Kalayarasan Raja, Sai Krishna Pothugunta
Department of Surgical Gastroenterology Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry India.
Ann Gastroenterol Surg. 2024 Sep 11;9(1):12-23. doi: 10.1002/ags3.12862. eCollection 2025 Jan.
Radical lymphadenectomy is the critical component of surgery for esophageal cancer. However, lymphadenectomy significantly contributes to postoperative morbidity, particularly in terms of pulmonary complications following esophagectomy. Function-preserving mediastinal lymphadenectomy seeks to balance the procedure's necessary radicality and optimal functional outcomes. This approach emphasizes the preservation of the thoracic duct, tracheobronchial vascularity, and the pulmonary and recurrent laryngeal branches of the vagus nerve. Preservation of the thoracic duct is facilitated by indocyanine green fluorescence. Compared to the conventional technique of thoracic duct identification using anatomical landmarks, indocyanine green fluorescence lymphangiography offers real-time feedback, making it particularly advantageous in cases with complex anatomy or when the thoracic duct is challenging to visualize using conventional methods. Preservation of pulmonary branches of the right vagus during subcarinal lymphadenectomy and left recurrent laryngeal nerve during left paratracheal node dissection are technically challenging. The description of two types of left recurrent laryngeal nerve node dissection and technical tips for nerve function preservation are outlined in this review. Intraoperative neuromonitoring is a useful adjunct for nerve-sparing mediastinal lymphadenectomy. As ischemia to the respiratory tract impairs respiratory protective mechanisms, preservation of the tracheobronchial blood supply is critical. Preoperative imaging to detect bronchial artery anatomical variations and intraoperative assessment of perfusion using laser doppler flowmetry and indocyanine green fluorescence angiography are useful strategies to minimize tracheobronchial ischemia. Function-preserving mediastinal lymphadenectomy has the potential to improve short- and long-term outcomes after esophagectomy for esophageal cancer.
根治性淋巴结清扫术是食管癌手术的关键组成部分。然而，淋巴结清扫术会显著增加术后发病率，尤其是在食管切除术后的肺部并发症方面。保留功能的纵隔淋巴结清扫术旨在平衡手术所需的根治性和最佳功能结果。这种方法强调保留胸导管、气管支气管血管以及迷走神经的肺支和喉返支。吲哚菁绿荧光有助于保留胸导管。与使用解剖标志识别胸导管的传统技术相比，吲哚菁绿荧光淋巴管造影提供实时反馈，在解剖结构复杂或使用传统方法难以观察到胸导管的情况下特别有利。在隆突下淋巴结清扫术中保留右迷走神经的肺支以及在左气管旁淋巴结清扫术中保留左喉返神经在技术上具有挑战性。本文综述概述了两种类型的左喉返神经淋巴结清扫术及神经功能保留的技术要点。术中神经监测是保留神经的纵隔淋巴结清扫术的有用辅助手段。由于呼吸道缺血会损害呼吸保护机制，因此保留气管支气管血供至关重要。术前成像检测支气管动脉解剖变异以及术中使用激光多普勒血流仪和吲哚菁绿荧光血管造影评估灌注是减少气管支气管缺血的有用策略。保留功能的纵隔淋巴结清扫术有可能改善食管癌食管切除术后的短期和长期结果。
