395. SURGICAL PROCEDURE AND PERIOPERATIVE OUTCOME OF TRANSMEDIASTINAL ESOPHAGECTOMY FOR ESOPHAGOGASTRIC JUNCTION CANCER

We started performing mediastinal lymph node dissection by a laparoscopic transhiatal approach (LTHA) in 2009. To date, 548 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 esophagectomy (TME) without thoracic approach (435 cases). Seventy five patients with EGJC were treated by TME. 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. Patients with EGJC performed TME were analyzed (n = 75, SCC/Adeno/Others = 37/35/3). Upper mediastinal lymph node metastasis was found in 13 cases (SCC/Adeno = 6/7), middle mediastinal lymph node metastasis was found in 10 cases (SCC/Adeno = 3/7), and all of them had advanced tumors. Their perioperative outcome was compared with those performed the right thoracotomy (n = 41). The operative time and bleeding were decreased by TME. The number of resected mediastinal lymph nodes, pR0 rate, and mediastinal recurrence in TME group were not inferior to the right thoracotomy group. In 93.3% of patients treated by TME, extubation was performed at 0 POD. Postoperative respiratory complication was decreased by TME (TME:6.7%, thoracotomy:17.1%). This procedure, TME, resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications in patients with EGJC.