P1.136. Toward Vagal-Sparing Esophagectomy: Defining Surgically Reproducible Zones of Pulmonary Autonomic Preservation

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Abstract Topic Esophageal Cancer: Other Background Pulmonary complications remain a major cause of morbidity after transthoracic esophagectomy. Injury to pulmonary vagal branches during mediastinal lymphadenectomy may contribute to postoperative respiratory dysfunction. Precise surgical anatomy of pulmonary vagal branching relative to bronchial landmarks remains insufficiently defined for consistent intraoperative nerve preservation. Methods Results All specimens demonstrated consistent identification of bilateral pulmonary vagal plexuses. On the right, major branching occurred at the upper border of the main bronchus, with a median of 13 posterior branches (range 10–13). On the left, the median was 12 posterior branches (range 9–13). The mean distance from the carina to the lower bronchial crossing point was 1 cm on the right and 3 cm on the left. A reproducible high-risk zone for pulmonary denervation extended from the upper bronchial margin to 0–3.5 cm below. Transection above the bronchial margin resulted in inferior lobe denervation in 68–100% (right) and 86–100% (left). Transection below the lowest major pulmonary branch preserved superior lobe innervation and limited inferior lobe loss to 0–13%. These findings define anatomically consistent zones of vulnerability and preservation. Conclusion Pulmonary vagal branching demonstrates consistent topography relative to bronchial landmarks, allowing identification of reproducible high- and lower-risk zones for denervation. Selective transection below the lowest major pulmonary branch appears anatomically feasible while preserving pulmonary innervation. These findings provide an anatomical framework for vagal-sparing transthoracic esophagectomy aimed at reducing postoperative pulmonary morbidity without compromising oncologic dissection.

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