title: Transoral endoscopic mediastinal surgery (TOEMS)-results of a first clinical study for scarless mediastinal lymph node biopsies.
abstract: BACKGROUND
  Video-assisted mediastinoscopy (VAM) represents the standard procedure for mediastinal lymph node biopsies. This operation results in a scar at prominent position at the anterior neck. Since there is a trend to less invasive procedures, natural orifice transluminal endoscopic surgery (NOTES) was introduced to different fields of surgery. Based on NOTES we developed a new approach for mediastinoscopy: transoral endoscopic mediastinal surgery (TOEMS). In previous studies using human cadavers and living pigs the feasibility of TOEMS was shown. It was unclear whether TOEMS could be safely applied in patients requiring mediastinal lymph node biopsies.
  
  
  METHODS
  We conducted a clinical phase I study recruiting ten patients with unclear mediastinal lymphadenopathy not resolved by prior bronchoscopy. All patients underwent TOEMS for mediastinal lymph node biopsy. The duration of the procedure and complications were monitored. In addition, all patients were examined for pain, swallowing dysfunction and sensation disturbance.
  
  
  RESULTS
  TOEMS was accomplished in eight patients. In two patients operation was converted to VAM due to technical problems. Mediastinal lymph nodes were dissected in all patients who finished with TOEMS. On average, two separate lymph stations were reached by TOEMS. Duration of the procedure was 159±22 min. Permanent palsy of the right recurrent laryngeal nerve was noticed in one patient postoperatively.
  
  
  CONCLUSIONS
  This is the first report for a human application of NOTES in thoracic surgery. In fact, transoral endoscopic surgery seems to be a feasible approach for mediastinal lymph node biopsies. Further studies are needed to show whether this procedure has an advantage over VAM in terms of pain, complications and accessibility of mediastinal lymph node stations.
authors.affiliation: Department of Thoracic Surgery, ELK Berlin Chest Hospital, Berlin, Germany.
authors.forename: Wolfram
authors.initials: W
authors.lastname: Klemm
authors.affiliation: Department of Thoracic Surgery, ELK Berlin Chest Hospital, Berlin, Germany.
authors.forename: Steffen
authors.initials: S
authors.lastname: Frese
authors.affiliation: Department of Thoracic Surgery, ELK Berlin Chest Hospital, Berlin, Germany.
authors.forename: Gunda
authors.initials: G
authors.lastname: Leschber
authors.affiliation: Division of Thoracic Surgery, Sana Krankenhaus Gerresheim, Düsseldorf, Germany.
authors.forename: André
authors.initials: A
authors.lastname: Nemat
authors.affiliation: Department of Otolaryngology, Head/Neck & Facial Plastic Surgery, Sana Kliniken Leipziger Land, Borna, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Wilhelm
keywords: Mediastinoscopy; clinical study; mediastinal lymph node biopsies; natural orifice transluminal endoscopic surgery (NOTES); transoral endoscopic mediastinal surgery (TOEMS)