Mediastinoscopy-Assisted Transhiatal Esophagectomy (MATHE) for Esophageal Squamous Cell Carcinoma (SCC)

Authors
Nichole Tan Wan Qian, Daryl Chia Kai Ann, A/Prof Asim Shabbir, Prof Jimmy So, Asst Prof Kim Guowei

Introduction
Transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are accepted procedures for esophageal cancer but the best approach has yet to be determined. TTE offers better visualization of the tumour and more extended lymph node resection whereas THE has reduced pulmonary morbidity at the cost of less radical mediastinal nodal dissection. MATHE is a relatively newer technique that allows for visualization and en-bloc dissection of mediastinal lymph nodes while retaining the benefits of THE.

Methods
This is a case of a 70-year-old female, a chronic smoker with borderline lung function. She presented with dysphagia and was worked up to have Stage 2 upper to middle esophageal SCC. She underwent chemoradiotherapy (CROSS regime) and subsequently underwent MATHE.

MATHE starts with a laparoscopic abdominal approach, mobilizing the stomach, along with radical upper abdominal lymph node dissection. The hiatus is then dissected, and the lower esophagus, along with the lower mediastinal nodes are dissected enbloc up to the level of the carina.

A 4cm left neck transverse incision is then performed. The left recurrent laryngeal nerve and cervical esophagus are identified and dissected. A Gelpoint Mini (Applied Medical) is placed into the neck incision. Mediastinoscopic dissection of the upper to mid esophagus with nodal dissection is then performed, taking the paraesophageal, subcarinal and bilateral recurrent laryngeal nodes. Via a 4cm upper midline mini laparotomy, the gastric tube is fashioned, and a retrosternal gastric pull-up is performed with esophago-gastric anastomosis in the neck.

Results
MATHE allows for en-bloc dissection of mediastinal lymph nodes while being able to avoid single lung ventilation and its potential morbidity. As MATHE is a relatively new advancement, more data can be collected to validate the outcomes of this novel approach.

Conclusion
MATHE is a feasible option for patients in whom one lung ventilation and TTE may not be ideal.