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Kikuchi et al. Mini-invasive Surg 2024;8:8 https://dx.doi.org/10.20517/2574-1225.2023.88 Page 7 of 11

Figure 6. Intraoperative views of upper mediastinal lymphadenectomy along the bilateral recurrent laryngeal nerves. (A) Operative field
after lymphadenectomy around the right recurrent laryngeal nerve; (B) Dissection of fat tissues containing lymph nodes no. 106recL
from the left side of the trachea using Maryland bipolar forceps or a vessel sealer; (C) Clipping and cutting of small vessels around the
left recurrent laryngeal nerve using Potts scissors; (D) Operation field after lymphadenectomy around the left recurrent laryngeal nerve.
A: Assistant; AoA: aortic arch; Eso: esophagus; LH: left hand; LS: linear stapler; Lt RLN: left recurrent laryngeal nerve; RH: right hand; Rt
RLN: right recurrent laryngeal nerve; Rt SCA: right subclavian artery; TD: thoracic duct; Tra: trachea.

evaluating for anastomotic leakage using computed tomography (CT) scan and gastrointestinal contrast
imaging and for swallowing function through a swallowing videofluorography on POD 7.

SHORT-TERM OUTCOMES
We performed RAMIE followed by reconstruction with a gastric conduit (n = 84) or second-stage
reconstruction with a right colon conduit (n = 7) in 91 patients with resectable thoracic esophageal or EGJ
cancer between October 2018 and March 2023. Their median age was 68 [interquartile range (IQR) 60-72].
The histological types were SCC (59.2%) and ADC (38.0%). The main tumor locations were in the upper,
middle, and lower esophagus in 14.1%, 23.9%, and 26.8%, respectively, and in the EGJ zone in 35.2% of the
patients. The clinical tumor depths were T1, T2, T3, and T4 in 31.0%, 7.0%, 50.7%, and 11.3% of patients,
respectively. No patients received chemoradiation or radiotherapy before surgery. Two- and three-field
lymphadenectomies were performed in 64.8% and 35.2% of them, respectively. The median total operative
time was 540 min (range, 508-587 min). No patients underwent conversion to open thoracotomy. Earlier, in
the introduction phase of RAMIE, we experienced a high volume of postoperative effusion and the
cumulative volume of drainage fluid from the right chest tube, compared with that of conventional MIE
(case nos. 1-7, Figure 7). In some cases, pharmacological treatments were needed to reduce the pleural
effusion while no major fatal effects were observed due to the increased pleural effusion. Therefore, we
standardized the use of a vessel sealer rather than Maryland bipolar forceps around the thoracic duct, which