title: Endoscopic transesophageal mediastinal lymph node dissection and en bloc resection by using mediastinal and thoracic approaches (with video).
abstract: BACKGROUND
  The criterion standard for sampling mediastinal lymph nodes is cervical mediastinoscopy. Current methods that require transthoracic or cervical incisions can result in significant postoperative pain.
  
  
  OBJECTIVE
  To determine the feasibility of a novel, transesophageal endoscopic technique for mediastinal lymph node dissection and en bloc resection.
  
  
  METHODS
  Nonsurvival and survival animal study.
  
  
  METHODS
  Animal trial at a tertiary-care academic center.
  
  
  METHODS
  This study involved 12 Yorkshire swine.
  
  
  METHODS
  An endoscopic cap band mucosectomy device was used to create an esophageal mucosal defect. By using the tip of the endoscope and biopsy forceps, a submucosal tunnel was fashioned, and, within the submucosal space, a hook-knife incised the muscular esophageal wall. The endoscope was then advanced into the mediastinum and chest. Mediastinoscopy and thoracoscopy were performed to identify lymph node stations. Prototype endoscopic devices permitted lymph node dissection prior to removal with an electrocautery snare. A covered prototype stent was placed over the mucosectomy site.
  
  
  METHODS
  Feasibility of endoscopic transesophageal lymphadenectomy.
  
  
  RESULTS
  Three lymph nodes (1 para-aortic and 2 right paratracheal) were removed in the 3 nonsurvival swine. Nine swine were survived for 14 days (range 13-14 days) and had a total of 7 lymph nodes (2 para-aortic and 5 paratracheal) removed. Two swine had no endoscopically visible lymph nodes in the mediastinum or chest. Lymph node dissection and resection was successful in all cases where lymph nodes were identified. Lymphadenectomy was completed in a median time of 20.0 minutes (range 8-60 minutes); median total procedure time was 70.0 minutes (range 28-105 minutes). Median lymph node size was 1.1 cm (range 0.6-1.4 cm).
  
  
  CONCLUSIONS
  Animal study.
  
  
  CONCLUSIONS
  An endoscopic transesophageal approach can accomplish mediastinal lymph node dissection and en bloc resection and provides architecturally intact lymph node specimens for histologic examination.
authors.affiliation: Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
authors.forename: Brian G
authors.initials: BG
authors.lastname: Turner
authors.forename: Denise W
authors.initials: DW
authors.lastname: Gee
authors.forename: Sevdenur
authors.initials: S
authors.lastname: Cizginer
authors.forename: Min-Chan
authors.initials: MC
authors.lastname: Kim
authors.forename: Mari
authors.initials: M
authors.lastname: Mino-Kenudson
authors.forename: Patricia
authors.initials: P
authors.lastname: Sylla
authors.forename: William R
authors.initials: WR
authors.lastname: Brugge
authors.forename: David W
authors.initials: DW
authors.lastname: Rattner
mesh_terms: D000818:Animals; D004947:Esophagus; D005240:Feasibility Studies; D008197:Lymph Node Excision / Q000379:methods*; D008481:Mediastinoscopy / Q000379:methods*; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D013552:Swine