title: A new concept of the anatomy of the thoracic oesophagus: the meso-oesophagus. Observational study during thoracoscopic esophagectomy.
abstract: BACKGROUND
  During thoracoscopic oesophageal surgery, we observed not previously described fascia-like structures. Description of similar structures in rectal cancer surgery was of paramount importance in improving the quality of resection. Therefore, we aimed to describe a new comprehensive concept of the surgical anatomy of the thoracic oesophagus with definition of the meso-oesophagus.
  
  
  METHODS
  We retrospectively evaluated 35 consecutive unedited videos of thoracoscopic oesophageal resections for cancer, to determine the surgical anatomy of the oesophageal fascia's vessels and lymphatic drainage. The resulting concept was validated in a prospective study, including 20 patients at three different centres. Additional confirmation was sought by a histologic study of a cadaver's thorax.
  
  
  RESULTS
  A thin layer of connective tissue around the infracarinal oesophagus, involving the lymph nodes at the level of the carina, was observed during thoracoscopic esophagectomy in 32 of the 35 patients included in the retrospective study and in 19 of the 20 patients included in the prospective study. A thick fascia-like structure from the upper thoracic aperture to the lower thoracic aperture was visualized in all patients. This fascia is encountered between the descending aorta and left aspect of the infracarinal oesophagus. Above the carina it expands on both sides of the oesophagus to lateral mediastinal structures. This fascia contains oesophageal vessels, lymph vessels and nodes and nerves. The histologic study confirmed these findings.
  
  
  CONCLUSIONS
  Here we described the concept of the "meso-oesophagus". Applying the description of the meso-oesophagus will create a better understanding of the oesophageal anatomy, leading to more adequate and reproducible surgery.
authors.affiliation: Department of Surgery, Vrije Universiteit Medical Centre, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands, ma.cuesta@vumc.nl.
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Cuesta
authors.forename: Teus J
authors.initials: TJ
authors.lastname: Weijs
authors.forename: Ronald L A W
authors.initials: RL
authors.lastname: Bleys
authors.forename: Richard
authors.initials: R
authors.lastname: van Hillegersberg
authors.forename: Mark I
authors.initials: MI
authors.lastname: van Berge Henegouwen
authors.forename: Suzanne S
authors.initials: SS
authors.lastname: Gisbertz
authors.forename: Jelle P
authors.initials: JP
authors.lastname: Ruurda
authors.forename: Jennifer
authors.initials: J
authors.lastname: Straatman
authors.forename: Harushi
authors.initials: H
authors.lastname: Osugi
authors.forename: Donald L
authors.initials: DL
authors.lastname: van der Peet
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000601:surgery; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods; D004947:Esophagus / Q000033:anatomy & histology* / Q000098:blood supply; D005260:Female; D006801:Humans; D042601:Lymphatic Vessels; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D013906:Thoracoscopy / Q000379:methods; D014741:Video Recording