Histological study of the structural layers around the esophagus in the lower mediastinum
Toshifumi SaitoSatoru MuroHisashi FujiwaraYuya UmebayashiYuya SatoMasanori TokunagaKeiichi AkitaYusuke Kinugasa
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Abstract:
In Japan, the transhiatal approach, including lower mediastinal lymph node dissection, is widely performed for Siewert type II esophagogastric junction adenocarcinoma. This procedure is generally performed in a magnified view using laparoscopy or a robotic system, therefore, the microanatomy of the lower mediastinum is important. However, mediastinal microanatomy is still unclear and classification of lower mediastinal lymph nodes is not currently based on fascia or other microanatomical structures.To clarify the fascia and layer structures of the lower mediastinum and classify the lower mediastinal tissue.We dissected the esophagus and surrounding organs en-bloc from seven cadavers fixed in 10% formalin. Organs and tissues were then cut at the level of the lower thoracic esophagus, embedded in paraffin, and serially sectioned. Tissue sections were stained with Hematoxylin-Eosin (all cadavers) and immunostained for the lymphatic endothelial marker D2-40 (three cadavers). We observed the periesophageal fasciae and layers, and defined lymph node boundaries based on the fasciae. Lymphatic vessels around the esophagus were observed on immunostained tissue sections.We identified two fasciae, A and B. We then classified lower mediastinal tissue into three areas, paraesophageal, paraaortic, and intermediate, using these fasciae as boundaries. Lymph nodes were found to be present and were counted in each area. The dorsal part of the intermediate area was thicker on the caudal side than on the cranial side in all cadavers. On the dorsal side, no blood vessels penetrated the fasciae in six of the seven cadavers, whereas the proper esophageal artery penetrated fascia B in one cadaver. D2-40 immunostaining showed lymphatic vessel connections between the paraesophageal and intermediate areas on the lateral and ventral sides of the esophagus, but no lymphatic connection between areas on the dorsal side of the esophagus.Histological studies identified two fasciae surrounding the esophagus in the lower mediastinum and the layers separated by these fasciae were used to classify the lower mediastinal tissues.Keywords:
Mediastinal lymph node
The role of systematic mediastinal lymph node dissection in the staging and treatment of non-small cell lung cancer (NSCLC) is the subject of ongoing debate. Surgical practice varies from simple visual inspection of the unopened mediastinum to radical, systematic lymphadenectomy of all accessible lymph node levels. As the evaluation of mediastinal lymph nodes is a precondition for accurate intraoperative staging of NSCLC we advocate for complete interlobar, hilar and mediastinal lymphadenectomy as compartment dissections in patients with NSCLC. The therapeutic effect of extensive mediastinal lymphadenectomy, however, remains controversial. In this review we discuss the role of mediastinal lymph node dissection in the management of NSCLC.
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To evaluate the outcomes with 2 and 3 lymph node dissection for patients with squamous cell carcinoma of the lower thoracic esophagus at a single institution.
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Mediastinal lymph node
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Recently the pros and cons of limited surgery for small-sized peripheral non-small-cell lung cancers (PNSCLCs), such as omission of mediastinal dissection, etc., have been vigorously debated. We analyzed whether hilar/mediastinal lymph node metastases were present in 30 small-sized PNSCLCs.In the nine years from 1990 to 1998, 294 lung cancer patients underwent lobectomy or pneumonectomy combined with hilar/mediastinal dissection in the Tokai University Hospital. Thirty of these patients diagnosed as having cT1N0M0 PNSCLC with tumor diameters of 1.5 cm or less by computed tomography, are evaluated in this article.The 30 PNSCLC patients consisted of 14 males and 16 females with a mean age of 61 +/- 9 years. Twenty six patients (87%) had no hilar nor mediastinal lymph node metastases (pN0), one patient (3%) had a hilar lymph node metastasis (pN1), and three patients (10%) had mediastinal lymph node metastases (pN2).Mediastinal lymph node metastases were histologically observed in 3 (10%) of 30 PNSCLC patients with tumor diameters of 1.5 cm or less. Our results show that mediastinal dissection is still necessary even for small-sized lung cancers.
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Anterior dissection of the rectum in the male pelvis represents one of the most complex phases of total meso-rectal excision. However, the possible existence of different anatomical planes is controversial and the exact anatomical topography of Denonvilliers' fascia is still debated. The aim of the study is to accurately define in a cadaveric simulation model the existence and boundaries of Denonvilliers' fascia, identifying the anatomical planes suitable for surgical dissection. The pelvises of 31 formalin-preserved male cadavers were dissected. Careful and detailed dissection was carried out to visualize the anatomical structures and the potential dissection planes, simulating an anterior meso-rectum dissection. Denonvilliers' fascia was identified in 100% of the pelvises, as a single-layer fascia that originates from the peritoneal reflection and descends until its firm adhesion to the prostate capsule. The fascia divides the space providing an anterior and a posterior plane. Anteriorly to the fascia, during the caudal dissection, its firm adhesion to the prostate capsule forces to section it sharply. The cadaveric simulation model allowed an accurate description of Denonvilliers' fascia, defining several planes for anterior dissection of the meso-rectum.
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To evaluate the complete thoracoscopic lower right lobectomy and mediastinal lymph node. During the surgery, the lower right pulmonary artery and vein, bronchi and lymph nodes were treated using a unidirectional approach. Eight stations (2, 3, 4, 7, 8, 9, 10 and 11) of lymph nodes were dissected completely en bloc. Repeated stretch and flipping was avoided in this procedure, which was beneficial for the unaffected side of the lung. The operation of lymph node dissection was completed thoroughly in accordance with standard principles.
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Objective:To investigate the clinical value of mediastinal lymph node resection using video-assisted thoracoscopic surgery(VATS) in the treatment of lung cancer.Methods:Fifty patients with lung cancer were treated by lobectomy combined with mediastinal lymph node resection using video-assisted thoracoscopic surgery(VATS),then they received open dissection of mediastinal lymph nodes.The lymph nodes dissected in the open surgery were labeled,counted and sent for histopathological detection.Results: Totally 48 lymph nodes were resected using co-resection of conventional surgery.Zero to 3 lymph nodes were resected in each patient with an average of 0.96.Moreover,the pathological results were negative.Conclusion:This study preliminarily demonstrates that mediastinal lymph node resection using video-assisted thoracoscopic surgery(VATS) has the identical clinical value in the treatment of lung cancer when compared with conventional surgery.
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Purpose: We compared open, video-assisted and robotic-assisted thoracoscopic surgical techniques in the dissection of N1 and N2-level lymph nodes during surgery for lung cancer.
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