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INTRODUCTION

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Multimodality approaches including surgery, radiotherapy, and chemotherapy are essential for the treatment of advanced esophageal carcinoma.1,2 Surgery has been used for locoregional control and has played a major role in the treatment of midstage esophageal cancer.3 The tumor site is an important factor in the selection of surgical approaches because the distribution and incidence of lymph node metastasis vary according to the location of primary tumors. Moreover, the midthoracic esophagus is the most frequent site of primary tumors of thoracic esophageal squamous cell carcinoma (SCC), whereas adenocarcinomas (ADC) are usually located in the lower thoracic esophagus or esophagogastric junction.4 Thoracic esophageal SCC are commonly accompanied by extensive lymph node metastases from cervical to abdominal regions. Although cervical and upper mediastinal nodes are more commonly involved in patients with carcinomas of the upper thoracic esophagus, lower mediastinal and perigastric nodes are the most common sites in patients with carcinomas of the lower thoracic esophagus.5 In patients with carcinomas of the middle thoracic esophagus, the primary lesion is often accompanied by extensive metastases in lymph nodes located from the neck to the abdomen. Thus, transthoracic esophagectomy and mediastinal lymph node dissection are generally performed as a curative surgical resection.

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Extensive three-field lymph node dissection of cervical, mediastinal, and abdominal lymph nodes was developed in Japan in the 1980s for surgically curable esophageal cancers of the middle or upper thoracic esophagus.4 Although the survival benefit of three-field lymphadenectomy for esophageal cancer has not been demonstrated in large-scale randomized controlled trials,6,7 there are several reports that suggest the importance of radical three-field lymph node dissection for locoregional control of esophageal cancer.3,4-12 In particular, significance of meticulous and extensive lymph node dissection along the bilateral recurrent laryngeal nerves is well recognized. In the clinical trials including surgical components, thoracic esophagectomy with D2 lymph node dissection is considered as a standard procedure for thoracic esophageal cancer.

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PREOPERATIVE EVALUATION

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Distribution and risk of lymph node involvement are closely related to tumor location, size, and depth of invasion. Therefore, preoperative evaluations using computed tomography, endoscopic ultrasonography, magnetic resonance imaging, or positron emission tomography are required to determine the extent of lymph node dissection for each patient.13

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TECHNIQUES OF D2 ESOPHAGECTOMY

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Thoracic Procedures

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In the left decubitus position, right posteriolateral thoracotomy at 5th intercostal space or anterolateral thoracotomy at 4th intercostal space is used as a standard open approach under the one lung ventilation anesthesia. After the division of the azygous arch, the posterior side of the right upper mediastinal pleura is incised up to the right subclavian artery. The right bronchial artery is then carefully isolated and preserved in case of open esophagectomy, and the dorsal and left sides of the upper esophagus are dissected from the left pleura. The thoracic duct with ...

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