Results of transmediastinal endoscopic oesophageal dissection.

A theoretical benefit of transhiatal oesophagectomy (THOE), the avoidance of thoracotomy, is counteracted by the fact that mediastinal dissection of the oesophagus is performed bluntly by hand and without direct vision. To overcome these difficulties, we have described a technique of oesophageal endodissection and evaluated its clinical results. This method allows for mediastinal dissection of the thoracic oesophagus by the use of a mediastinoscope, videoendoscopy and dedicated instruments. Structures such as the trachea, both main bronchi, the vagal trunks, the parietal pleura and mediastinal lymph nodes can be regularly identified. From April/91 until October/93 57 patients underwent endodissection for THOE because of adenocarcinoma of the oesophagus; most of these patients were included in a separate prospective analysis. We found that endodissection was helpful intraoperatively because mediastinal dissection can be performed simultaneously with the abdominal approach; main anatomic structures as well as tumor staging information can be determined even before the hiatus is opened by the abdominal team. Major intraoperative complications were rare (n = 3, 5.3%) and all but one (lesion of the right main bronchus) were managed without thoracotomy. 30-day mortality of all patients was 5.3% (n = 3). Comparative data from a previous prospective study revealed that the main clinical advantage of endodissection over conventional THOE was the lower rate of postoperative pulmonary complications and a low rate of recurrent nerve palsy. Thus, we believe that endodissection is a technical improvement; the method, however, does not solve the problem of the limited dissection of THOE because a systematic lymphadenectomy cannot be performed.