Minimally invasive oesophagectomy in prone versus lateral decubitus position: A comparative study

Abstract

BACKGROUND:Thoracoscopic oesophageal mobilisation during a minimally invasive oesophagectomy (MIE) is most commonly performed with the patient placed in the lateral decubitus position (LDP). The prone position (PP) for thoracoscopic oesophageal mobilisation has been proposed as an alternative.MATERIALS AND METHODS:This was a retrospective, comparative study designed to compare early outcomes following a minimally invasive thoracolaparoscopic oesophagectomy for oesophageal cancer in LDP and in PP.RESULTS:During the study period, between January 2011 and February 2014, 104 patients underwent an oesophagectomy for cancer. Of these, 42 were open procedures (transhiatal and transthoracic oesophagectomy) and 62 were minimally invasive. The study group included patients who underwent thoracolaparoscopic oesophagectomy in LDP (n = 23) and in PP (n = 25). The median age of the study population was 55 (24-71) years, and there were 25 males. Twenty-one (21) patients had tumours in the middle third of the oesophagus, 24 in the lower third, and 3 arising from the gastro-oesophageal junction. The most common histology was squamous cell cancer (85.4%). The median duration of surgery was similar in the two groups; however, the estimated median intraoperative blood loss was less in the PP group [200 (50-400) mL vs 300 (100-600) mL; P = 0.01)]. In the post-operative period, 26.1% patients in the LDP group and 8% in the PP group (8%) developed respiratory complications. The incidence of other post-operative complications, including cervical oesophagogastric anastomosis, hoarseness of voice and chylothorax, was not different in the two groups. The T stage of the tumour was similar in the two groups, with the majority (37) having T3 disease. A mean of 8 lymph nodes (range 2-33) were retrieved in the LDP group, and 17.5 (range 5-41) lymph nodes were retrieved in the PP group (P = 0.0004). The number of patients with node-positive disease was also higher in the PP group (19 vs 10, P = 0.037).CONCLUSION:MIE in the PP is an effective alternative to LDP. The exposure obtained is excellent even without the need for a complete lung collapse, thereby obviating the need for a double-lumen endotracheal tube. A more meticulous dissection can be performed resulting in a higher lymph nodal yield.

An Unusual Cause of Chylothorax after Esophagectomy

“…Subsequently, we thoracoscopically completed esophagectomy in the prone position according to our standard technique. 3 As expected from the imaging, the ulceroproliferative growth was involving the lower esophagus, gastroesophageal junction, and initial 2 cm of cardia and lesser curvature. The tumor was not adherent to the surrounding pericardium, aorta, or diaphragm and could be removed with a safe margin along with an adequate extended two-field lymphadenectomy.…”

Minimally Invasive Esophagectomy

“…Although they describe slightly higher number of the resected lymph nodes in the PP, they do not ind significant diferences. On the other hand, Javed et al [61] show a signiicantly higher lymph node yield in PP and the number of patients with afected lymph nodes is also signiicantly higher.…”

“…Most of the reports [10,61] describe a shorter operative time for a thoracoscopic esophagectomy in PP than in LDP. As we have said before, the best exposure of the surgical ield allows for faster and beter quality surgery.…”

Recent Advances in Minimally Invasive Esophagectomy

“…The prone position was used during the thoracoscopic esophagectomy and a much better exposure of the intrathoracic anatomical structures was obtained without fully collapsing the right lung and it can reduce the postoperative respiratory complications (11). Compared to the standard left lateral position, a much better approach at the level of the right hemithorax is obtained, with less amplitude of movement of the mediastinum, the exposure is much better behind the right pulmonary hill with much easier visualization of the vascular elements , the lung is moved from the operative field of esophageal dissection even by its own weight, and the esophagus is not the most lower point of right hemythorax, and thus the blood resulting from the dissection is leaving the operative field (as opposed to the left lateral left decubitus in which the blood stagnates in the dissection area and its aspiration is required) (12).…”