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Eur J Cardiothorac Surg 2005;27:384-390
© 2005 Elsevier Science NL

Transcervical extended mediastinal lymphadenectomy—the new operative technique and early results in lung cancer staging

Jarosaw Kuda^a,*, Marcin Zieliski^a, Bolesaw Papla^b, Artur Szlubowski^a, ukasz Hauer^a, Tomasz Nabiaek^a, Witold Sonicki^a, Juliusz Pankowski^c

^a Department of Thoracic Surgery, Pulmonary Hospital Zakopane, ul. Gadkie 1, 34-500 Zakopane, Poland
^b Chair and Department of Clinical and Experimental Pathology, Jagiellonian University, Cracow, Poland
^c Department of Pathology, Pulmonary Hospital Zakopane, Zakopane, Poland

Received 15 September 2004; received in revised form 27 November 2004; accepted 6 December 2004.

^* Corresponding author. Tel.: +48 600 815664; fax: +48 18 20 14632. (E-mail: j.kuzdzal{at}mp.pl).

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Conference... References

 
Objective: Mediastinal staging is one of the most important problems in thoracic surgery. Although the pathological examination is a generally accepted standard, none of the currently used techniques enables complete removal of all lymph node stations of the mediastinum. The aim of the study is to present a new technique of transcervical extended mediastinal lymphadenctomy (TEMLA) and to analyze its value in lung cancer staging. Methods: In the prospective study of consecutive group of non-small cell lung cancer (NSCLC) patients, operated on between January and August 2004, we evaluated the usefulness of this original technique of bilateral mediastinal lymphadenectomy, assessing its accuracy and safety. The operations were performed through the transcervical approach, were videomediastinoscopy-assisted, with sternum elevation. Lymph node stations 1, 2R, 2L, 3a, 4R, 4L, 5, 6, 7 and 8 were removed. In patients without mediastinal metastases thoracotomy with pulmonary resection was performed and mediastinum searched for any missed lymph nodes. Results: There were 83 patients operated on with the TEMLA technique. The mean number of nodes removed was 43 (range: 26–85). The sensitivity, specificity and accuracy of the presented method in detecting mediastinal node metastases were: 90, 100, and 96%, respectively, whereas the positive and negative predictive values were: 100 and 95%, respectively. Conclusions: The TEMLA technique is a safe and highly accurate method of mediastinal staging in NSCLC.

Key Words: Non-small cell lung carcinoma • Lymph node excision • Mediastinum • Neoplasm staging

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Conference... References

 
Staging of lung cancer is one of the fundamental elements of pre-treatment work-up, as it allows for choosing appropriate management of the patient. Proper evaluation of the N status is of particular importance, due to its impact on therapeutic decisions. The ideal staging procedure should be characterized by the following features: (1) high accuracy, defined by the sensitivity, specificity and positive and negative predictive values, (2) limited invasiveness and (3) cost-effectiveness. The most widely used imaging technique, the computed tomography (CT), has limited accuracy, as well as the magnetic resonance imaging; the positron emission tomography (PET), although more precise, has also specific limitations and the high cost makes it unsuitable for routine practice. Due to these limitations the mainstay of mediastinal staging remain invasive procedures, aimed to establish the tissue diagnosis. These techniques include: cervical mediastinoscopy, transbronchial needle aspiration (TBNA), transthoracic needle aspiration (TTNA) and endoscopic ultrasound needle aspiration (EUS-NA). The gold standard is still the mediastinoscopy, which usefulness was shown in many studies [1–4]. However, this technique has also specific drawbacks, the most important of which are: (1) difficulties in the whole nodes removal (sampling); routinely only the nodal biopsy is performed and (2) access to a limited number of lymph node stations—usually only 2R, 4R, 2L, 4L and 7 and (3) difficulties in demarcation between stations 2 and 4. There were several techniques described to overcome these difficulties, like the extended cervical mediastinoscopy [5,6], mediastinoscopy combined with anterior mediastinotomy [7] and the radical video-assisted mediastinoscopic lymphadenectomy [8], but none of them addressed all the drawbacks of mediastinoscopy. The superradical bilateral mediastinal dissection, described by Hata et al., is the only technique allowing for a really complete dissection of all stations of mediastinal lymph nodes [9,10]. However, it never gained a wide acceptance because of its significant invasiveness, unacceptable for a diagnostic/staging procedure.

Based on our experience with the technique of transcervical-subxiphoid-videothoracoscopic ‘maximal’ thymectomy [11], one of us (MZ) developed the technique of the transcervical extended mediastinal lymphadenectomy (TEMLA), enabling the complete removal of lymph node stations 1,2 R, 2L, 3a 4R, 4L, 5, 6, 7, and partially 8. This procedure is performed through the cervical incision, using a retractor elevating the sternum. Despite its safety and limited invasiveness, its completeness is—with exception of node station 9—comparable to the transsternal-transcervical extended lymphadenectomy described by Hata et al. [9,10].

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Conference... References

 
2.1. Patients
From January 1, 2004 we have been conducting a prospective trial to assess the usefulness of the new operative technique of TEMLA in mediastinal staging of NSCLC patients. The inclusion criteria for the study were as follows:

(1) diagnosed NSCLC in clinical stage I–IIIA

(2) absence of bulky N2 disease

(3) general performance status enabling major pulmonary resection (lobectomy or pneumonectomy, as indicated by the T status)

(4) informed consent of patients regarding the new operative technique.

The basic preoperative work-up included medical history, physical examination, blood and urine tests, abdominal ultrasonography, bronchoscopy, CT of the chest and upper abdomen and spirography. Other diagnostic studies were used when indicated.

All the patients were operated on using the TEMLA technique. The lymph nodes removed from each station were counted and labelled separately. The examination of the specimen stained with hematoxylin and eosin were performed by two pathologists especially dedicated to pulmonary pathology.

Patients with mediastinal nodes involvement (N2 or N3) were referred for neoadjuvant therapy, whereas those with negative nodes were reevaluated for their general fitness and scheduled for pulmonary resection.

During the time of the study two subgroups of patients are to be distinguished: the first one (group A) consisted of 50 patients operated on before May 17, in which the aortic lymph nodes (stations 5 and 6) were dissected only if the primary tumor was localized in the left lung. The second subgroup (group B) consisted of 33 patients operated on after this date, in which removal of node stations 5 and 6 was routinely performed regardless of the side of the primary tumor.

As a control measure of the completeness of the lymphadenectomy we used the total number of nodes removed and the number of nodes removed in each station. The confirmatory test, used in the patients subset undergoing pulmonary resection was the finding at thoracotomy; during the pulmonary resection the mediastinum was dissected and carefully searched for any missed nodes. At the right thoracotomy we searched for node stations 2R, 3a 4R, 7 and 8, and at the left thoracotomy stations: 5, 6, 7 and 8. The nodes found were recorded and sent for a pathological examination.

The statistical analysis was performed using the STATISTICA software package. The significance of the correlation coefficient was calculated using a regression line analysis and the Pearson linear correlation coefficient. The significance was set at p<0.05.

The study design was accepted by the Bioethical Committee of the Jagiellonian University in Cracow.

2.2. Operative technique
The 5–6cm collar incision is made above the sternal notch, and—after dividing the anterior jugular veins—the skin flaps are developed: the upper one to the level of the thyroid cartilage and the lower one to the sternum. The strap muscles are divided in the median line and then dissected from the thyroid gland. The dissection is started on the right side first. The middle thyroid veins are divided and the right carotid artery and brachiocephalic artery are dissected free; when dividing step-by-step the fascial layers covering the artery, it is very important to keep the line of cutting strictly over the anterior surface of the artery, to prevent the laryngeal recurrent nerve from injury. The right laryngeal recurrent nerve is visualized first. Our technique for visualization of the laryngeal recurrent nerves is described in details elsewhere [12]. After full mobilization of the right common carotid and brachiocephalic arteries, the left carotid artery is dissected and mobilized, and the left laryngeal recurrent nerve is visualized in the same manner. At this stage of the procedure a retractor is placed under the manubrium of the sternum and connected to the frame with a traction system, mounted on the operating table. The sternum is elevated, allowing much better exposure of the mediastinum. The upper poles of the thymus are divided from the thyroid gland and retracted upwards and the superior surface of the innominate vein is dissected free. It should be stressed, that dissecting free of the great arteries and veins (right and left common carotid artery, brachiocephalic artery, left internal jugular vein, left and right inominate vein) is of utmost importance, because retracting these vessels right or left considerably improves exposure of particular areas of the mediastinum. Firstly, station 1 of lymph nodes is dissected: having both laryngeal recurrent nerves visualized, we remove en block the whole tissue lying in front of the trachea, behind the upper poles of the thymus, and above the left innominate vein; the laryngeal recurrent nerves are the lateral margins of dissection. Next, the confluence of the innominate veins is elevated using the retractor, the trachea is retracted to the left side and the right paratracheal space is opened by blunt dissection under the brachiocephalic artery and above it, along the course of the vagus nerve as well. The access above the artery is more convenient for dissection of the 2R nodes, whereas the access between the artery and the tracheal wall is better for removing of 4R nodes. All the dissection is performed in the open fashion, using standard instruments rather than the fine instruments for endosurgery. All of the tissue from the right paratracheal space is removed to the level below the azygos vein. The borders of dissection are: the innominate vein and vena cava superiorly, vertebral column inferiorly, mediastinal pleura laterally and the trachea, ascending aorta and right main bronchus medially. The next step is the dissection of the left paratracheal space: retracting the trachea to the right side and the left common carotid artery to the left and upwards, enables excellent visualization of the whole left paratracheal space to the level of the proximal 1/3 of the left main bronchus. Carefully preserving the left laryngeal recurrent nerve, the lymph nodes 2L and 4L are dissected. For removing of the node station 7 and 8, the mediastinoscope is used; we prefer the operative Wolf videomediastinoscope (Richard Wolf GmbH, Knittlingen, Germany), equipped with moving blades, which are very useful for retracting the pulmonary artery from the carina during dissection of node station 7, and the left atrium from the esophagus during dissection of node station 8. The mediastionoscope is used for retracting of these structures and visualization only—the removing of lymph nodes is carried out using a standard dissector for open surgery, introduced through the right paratracheal space along the mediastionoscope. The dissection of the lymph node station 8 is possible only partially; the 19cm long mediastinoscope enables access to a level 4–7cm below the carina, depending on the size of the patient's chest. The paraaortic nodes are dissected next. The space between the left common carotid artery and the left innominate vein is created by blunt and sharp dissection and the left vagus nerve is visualized. After retracting of the vein upwards using a long retractor the plane is developed at the anterior surface of the aortic arch and the nodes-containing (station 6) tissue from between the arch and the mediastinal pleura is dissected down to the level of the aorto-pulmonary window. The aorto-pulmonary window nodes are difficult to remove under direct visual control, so we use the 30° thoracoscopic telescope and the video-camera to visualize them; the videothoracoscope is introduced to the region of the aorto-pulmonary window through the operative incision, between the left innominate vein and the common carotid artery. The inferior border of dissection is the left pulmonary artery. During the dissecting of the paraaortic space it is important to follow the left vagus nerve, being the important landmark and not to injure the accessory hemiazygos vein, passing in some patients vertically to the left innominate vein. The last group of lymph nodes dissected is station 3. Retracting the upper poles of the thymus upwards and to the left side, the confluence of the innominate veins is dissected blunt using the cloth-tipped dissector. The same instrument is used to retract downwards the confluence and the superior vena cava, while the prevascular lymph nodes are removed. The hemostasis is checked and the wound closed in the standard manner without any drain.

The video movie with the step-by-step presentation of the TEMLA operative technique may be downloaded free from: http://www.mp.pl/temla/.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Conference... References

 
Between January 1, 2004 and August 20, 2004 eighty three consecutive patients meeting inclusion criteria were operated on using the new TEMLA technique. There were 70 men and 13 women, mean age 62 years (range: 41–79). The rates of particular histologic types of cancer were: squamous cell carcinoma—68.7%, adenocarcinoma—24.1%, large cell carcinoma—4.8%. The remaining 2.4% were patients, in whom the mediastinal nodes were negative, but because of deterioration of their general condition they were finally not considered as candidates for surgery—the pre-treatment cytological diagnosis of non-small cell cancer in this subgroup is therefore the final diagnosis. The localisation of the primary tumours was: right upper lobe—19.3%, right middle lobe—6.0%, right upper lobe/right lower lobe—1.2%, right lower lobe—30.1%, left upper lobe—26.5% and left lower lobe—14.5%, central left-side tumor—1.2% and central right-side tumor—1.2%. The characteristics of the patients is shown in Table 1.

View larger version (12K): [in this window] [in a new window]   Fig. 1. Box plot showing the number of lymph nodes removed.

There were 30.3% of patients with positive mediastinal lymph nodes in the group B; in 18.2% there was one station involved, in 3% two stations and in 9.1% three stations.

The sensitivity, specificity, accuracy and positive and negative predictive values, calculated for each nodes group (per-site basis) and for the patients group (per-patient basis) are shown in Table 3.

View larger version (25K): [in this window] [in a new window]   Fig. 2. Scatterplot with regression line shows statistically significant decrease in operative time of subsequent procedures.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Conference... References

 
The removal of the whole regional lymphatic system together with the primary tumor is one of the fundamental rules in oncological surgery. Performing complete mediastinal lymphadenectomy in NSCLC patients seems to be beneficial. The advantages of such an approach are: (1) the most accurate staging, enabling selection of patients who benefit from neoadjuvant therapy, and (2) potentially curative effect, affecting survival [13–15,9]. The reason, why the removal of all mediastinal lymph nodes has not been routinely used so far, is the lack of a technique enabling this without unreasonable increase of the patient's burden. Although the reports on extended or superradical mediastinal lymphadenectomy were published by authors from Japan [9,10], these techniques—requiring a sternotomy or a bilateral thoracotomy—have never gained a wide acceptance. The main reasons were the excessive invasiveness of such procedures and the technical difficulties of lung resection through the sternotomy. Even more difficult to accept would be the use of these techniques as a routine diagnostic or staging procedure. The TEMLA procedure seems to be safe and, with the exception of nodes station 9, as complete as the technique described by Hata et al. Moreover, the dissection of mediastinal lymph nodes using TEMLA is much more convenient than via sternotomy, at which the approach to stations 4R and 7 is difficult, and to station 8 and 4L very difficult.

With the rapid development of imaging techniques during the last decade, the question is sometimes asked, if these techniques (and particularly PET) can be used as an alternative to invasive mediastinal staging. It seems, however, to be generally accepted, that pathological assessment of mediastinal lymph nodes remains the gold standard [1–4].

Our results show the high accuracy of the TEMLA in mediastinal staging, superior to the published results of imaging studies. According to the meta-analyses published to date, the summarized sensitivity and specificity of CT in mediastinal nodes staging were 0.57–0.83 and 0.77–0.82, respectively [16–18], for EUS, 0.78 and 0.71, respectively [18], and for PET scanning, 0.79–0.88 and 0.89–92, respectively [17–19]. The selection criteria of studies for the meta-analyses mentioned above included histological or cytological confirmation of mediastinal nodes, however the methods of this confirmation used in most of the studies analyzed bring the results in question. In fact, there were no study including the pathological examination of all stations of mediastinal lymph nodes as a control of accuracy of the imaging study. Each confirmatory technique used, implies leaving some node stations intact and it would not be logical to assume, that the nodes left behind were always free of metastases. We conclude, that due to the weakness of the confirmatory tests used, the mentioned above results of imaging studies may be in fact worse than it appears. Interestingly, the study of Gonzales-Stawinski et al. [20], using additionally the 1–2 year follow up to confirm the absence of mediastinal recurrence, what makes the results of it more reliable, has shown considerably worse results of PET (sensitivity and specificity 0.64 and 0.71, respectively, with the accuracy of 0.74).

The analysis of the accuracy of invasive studies shows, not surprisingly, relatively high specificity, but the summarized sensitivity was low in the recent review. For TBNA, EUS needle aspiration, mediastinoscopic biopsy and mediastinoscopy combined with the extended cervical mediastinoscopy the sensitivity was: 0.76, 0.88, 0.81 and 0.69–0.76, respectively. The negative predictive values were, respectively: 0.71, 0.77, 0.91 and 0.82–0.89 [21]. The results of TEMLA in our series are markedly superior to all these values.

The number of lymph nodes removed using TEMLA is significantly higher than during thoracotomy and the video-assisted mediastinoscopic lymphadenectomy [7].

The complications of TEMLA are relatively infrequent and usually mild. The arrythmias, respiratory and circulatory insufficiency as well as the deterioration of the mental status are attributable to the general anesthesia, rather than the procedure itself. The laryngeal recurrent nerve palsy occurred in 4 patients (4.8%), but in 2 of them it subsided after 3 months. The remaining 2 patients were operated on within the last 3 months, so it is to early to assess, if the palsy is temporary or permanent. Even if permanent, this rate (2.4%) would be low when compared with other surgical procedures in the region of the lower neck and mediastinum. During thyroid surgery the permanent laryngeal recurrent nerve palsy occurs in 1.7–3.8% patients operated on for benign conditions and in 8% for thyroid cancer [22]. Comparing these figures we should keep in mind, that during thyroid surgery the recurrent nerves are vulnerable only in the short part in the region of the lower thyroid artery, whereas during TEMLA they are dissected free over all their length, and that the left paratracheal nodes lie directly on, or around the left recurrent nerve. The only other technique, including a comparable extent of mediastinal lymph node dissection in the region at risk is esophagectomy with three-field lymphadenectomy. For this procedure the overall rate of the laryngeal recurrent nerve palsy was reported to be as high as 69% (42% temporary and 27% permanent) despite the operation being performed in the open fashion [23].

The long operative time is undoubtedly the drawback of the TEMLA technique, although the regression analysis of the operative times shows its significant decrease, as the experience of the team increases. Dissection of the vital structures of the mediastinum and lower neck, particularly nerves and great vessels, using the limited approach requires a meticulous and very careful operative technique and the minimal invasiveness is associated with the longer operative time. Another drawback of TEMLA is scarring of the mediastinum, making subsequent pulmonary resection more demanding—this is seen when the patient is operated on more than a few days after TEMLA. The short time of a pathological work-up of the specimen and the prompt scheduling of the patient for pulmonary resection seems to be a solution to this problem.

The subgroup of 12 patients without metastatic involvement of mediastonal nodes at TEMLA, were finally not considered as candidates for pulmonary resection due to the deterioration of their general status. In these patients, the relatively low invasive procedure proves the poor performance status, unsuspected preoperatively based on the routine preoperative work-up. In this regard, the TEMLA may be considered as a kind of physiological test, allowing better selection for major pulmonary resection. However, we cannot exclude the potential contribution of the procedure to the deterioration of the general status.

The data regarding the correlation between the extent of mediastinal lymphadenectomy and long term survival are inconsistent; some reports support such correlation [13–15], whereas others do not [24], or show significant difference in some subgroups of patients only [25]. However, the studies using more extensive mediastinal lymph node dissection are more likely to show survival benefit than those implementing a lesser extent of lymphadenectomy. As the TEMLA is undoubtedly one of the most radical techniques of mediastinal dissection, we may expect a more marked effect on survival. The long-term follow up will allow us to verify this expectation.

	5. Conclusions

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Conference... References

 
The TEMLA makes it possible to remove a significantly higher number of mediastinal lymph nodes than other operative techniques, including—with the exception of station 9—all groups of mediastinal lymph nodes. It was shown to be highly effective in mediastinal staging of NSCLC patients; its sensitivity, accuracy, and negative predictive value compares favorably with other, non-invasive and invasive staging procedures. Although time-consuming, the TEMLA is safe and associated with relatively low morbidity. The effect of this procedure on survival is to be investigated.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Conference... References

 
Dr A. Turna (Istanbul, Turkey): Did you compare the N2 positivity results obtained from a normal, standard mediastinoscopy and TEMLA, and can you say that TEMLA is more effective in finding N2 disease? The second question is, did you think to perform extended mediastinoscopy, video-assisted extended mediastinoscopy in order to resect No. 5 and No. 6 nodes rather than the videothoracoscopic method?

Dr Kuda: Regarding the first question, this is a first report of our initial experience with this technique and we are about to start a prospective randomized trial to compare this with the standard cervical mediastinoscopy. The value of this technique was assessed only by the technique of subsequent thoracotomy which confirmed the completeness of dissection of nodes.

The second question, the mediastinoscopy, both standard or extended, have one important drawback; namely, it is usually used not for removal but only to biopsy the nodes. Moreover, in our opinion the extended lymphadenectomy may be hazardous. We believe that this technique which is performed under visual control is safer because the dissection of the vital structures is performed in a better controlled manner.

Dr T. Dosios (Athens, Greece): I agree with you that this technique is effective, but it seems that it is not safe. I am afraid that, if the surgeons who are in this room leave the Congress, go back to their hospitals, and perform this operation, we will have a couple of deaths within one week or one month. Since this operation is for staging and consequently has no therapeutic benefit, I think we should compare the diagnostic benefit versus the risk to the patient. Can you comment on that, please?

Dr Kuda: Of course. As I have shown, in the consecutive group of 83 patients, there were no operative deaths and no hospital deaths. So I don't expect such fatal effects if you perform this procedure. It is true that we began with this procedure based on our experience with the minimally-invasive transcervical thymectomy developed by Dr Zielinski, but one of the surgeons from our staff, without any experience with the transcervical thymectomy technique, began recently to perform these operations, and he is able to do it without any complications. So I think that the fear about the risk of damage to vital structures should not be as great as it seems to be.

Dr T. Grodzki (Szczecin, Poland): I shared the opinion of Dr Dosios until I saw this procedure by myself. I went to Zakopane to check it, and I can assure you that it is much, much safer than, for example, extended mediastinoscopy or something like that because it is made in an open fashion. I think you should call it not only a diagnostic procedure but also somehow a curative procedure because you are performing lymphadenectomy, and if you follow it by, let's say, a right lobectomy, you have left nodes removed. So it's not only a diagnostic procedure, in my opinion.

But definitely I think the audience will require some more details, technical details, and you should work on it.

Dr Kuda: Well, in answering this question, I have presented only our results. We have not assessed the influence of this technique on survival. So this is a matter of future studies. The second point, of course the time limit of our presentation makes it impossible to present the details of such a technique. For this reason, I would like to inform the audience that we have prepared a video movie on a CD with a step-by-step presentation of the whole technique and this CD movie is available to you at the desk of Mrs. Hesford. So if you are interested in our technique, feel free to get a copy of this CD.

Dr S. Elia (Rome, Italy): I assume that all these patients underwent a chest CT scan just to detect if there were enlarged lymph nodes. So I would say that if you find enlarged lymph nodes on CT scan, probably videomediastinoscopy would help in finding N2 disease instead of submitting the patient to this trauma and this prolongation of the surgical time. What about the additional time that you have to a normal lobectomy by performing this surgical procedure?

Dr Kuda: As you have seen during the presentation, clinical findings based predominantly on CT scans were in a large percentage of patients false-positive and also false-negative in some. So we do not rely on the CT findings, and all the patients meeting the criteria were included in the study. Regarding the additional time: of course this procedure is time-consuming, but we believe that the completeness of lymphadenectomy enables better selection of patients who could benefit from neoadjuvant therapy and there is also a potential of survival benefit from mediastinoscopy.

Dr G. Leoncini (Genoa, Italy): Congratulations on your operation, which is very fascinating from a technical point of view, but in an era in which pulmonologists and radiologists emphasize the use of PET scan or CT-PET scan for staging proposes, do you think there is a place for such an operation?

Dr Kuda: In my opinion, there is a place for such an operation for two reasons. The first reason is that we all know well that all of the imaging studies have a limited yield, and there is no technique available that could replace the pathological examination of the removed nodes. Second, it is also well known that removal of the whole regional lymphatic system together with the primary tumor is one of the principles in oncological surgery. So the potential benefit in survival is also an advantage of this technique. And, as you have seen, the risk for patients is not much higher than after cervical mediastinoscopy. I hope we will be able to prove it in the prospective study and to show you the details of this comparison during one of our next meetings.

	Footnotes

 
^☆ Presented at the joint 18th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 12th Annual Meeting of the European Society of Thoracic Surgeons, Leipzig, Germany, September 12–15, 2004.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Conclusions Appendix A. Conference... References

 

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