Expanding Horizons in Esophageal Cancer Surgery: The Promise of EMLE

Esophageal cancer is a significant global health concern, ranking seventh in terms of morbidity and sixth in terms of mortality worldwide. Traditional surgical approaches for esophageal cancer, such as thoracotomy and laparotomy, have been associated with significant patient trauma and postoperative complications. Video-assisted thoracoscopic and laparoscopic radical esophagectomy (VATLE) has gained popularity due to its minimally invasive nature and reduced patient trauma, but it still has limitations, including the need to change body position during surgery and a long operation time. Additionally, some patients may not be suitable candidates for VATLE due to factors like cardiopulmonary function reserve or chest deformities.

To address these limitations and provide more surgical options for esophageal cancer patients, Professor Weidong Zhang, Dr. Dong Cui, Dr. Kefeng Shi, Dr. Maolin Chen, Dr. Binbin Zhang, and Professor Rulin Qian from  introduced a novel surgical approach called Expandable Mediastinoscopic and Laparoscopic Radical Esophagectomy (EMLE) in 2019. This technique aims to improve patient outcomes by reducing surgical trauma, increasing surgical space, and minimizing interference with the heart and lungs during the procedure.

The research team analyzed the therapeutic efficacy and safety of EMLE in 106 patients with esophageal cancer from January 2019 to June 2022. The inclusion criteria for EMLE surgery included a diagnosis of esophageal squamous cell carcinoma, clinical stage I–IIIA, age between 18 and 80 years, adequate cardiopulmonary function, absence of other cancers, and voluntary patient participation. The study was approved by the Ethics Committee of Henan Provincial Chest Hospital, and informed consent was obtained from all patients.

Briefly, the surgical procedure for EMLE developed by the authors involves several steps:

1. Cervical Mobilization of the Esophagus and Lymphadenectomy: This step involves making an incision in the neck, identifying and protecting the left recurrent laryngeal nerve, and dissecting the left paraesophageal cervical lymph nodes and left supraclavicular lymph nodes. An esophageal band is placed at the cervical esophagus, and the right paraesophageal cervical lymph nodes and right supraclavicular lymph nodes are dissected.
2. Mediastinoscopic Mobilization of the Upper and Middle Thoracic Esophagus and Lymphadenectomy: The expandable mediastinoscope is used to dissect lymph nodes in the mediastinal cavity, including those around the right recurrent laryngeal nerve, subcarinal space, and left recurrent laryngeal nerve lymph nodes. The procedure s around the thoracic esophagus to meet the laparoscopy procedure.
3. Laparoscopic Mobilization and Formation of a Gastric Conduit and Lymphadenectomy: Abdominal stage operations are performed, including forming a gastric conduit, dissociating the middle and lower thoracic esophagus, and dissecting lymph nodes in the abdomen.
4. Gastroesophageal Anastomosis: The tubular stomach is pulled up to the cervical incision, and an end-to-side gastroesophageal anastomosis is performed.
5. Postoperatively, patients receive parenteral nutrition support and are closely monitored for complications. The mediastinal drainage tube is removed when drainage volume is minimal, and the patient resumes a normal liquid diet.

The authors findings showed that EMLE is a safe and reliable surgical method for esophageal cancer. They found low conversion rates to thoracotomy or laparotomy, shorter operation times and lower intraoperative blood loss compared to traditional thoracotomy and VATLE, favorable lymph node dissection outcomes, low incidence of postoperative complications, with no perioperative deaths and a relatively short postoperative hospital stay.

While EMLE demonstrated promising results in this study, the authors acknowledged the need for further research and prospective randomized controlled trials to validate its long-term safety and efficacy fully. Despite its potential, EMLE should be considered for patients with esophageal cancer, especially those with poor cardiopulmonary function or specific clinical characteristics.

In conclusion, Expandable Mediastinoscopic and Laparoscopic Radical Esophagectomy represents a valuable addition to the surgical options available for esophageal cancer patients. It offers the potential to improve patient outcomes, reduce surgical trauma, and expand the range of candidates suitable for minimally invasive esophageal cancer surgery. Further research and clinical validation are warrented to confirm its role in the management of this challenging disease.