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Three-Field Lymphadenectomy for Esophageal Cancer Masamichi Baba, Shoji Natsugoe, Takashi Aikou Introduction Lymphatic drainage from the upper two-thirds of the thoracic esophagus occurs mainly towards the neck and upper mediastinum, although there is also some drainage to the nodes along the left gastric artery. In 1981, the first reported study of three-field lymphadenectomy in Japan noted that 10 of 36 patients with esophagectomy had skip metastases to the neck or abdominal lymph nodes in the absence of associated intrathoracic spread. In this chapter, we focus on the lymph node dissection of the upper mediastinal and cervical regions. Indications and Contraindications Indications ■ Tumors of the supracarinal esophagus (>T1m stage) Contraindications ■ Superficial carcinoma (T1m stage) Severe comorbidity (heart disease, pulmonary and/or liver dysfunction) No evidence of cervical lymph node metastases preoperatively in high risk patients (relative) Infracarinal tumors (relative) ■ ■ ■ Preoperative Investigation/Preparation for the Procedure ■ ■ ■ See transhiatal approach US+CT scan of the neck In locally advanced tumors: primary radiochemotherapy and surgery is done secondarily Procedure Access ■ Anterior-lateral thoracotomy through the right 5th ICS ■ Supine position and T-shaped incision in the neck 100 SECTION 2 STEP 1 Exposure and lymphadenectomy of the right upper mediastinum Esophagus, Stomach and Duodenum The arch of the azygous vein is resected, and the right bronchial artery is ligated and secured at its root to evaluate the tumor for its resectability. This procedure provides a good exposure of the upper and middle mediastinum. The brachiocephalic and right subclavian arteries are exposed in order to remove the right recurrent nerve nodes and right paratracheal nodes followed by carefully ligating the branches of the inferior thyroid artery (arrow indicates the direction of lymphadenectomy). Three-Field Lymphadenectomy for Esophageal Cancer STEP 2 101 Transection; resection of the esophagus and completion of lymph node clearance After proximal transection of the esophagus at the level of the aortic arch, the left recurrent nerve nodes (left paratracheal nodes) are removed. The middle mediastinal nodes, comprising the infra-aortic, infracarinal, and periesophageal nodes, are cleared in conjunction with the esophagus. This exposes the main bronchus, the left pulmonary artery, branches of the vagus nerve, and the pericardium. Both pulmonary branches of the bilateral vagus nerves and the left bronchial artery originating from the descending aorta near the left pulmonary hilum are preserved. However, the esophageal branches of the vagus nerves are severed, and the thoracic duct is also removed together with the esophagus. 102 SECTION 2 STEP 3 T-shaped neck incision Esophagus, Stomach and Duodenum A T-shaped neck incision is made and the sternothyroid, sternohyoid and sternomastoid muscles are divided to the clavicular head and the omohyoid muscle is incised at its fascia. After identification of the recurrent nerve, lymph nodes along this nerve (which are in continuity with the nodes previously dissected out in the superior mediastinum) are dissected. The inferior thyroid arteries are then ligated and divided. The paraesophageal nodes, including the recurrent nerve nodes at the cervicothoracic junction, are classified as either cervical or upper mediastinal nodes, according to their position relative to the bifurcation of the right common carotid and right subclavian arteries. Three-Field Lymphadenectomy for Esophageal Cancer STEP 4 103 Cervical lymphadenectomy The jugular vein, common carotid artery, and vagus nerve are subsequently identified and divided. On the lateral side, after careful preservation of the accessory nerve, lymph nodes situated lateral to the internal jugular vein are removed. The thyrocervical trunk and its branches and the phrenic nerve are then identified. In this procedure, the cervical nodes (internal jugular nodes below the level of the cricoid cartilage, supraclavicular nodes, and cervical paraesophageal nodes) are cleared bilaterally (arrow indicates the direction of lymphadenectomy). See transhiatal approach for standard postoperative investigations and complications. 104 SECTION 2 Esophagus, Stomach and Duodenum Tricks of the Senior Surgeon ■ A better exposure of the upper mediastinum requires transection of the medial head of the sternocleidomastoid muscle and/or partial upper sternotomy.
