Multimodality approaches including surgery, radiotherapy, and chemotherapy are essential for the treatment of advanced esophageal carcinoma.^1,2 Surgery has been used for locoregional control and has played a major role in the treatment of midstage esophageal cancer.³ The tumor site is an important factor in the selection of surgical approaches because the distribution and incidence of lymph node metastasis vary according to the location of primary tumors. Moreover, the midthoracic esophagus is the most frequent site of primary tumors of thoracic esophageal squamous cell carcinoma (SCC), whereas adenocarcinomas (ADC) are usually located in the lower thoracic esophagus or esophagogastric junction.⁴ Thoracic esophageal SCC are commonly accompanied by extensive lymph node metastases from cervical to abdominal regions. Although cervical and upper mediastinal nodes are more commonly involved in patients with carcinomas of the upper thoracic esophagus, lower mediastinal and perigastric nodes are the most common sites in patients with carcinomas of the lower thoracic esophagus.⁵ In patients with carcinomas of the middle thoracic esophagus, the primary lesion is often accompanied by extensive metastases in lymph nodes located from the neck to the abdomen. Thus, transthoracic esophagectomy and mediastinal lymph node dissection are generally performed as a curative surgical resection.

Extensive three-field lymph node dissection of cervical, mediastinal, and abdominal lymph nodes was developed in Japan in the 1980s for surgically curable esophageal cancers of the middle or upper thoracic esophagus.⁴ Although the survival benefit of three-field lymphadenectomy for esophageal cancer has not been demonstrated in large-scale randomized controlled trials,^6,7 there are several reports that suggest the importance of radical three-field lymph node dissection for locoregional control of esophageal cancer.^3,4–12 In particular, significance of meticulous and extensive lymph node dissection along the bilateral recurrent laryngeal nerves is well recognized. In the clinical trials including surgical components, thoracic esophagectomy with D2 lymph node dissection is considered as a standard procedure for thoracic esophageal cancer.

Distribution and risk of lymph node involvement are closely related to tumor location, size, and depth of invasion. Therefore, preoperative evaluations using computed tomography, endoscopic ultrasonography, magnetic resonance imaging, or positron emission tomography are required to determine the extent of lymph node dissection for each patient.¹³

Thoracic Procedures

In the left decubitus position, right posteriolateral thoracotomy at 5th intercostal space or anterolateral thoracotomy at 4th intercostal space is used as a standard open approach under the one lung ventilation anesthesia. After the division of the azygous arch, the posterior side of the right upper mediastinal pleura is incised up to the right subclavian artery. The right bronchial artery is then carefully isolated and preserved in case of open esophagectomy, and the dorsal and left sides of the upper esophagus are dissected from the left pleura. The thoracic duct with fat tissue is mobilized with esophagus from dorsal side to ventral side. Subsequently, the anterior side of the right upper mediastinal pleura is incised along the right vagal nerve up to the right subclavian artery, and the right recurrent laryngeal nerve is identified at the caudal end of the right subclavian artery. To prevent nerve injury, lymph nodes around the right recurrent laryngeal nerve are then carefully dissected sharply without usage of energy devices, and the anterior part of the upper esophagus is circumferentially dissected with the surrounding nodes. Posterior traction of the taped esophagus and anterior traction of the trachea provide an approach area to the left anterior side of the trachea, and the nodes around the left recurrent laryngeal nerve are dissected from the aortic arch level to the cervical area. Sharp dissection procedure without any energy devices is also essential for the lymph node dissection along the left recurrent laryngeal nerve. The left subclavian artery is then exposed to dissect the left recurrent laryngeal lymph nodes. The cranial end of thoracic duct is divided and lymph nodes along left recurrent laryngeal nerve are dissected with upper thoracic part of thoracic duct. During the dissection of the left tracheobronchial lymph nodes, the left recurrent laryngeal nerve under the aortic arch and left bronchial artery were preserved on the right side of the trunk of the left pulmonary artery.

The middle and lower mediastinal pleura are incised along the anterior edge of the vertebrae down to the hiatus, and the posterior side of the middle to lower esophagus dissected to expose the aortic arch and the descending aorta. The thoracic duct is then ligated and divided behind the lower esophagus, and resected with the esophagus. After incision of the anterior side of the middle and lower mediastinal pleura, the esophagus is divided using a linear stapler above the primary tumor, and the proximal stump of the resected esophagus and surrounding tissue are dissected up to the hiatus. Finally, the subcarinal nodes are resected separately to complete the esophageal mobilization and mediastinal lymphadenectomy.