The rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in Japan. We retrospectively reviewed short- and long-term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position. Between 1996 and 2015, 654 patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position. Patients were divided into early (1996–2008) and late groups (2009–2015, with standardization of the procedure and formalized training), and their clinical outcomes reviewed. The completion rate of thoracoscopic esophagectomy was 99.5%, and the procedure was converted to thoracotomy in three patients, due to hemorrhage. The mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were 205.0 min, 127.3 mL, and 24.7, respectively. Postoperative complications included pneumonia (8.5%), anastomotic leakage (7.5%), and recurrent nerve paralysis (3.5%). Postoperative (30d) mortality was 4/654 (0.61%) due to anastomotic leak and pneumonia. The five year overall survival rate was 70%. A comparison of the 289 early- and 365 late-study period cases revealed significant differences in mean intrathoracic blood loss (174.0 vs. 94.2 mL), number of mediastinal lymph nodes dissected (20.0 vs. 28.4), hospital length of stay (33.4 vs. 20.0 days, p < 0.001), and postoperative anastomotic leakage (14% vs. 1.6%, p < 0.0001). Standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position, with a standardized clinical pathway for perioperative care led to significant improvements in surgical outcomes.

INTRODUCTION: An epiphrenic esophageal diverticulum (EED) typically occurs in association with esophageal motility disorders such as esophageal achalasia. Although peroral esophageal myotomy (POEM) is the current standard treatment for esophageal achalasia, laparoscopic diverticulectomy with esophageal myotomy and fundoplication are usually performed for EED. Here, we report four cases of thoracoscopic esophageal diverticulectomy performed for symptomatic EED after POEM for esophageal achalasia.CASE PRESENTATION: Between 2022 and March 2024, four patients with EED (average diameter, 68 mm) underwent endoscopic esophageal cleaning prior to surgery. POEM was initially performed in all four cases; however, two patients experienced persistent symptoms, while two experienced progressive EED enlargement over the years, necessitating additional surgery. All operations were performed thoracoscopically with the patient in the left lateral position. After resection of the EED, the mediastinal pleura was sutured. Endoscopy, using an endoscopic balloon, was effective in preventing esophageal strictures. No postoperative complications occurred, and the mean postoperative hospital stay was 5.5 (4–8) days. All patients improved postoperatively and remained relapse-free.CONCLUSIONS: Thoracoscopic esophageal diverticulectomy for large EED can be safely performed with better working space than laparoscopic procedures. Therefore, this technique should be considered a minimally invasive treatment for symptomatic EED cases unresponsive to POEM.

Background and Objectives: The benefits of prophylactic supraclavicular lymph node dissection for esophageal squamous cell carcinoma (ESCC) remain controversial. This study investigated whether prophylactic supraclavicular (cervical) lymphadenectomy improves the long-term outcomes of patients with upper or middle thoracic esophageal squamous cell carcinoma. Materials and Methods: This retrospective, single-center study included 290 patients who underwent thoracoscopic esophagectomy between January 2010 and December 2017. Patients treated with two-field lymphadenectomy (2FL) were compared with those who underwent prophylactic three-field lymphadenectomy (p3FL) after propensity score matching based on age, tumor location, clinical T and N stage, and preoperative treatment. The primary outcome was overall survival (OS), and secondary outcomes included postoperative complications and recurrence patterns. In a secondary analysis, the long-term outcomes were assessed in patients with solitary postoperative cervical (supraclavicular) lymph node recurrence in the 2FL group. Results: In the overall cohort, statistically significant differences were observed between the groups with respect to age, tumor location (p = 0.0002), cT and cN stages (p < 0.0001 and p < 0.0001), preoperative treatment (p = 0.02). No significant differences were observed between groups regarding age, organ for reconstruction, or postoperative complications. After propensity score matching, no significant differences were observed between the 2FL and p3FL groups in terms of overall survival or postoperative complications. Six patients (4.4%) in the p3FL group had pathologically confirmed supraclavicular lymph node metastasis, whereas four patients (2.6%) in the 2FL group developed solitary postoperative cervical lymph node recurrence. Patients with isolated cervical recurrence achieved favorable long-term survival following additional treatment. Conclusions: Prophylactic cervical lymphadenectomy did not improve the survival of patients with upper or middle thoracic esophageal squamous cell carcinoma. Given the low incidence of isolated cervical lymph node recurrence and the favorable outcomes achievable with additional treatment, routine prophylactic supraclavicular dissection appears unnecessary when two-field lymphadenectomy is feasible.

Background/Aim: Esophagogastric junction (EGJ) adenocarcinoma is an aggressive cancer with poor prognosis. Metastasis to the upper mediastinal lymph nodes is rare, with reported rates of 3.8% to 6.1%. This case report highlights the diagnostic and therapeutic challenges of oligometastatic recurrence in EGJ adenocarcinoma, emphasizing the role of surgery in selected cases. Case Report: A 63-year-old male underwent proximal gastrectomy for a Siewert type 2 poorly differentiated EGJ adenocarcinoma. Postoperative histopathology confirmed the diagnosis of stage 1 cancer. At 30 months, contrast-enhanced computed tomography (CT) scan detected a right paratracheal lymph node recurrence. Subsequent follow-up CT and positron emission tomography (PET) scan revealed progressive enlargement of the same lymph node with negative PET uptake. Owing to strong clinical and radiological suspicion of oligometastasis, thoracoscopic lymphadenectomy was performed with the patient in the left lateral decubitus position under one-lung ventilation. The postoperative histopathological examination confirmed metastatic adenocarcinoma. The patient was discharged uneventfully on postoperative day 5 and prescribed with adjuvant tegafur–gimeracil–oteracil (S-1). He remained asymptomatic during ongoing surveillance. Conclusion: This case highlights the challenges in diagnosing oligometastatic recurrence of EGJ adenocarcinoma, particularly when typical imaging signs are absent. It also demonstrates the importance of a multidisciplinary treatment approach, including careful surveillance and timely intervention. Surgery is one of the options for oligometastasis.

Minimally invasive esophagectomy (MIE) has become increasingly prominent in the surgical management of esophageal cancer (EC) over the past three decades. The adoption of minimally invasive techniques has significantly enhanced oncologic esophageal surgery by improving safety, achieving oncological radicality, preserving physiological function, and elevating the postoperative quality of life of the patients. The complexity of MIE lies in its technical nuances, which critically influence postoperative morbidity and, in severe cases, mortality, especially when complications evolve unchecked. These risks underscore the importance of meticulous surgical execution and perioperative management. The optimization of mediastinal lymphadenectomy and the reduction of procedure-related morbidity have consistently represented focal points of scientific inquiry and clinical refinement, posing a persistent challenge for esophageal surgeons. MIE is widely regarded as one of the most technically demanding procedures in oncologic surgery. Its advantages, however, are most evident in the postoperative phase, where reduced trauma and faster recovery are key benefits. Experienced surgical teams have introduced refinements to MIE protocols, aiming to optimize precision and reduce complication rates. This study aims to systematically synthesize the main technological advancements and innovations currently employed in the minimally invasive management of EC, presenting them in a structured classification designed to be both accessible and practical for specialists engaged in this domain.