicopathological factors, and risk factors of PRC were analyzed. Results 1) Percentage of elderly patients was higher in TME group (20.2% vs 8.1%). The operative time and bleeding were decreased by TME. The number of resected LNs and pR0 rate were not different between two groups. In TME groups, the occurrence of PRC was significantly reduced (10.1% vs 28.1%). 2) 81.3% of elderly patients were able to extubation on 0POD, and there was no significant difference in PRC between two groups. 3) Univariate analysis showed that surgical approach was significantly different between two groups. Multivariate analysis showed that thoracotomy was the strongest risk factor of PRC for elderly patients. Conclusion This study showed that our surgical procedure was less invasive during operation and resulted in a safe en-bloc mediastinal lymph node dissection. For elderly patients, TME was the effective minimally invasive approach and was able to reduce the occurrence of PRC.

152 SURGICAL PROCEDURE AND OUTCOME OF MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY FOR ESOPHAGOGASTRIC JUNCTION CANCER

We started performing mediastinal lymph node dissection by a laparoscopic transhiatal approach (LTHA) in 2009. To date, 371 patients had undergone our method during various esophageal surgical procedures, including esophagogastric junction cancer (EGJC). Furthermore, we started performing single-port mediastinoscopic cervical approach in 2014, and developed a simple technique for transmediastinal radical esophagectomy (TMr) without thoracic approach (258 cases). Forty patients with EGJC were also treated by TMr. Methods Left single-port mediastinoscopic cervical approach was performed with pneumomediastinum. Mainly for advanced SCC, upper mediastinal lymph node dissection including recurrent laryngeal nerve LNs was performed with intraoperative monitoring using NIM system. Next, LTHA was performed for en bloc mediastinal lymph node dissection. The esophageal hiatus was opened, and working space was secured by Long Retractors. The posterior plane of the pericardium was extended. The posterior side of LNs was then separated. Finally, while lifting LNs like a membrane, they were resected from bilateral mediastinal pleura. Reconstruction with narrow gastric conduit was performed through substernal tract. Results Patients with EGJC performed TMr were analyzed (n = 40, SCC/Adeno/Others = 21/17/2). Upper mediastinal lymph node metastasis was found in 6 cases (SCC/Adeno = 3/3), middle mediastinal lymph node metastasis was found in 2 cases (SCC/Adeno = 1/1), and all of them had advanced tumors. Their perioperative outcome were compared with those performed the right thoracotomy (n = 41). The operative time and bleeding were decreased by TMr. The number of resected mediastinal lymph nodes, pR0 rate, and mediastinal recurrence in the two groups were not different. In 95.0% of patients treated by TMr, extubation was performed at 0 POD. Postoperative respiratory complications was decreased by TMr (TMr:7.5%, thoracotomy:17.1%). Conclusion This procedure, TMr, resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications in patients with EGJC.