Oncological outcomes of thoracic duct preservation and resection for esophageal carcinoma based on an understanding of its surgical microanatomy in the era of minimally invasive esophagectomy and neoadjuvant chemotherapy

Background

Although the oncological benefits of thoracic duct (TD) resection have been reported, recent research has questioned its impact on survival. With advancements in minimally invasive esophagectomy (MIE) and a deeper understanding of the microanatomy, standardizing techniques for TD resection/preservation have become increasingly important. We demonstrated a minimally invasive surgical procedure for esophagectomy, with and without TD resection, in patients who received neoadjuvant chemotherapy.

Methods

This multicenter, retrospective cohort study evaluated patients with cT1–3 thoracic esophageal cancer who underwent thoracoscopic McKeown esophagectomy after neoadjuvant chemotherapy at two Japanese cancer centers between 2012 and 2019. The effects of TD preservation and resection were compared using propensity score-matching. Short- and long-term outcomes were analyzed.

Results

We showed the standard procedure for TD resection and preservation and demonstrated that recognizing membrane structures is crucial for precise resection of the esophagus and regional lymph nodes. After matching, 255 patients in each group were analyzed. The TD resection group showed no significant differences in short-term outcomes, complication rates, or thoracic lymph node harvest compared to the TD preservation group. Both groups had similar 5-year overall and recurrence-free survival rates, with no significant differences in recurrence patterns.

Conclusions

In the context of modern esophageal carcinoma treatment, in which MIE and neoadjuvant chemotherapy are standard practices, the impact of TD resection on prognosis is limited. Recognizing membrane structures is crucial for accurate esophagectomy using the MIE approach.