Esophagectomy In Prone Position Research Articles

ASO Visual Abstract: The Influence of Preoperative Smoking Status on Postoperative Complications and Long-Term Outcome Following Thoracoscopic Esophagectomy in Prone Position for Esophageal Carcinoma.

ASO Visual Abstract: The Influence of Preoperative Smoking Status on Postoperative Complications and Long-Term Outcome Following Thoracoscopic Esophagectomy in Prone Position for Esophageal Carcinoma.

Minimally invasive esophagectomy for cancer in a patient with giant paraesophageal hernia

Minimally invasive esophagectomy in prone position is a procedure during which the patient is placed in a prone position during the thoracoscopic approach. A 67-year-old male patient consulted whit giant paraesophageal hernia and esophageal cancer. The treatment should be focused on the oncological resection of the esophagus despite the technical difficulties caused by the presence of a large hernia. A minimally invasive approach in the prone position and laparoscopic hernia repair can be considered an appropriate option for the resolution of both diseases with satisfactory results.

The Influence of Preoperative Smoking Status on Postoperative Complications and Long-Term Outcome Following Thoracoscopic Esophagectomy in Prone Position for Esophageal Carcinoma.

Esophagectomy for esophageal carcinoma is associated with higher morbidity and mortality rates than other gastrointestinal surgeries. Smoking is an established risk factor for postoperative complications after esophagectomy. This study aimed retrospectively to investigate the impact of smoking status on short- and long-term outcomes for patients undergoing thoracoscopic esophagectomy in the prone position (TEP) for esophageal carcinoma. In this study, 234 patients with esophageal carcinoma who underwent TEP between 2012 and 2020 were divided into two groups based on smoking status (current or non-current smokers and the Brinkman index) by patients' declarations. Postoperative complications (Clavien-Dindo classification grade ≥2), overall survival (OS), and disease-free survival (DFS) were compared between smoking statuses. The rates of postoperative complications did not differ significantly between the two groups (current smoker vs non-current smoker; Brinkman index ≥800 vs <800). The rate of postoperative pneumonia was higher in the combination group of current and higher Brinkman index (≥800) smokers than in the other group (25.0 % vs 11.8 %; P = 0.036). Multivariate analysis showed that smoking status was an independent risk factor for postoperative pneumonia (hazard ratio, 0.41; 95 % confidence interval, 0.18-0.93; P = 0.037). According to the long-term outcomes, no significant differences in OS and DFS were observed between the smoking statuses. The combination of current smoking and heavy smoking history is a risk factor for postoperative pneumonia in patients who have esophageal carcinoma treated with TEP, although no correlation was observed between the long-term outcomes and smoking status.

687 ADVERSE EVENTS DURING MINIMALLY INVASIVE ESOPHAGECTOMY IN PRONE POSITION

Abstract Since the initial description of laparoscopic fundoplication in 1991 for the treatment of gastroesophageal reflux disease, different minimally invasive procedures have been developed until nowadays, when esophagectomy is performed using combined thoracoscopy and laparoscopy. Objective: The aim of our study is to analyze the intraoperative complications of minimally invasive esophagectomy in prone position. Methods Between November 2011 and January 2021, 70 patients underwent minimally invasive esophagectomy in prone position in the Hospital Interzonal General de Agudos General San Martín and private practice of La Plata city. Results During the abdominal stage one patient presented coronary vessel injury and the other with short vessel injury. The complications occurring in the thoracic stage included lung injury, azygos arch injury, thoracic duct section, laryngeal recurrent nerve lesion, main stem bronchus injury, and pericardium lesion, during lymph node resection. Most of these complications occurred in the first 30 patients, while in the remaining 40 cases only two complications (p value = 0.4). Conclusion Minimally invasive esophagectomy in prone position is a feasible and safe procedure that can cause serious intraoperative complications due to its complexity. Although the results of our series did not show statistically significant differences, the number of complications during surgeries performed by the same team showed an important reduction associated with better training.

9 SURGICAL TECHNIQUES AND POTENTIAL OF MEDIASTINAL LYMPHADENECTOMY IN ROBOTIC SURGERY

Abstract Procedure of minimally invasive esophagectomy in prone position (Conventional prone-MIE) is standardized leading to feasible short outcomes. On the other hand, robot assisted MIE (Robotic MIE) was approved as Japanese health insurance treatment since 2018. Especially, reduction of recurrent laryngeal nerve (RLN) palsy leading to aspiration pneumonia is expected for Robotic MIE. The purpose of this study is to clarify the potential of Robotic MIE for improvement of short outcomes. Methods Twenty-four Robotic MIEs in introduction period since 2018 and 128 Conventional prone-MIEs in established period since 2015 from all of the 375 cases were compared using propensity score matching. Results Operative times in both entire and thoracic procedures were significantly longer in Robotic MIE. There were no significant differences between two groups in the number of harvested lymph nodes, amount of the blood loss, left RLN palsy rate (13% vs 14%, &amp;gt; Clavien-Dindo classification: C-D grade I), right RLN palsy rate (4% vs 8%, &amp;gt; C-D grade I), and pneumonia rate (7% vs 7%, &amp;gt; C-D grade II). Conclusion Short outcomes of Robotic MIE in introduction period were not inferior to those of Conventional prone-MIE in established period. More improvement is expected for Robotic MIE via learning curve. In conclusion, Robotic MIE has hidden potential to outstrip Conventional prone-MIE in outcomes. Video https://www.dropbox.com/s/7byc8nsqupgetsp/2020%20ISDE%20movie%20for%20submission.wmv?dl=0.

487 MINIMALLY INVASIVE ESOPHAGECTOMY AFTER A NEOADJUVANT PROTOCOL WITH INDUCTION CHEMOTHERAPY AND CHEMORADIATION

Abstract Neoadjuvant chemoradiation (CR) became the standard of care for the treatment of resectable esophageal cancer, but the survival rates are still worse than the observed in other gastrointestinal malignancies. The optimal neoadjuvant approach is still matter of debate. Based on these considerations, we started a phase II trial (QUIMERA) to investigate the safety and efficacy of preoperative induction chemotherapy followed by CR and minimally invasive surgery for esophageal cancer. We report the initial results. Methods Patients with confirmed squamous cell or adenocarcinoma of the thoracic esophagus or GEJ (Siewert type I or II), aged 18–75 years, with a PS 0–2, clinical stage cT1b-3 cN0–2 were eligible. After staging, patients received two cycles of IC with carboplatin (175 mg/m2) and paclitaxel (AUC = 5) on days 1 and 22, followed by radiotherapy (45 Gy (25 x 1.8 Gy)) and chemotherapy (carboplatin (AUC = 2) and paclitaxel (50 mg/m2) weekly for five weeks. After re-staging, patients with no stage M1 disease and/or inoperable T4 disease proceeded to surgery, minimally invasive esophagectomy in prone position, 8–12 weeks after the completion of chemoradiation. Results From March 2017 to December 2019, 86 were registered in the clinical trial. Forty-eight were excluded due to T4 or M1 disease, 26 patients finished the IC + chemoradiation protocol. Sixteen minimally invasive esophagectomy were performed. There were no conversions to open surgery. The surgical outcomes are presented in Table 1. The mean node count in the surgical specimen was 27 (13-49). A complete pathological response was observed in 6 (37,5%) cases (4 SCC; 2 Adenocarcinoma). Conclusion Our initial results are encouraging and suggests that IC followed by chemoradiation is a safe, feasible, active and well-tolerated regimen and that it may increase the PCR, especially for squamous cell carcinoma. The minimally invasive esophagectomy following the IC + CR was feasible, safe and had an adequate oncologic result. After the protocol completion there will be data available for a definitive evaluation of the procedure.

ASO Visual Abstract: Incidence of Recurrent Laryngeal Nerve Palsy in Robot-Assisted Versus Conventional Minimally Invasive McKeown Esophagectomy in Prone Position: A Propensity Score-Matched Study

ASO Visual Abstract: Incidence of Recurrent Laryngeal Nerve Palsy in Robot-Assisted Versus Conventional Minimally Invasive McKeown Esophagectomy in Prone Position: A Propensity Score-Matched Study

Incidence of Recurrent Laryngeal Nerve Palsy in Robot-Assisted Versus Conventional Minimally Invasive McKeown Esophagectomy in Prone Position: A Propensity Score-Matched Study.

Esophagectomy with lymphadenectomy is the principal treatment for localized esophageal cancer. Conventional minimally invasive esophagectomy (C-MIE) in prone position has spread worldwide as it is less invasive. However, its efficacy remains controversial. Robot-assisted MIE (RAMIE) can have more advantages than C-MIE. Therefore, the current study aimed to validate whether RAMIE is associated with lower incidence of left recurrent laryngeal nerve (RLN) palsy compared with C-MIE in prone position. In total, 404 patients with esophageal carcinoma underwent MIE (353 C-MIEs and 51 RAMIEs) in prone position at Kobe University between 2010 and 2020. Then, propensity score matching was performed, and results showed that 51 patients should be included in each group. Thereafter, the perioperative outcomes between the two groups were compared. The RAMIE group had a significantly longer operative time than the C-MIE group (P<0.0001). However, the number of lymph nodes resected along the left RLN was similar in both groups. Moreover, the incidence of left RLN palsy was significantly lower in the RAMIE group than in the C-MIE [Clavien-Dindo classification grade II; 0 (0%) versus 32 (9%), P=0.022 in entire cohort, and 0 (0%) versus 5 (10%), P=0.022 in matched cohort. Esophagectomy Complications Consensus Group definitions type I; 8 (16%) versus 101 (29%), P=0.041 in entire cohort and 8 (16%) versus 18 (35%) in matched cohort, P=0.023]. RAMIE is superior to C-MIE in prone position in decreasing the incidence of left RLN palsy.

Changes in respiratory mechanics of artificial pneumothorax two-lung ventilation in video-assisted thoracoscopic esophagectomy in prone position

We aimed to clarify the changes in respiratory mechanics and factors associated with them in artificial pneumothorax two-lung ventilation in video-assisted thoracoscopic esophagectomy in the prone position (PP-VATS-E) for esophageal cancer. Data of patients with esophageal cancer, who underwent PP-VATs-E were retrospectively analyzed. Our primary outcome was the change in the respiratory mechanics after intubation (T1), in the prone position (T2), after initiation of the artificial pneumothorax two-lung ventilation (T3), at 1 and 2 h (T4 and T5), in the supine position (T6), and after laparoscopy (T7). The secondary outcome was identifying factors affecting the change in dynamic lung compliance (Cdyn). Sixty-seven patients were included. Cdyn values were significantly lower at T3, T4, and T5 than at T1 (p < 0.001). End-expiratory flow was significantly higher at T4 and T5 than at T1 (p < 0.05). Body mass index and preoperative FEV1.0% were found to significantly influence Cdyn reduction during artificial pneumothorax and two-lung ventilation (OR [95% CI]: 1.29 [1.03–2.24] and 0.20 (0.05–0.44); p = 0.010 and p = 0.034, respectively]. Changes in driving pressure were nonsignificant, and hypoxemia requiring treatment was not noted. This study suggests that in PP-VATs-E, artificial pneumothorax two-lung ventilation is safer for the management of anesthesia than conventional one-lung ventilation (UMIN Registry: 000042174).

P133 INTRATORATHIC ANASTOMOSIS IN IVOR-LEWIS ESOFAGUECTOMY: TECHNICAL DESCRIPTION AND RESULTS

Abstract Aim Description of the technique of intrathoracic anastomosis in Ivor-Lewis esophagectomy in prone position with minimally invasive approach (MIE) by manual tobacco-bag suture and anastomosis with circular stapler and its results. Background &amp; Methods Retrospective descriptive analysis of the intrathoracic anastomosis technique in prone of the cases performed in our Health Care Center by thoracoscopic and laparoscopic approach in Ivor-Lewis esophagectomy between April 2017 and December 2018. Patients who required conversion to thoracotomy due to pleural adhesions were excluded Results The median age of the 18 patients was 59 years (54-67 years). In the 18 analyzed (17 adenocarcinomas of 1/3 lower or gastro-esophageal junction and 1 benign stenosis post-RT) 12 were performed with mechanical anastomosis CEA 25, 2 with CEA 28 and 4 with Orvyl CEA 25. No leakage occurred during the postoperative period, performing in 16 a TEGD at 4-5º DPO. Three patients underwent feeding jejunostomy. In the postoperative period, 2 patients presented with ARDS, 2 with pneumonia, 2 with pleural effusion, and 1 with AF. In the follow-up performed until May 2019 1 patient presented stenosis of the anastomosis that was treated by endoscopic dilation. No leakage of the anastomosis has been recorded. The postoperative mortality (&lt;30 days) was 0% Conclusion Compared with other technical variations, even with another type of anastomosis, the circular mechanical anastomosis, making the tobacco bag around the head by manual suture and reinforcing it by Endoloop is a safe and reproducible technique with a 0% leakage rate and stenosis of 5.88%. According to the literature, the rate of anastomotic leakage in the thoracoscopic approach is between 0-20% and that of anastomotic stenosis is 0-27.5%, without finding significant differences between the different types of anastomosis. It has been demonstrated in numerous series that the thoracoscopic approach is oncologically equal to or better than the approach by thoracotomy because it allows a better dissection with resection of a greater number of nodes and that provides benefits such as less postoperative pain, better patient ventilation, better ergonomics for the surgeon and better vision of the operative field. However, we believe that this new approach should not change the usual technique of performing the anastomosis or the indication of the Ivor-Lewis esophagectomy. Randomized studies with a larger number of cases are necessary to determine which anastomosis technique is safest and reproducible in MIE surgery of esophageal cancer.

Adverse events during minimally invasive esophagectomy in prone position associated with the learning curve

Background: Since the initial description of laparoscopic fundoplication in 1991 for the treatment of gastroesophageal reflux disease, different minimally invasive procedures have been developed until nowadays, when esophagectomy is performed using combined thoracoscopy and laparoscopy. Objective: The aim of our study is to analyze the adverse events of minimally invasive esophagectomy in prone position during the learning curve. Material and methods: Between November 2011 and June 2017, 36 patients underwent minimally invasive esophagectomy in prone position in the Hospital Interzonal General de Agudos (HIGA) San Martín and the Instituto de Diagnóstico de La Plata. Results: During the abdominal stage one patient presented coronary vessel injury. The complications occurring in the thoracic stage included lung injury (n =2), azygos arch injury (n = 1), thoracic duct dissection (n = 1), laryngeal recurrent nerve lesion (n = 1) and main stem bronchus injury (n = 1) during lymph node resection. Most of these complications occurred in the first 20 patients, while in the remaining 16 cases only lung injury occurred (p = 0.10) Conclusion: Minimally invasive esophagectomy in prone position is a feasible and safe procedure that can cause serious intraoperative complications due to its complexity. Although the results of our series did not show statistically significant differences, the number of adverse events during surgeries performed by the same team showed an important reduction associated with better training.

PS01.234: MINIMALLY INVASIVE ESOPHAGECTOMY IN PATIENTS WITH MORBID OBESITY

Abstract Background The first publication of minimally invasive esophagectomy in prone position (MIE PP) was developed by Cuschieri in 1994. This approach was described to access the posterior mediastinum and esophagus for mobilization and resection. In 2006, after several reports, Palanivelu presented his study, which was one of the most important series published at that time.The objective is to analyze the mortality of a group of patients with morbid obesity that underwent MIE PP. Retrospective, observational study. Methods From November 2011 to June 2017, 52 esophagectomies were performed in H.I.G.A San Martín and Instituto de Diagnóstico of La Plata city. Out of the 52 cases, only 36 of them were MIE PP, and were the ones chosen to be included in the study. Results Perioperative mortality was 8.3% (3 cases) Two cases, in the group of patients with obesity (IMC ≥ 30) were due to pneumonia and heart failure and surgery was performed using the McKeown procedure. Another case was in the group of patients without obesity (IMC ≤ 30) due to mediastinitis by leak, and the surgery performed was applying Ivor-Lewis procedure. These results did not evidence statistically significance (P ≤ 0.54) However, in the analysis of patients with morbid obesity (BMI ≥ 35) when compared with all the remaining cases, the difference was significant (P = 0.02) Conclusion There are many publications suggesting that obesity is not a risk factor for mortality after MIE. However, in our study, although it is a series with a small number of cases, there was evidence that mortality increases in patients with BMI ≥ 35 Disclosure All authors have declared no conflicts of interest.

PS01.223: ‘ENERGY-LESS TECHNIQUE’ WITH MINI-CLIPS FOR RECURRENT LARYNGEAL NERVE LYMPH NODE DISSECTION IN PRONE THORACOSCOPIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background Esophagectomy with radical mediastinal lymph node dissection remains the standard option for the curative treatment of esophageal squamous cell carcinoma. However, meticulous lymph node dissection along the recurrent laryngeal nerve (RLN), often results in recurrent laryngeal nerve paralysis (RLNP), leading to postoperative laryngopharyngeal dysfunction. Recently, thoracoscopic radical esophagectomy has been performed as a minimally invasive surgery for esophageal cancer. Although thoracoscopic surgery appears to reduce the risk of postoperative pulmonary complications and permits earlier postoperative recovery, the issue of postoperative RLNP remains unresolved. Methods We had attempted to simply cut the vessels around RLN sharply with scissors without using energy device in order to prevent RLN paralysis. However, these procedures often result in minor bleeding. Then we introduced the use of mini-clips for hemostasis before cutting the vessels with scissors. In this study, we analyzed data from 64 patients with esophageal cancer who underwent thoracoscopic esophagectomy in prone position. The patients were divided into two groups according to the period of operation: before and after the introduction of energy-less techniques with mini-clips. Surgical results were compared between the 2 groups. Results With regard to RLNP, the incidence was 24.0% in the before group; this incidence went down to 5.1% in the after group, after the introduction of energy-less techniques with mini-clips (P = 0.0259). Moreover, length of hospital stay after surgery was significantly shortened, from 36.1 days to 22.0 days, after the introduction of energy-less techniques with mini-clips (P = 0.0075). There were two operators performing thoracoscopic esophagectomy at our institution: surgeon A, a senior doctor with a 22-year career; and surgeon B, a junior doctor with a 12-year career. We compared all surgical results and found that there were no differences between the two doctors. Conclusion Our energy-less technique with mini-clips in RLN lymph node dissection could keep the surgical field dry by preventing minor bleeding. This contributed both to prevent RLNP and to shorten the patient's hospital stay. This technique was also considered useful for standardizing procedures within our institution, because special skills were not needed. Disclosure All authors have declared no conflicts of interest.

PS02.005: THORACOSCOPIC ESOPHAGECTOMY IN PRONE POSITION USING A PRECEDING ANTERIOR APPROACH FOR ESOPHAGEAL CANCER: LONG-TERM AND SHORT-TERM OUTCOMES

Abstract Background The purpose of this study was to clarify the long-term and short-term outcomes of consecutive patients who underwent thoracoscopic esophagectomy in prone position using a preceding anterior approach for the resection of esophageal cancer at a single institution. Methods We retrospectively reviewed a database of 690 patients with thoracic esophageal cancer who had undergone a thoracoscopic esophagectomy (TE, 351 patients) or an esophagectomy through thoracotomy (OE, 343 patients) between 2003 and 2017. To compare the long-term outcomes of TE and OE, we used a propensity score matching analysis and a Kaplan-Meier survival analysis. To analyze the short-term outcomes of TE, patients were chronologically divided into three groups (117 patients per group). As for thoracoscopic procedure, the esophagus was mobilized from the anterior structure during the first step and from the posterior structure during the second step. The lymph nodes around the esophagus were also dissected anteriorly and posteriorly. The intraoperative factors, the number of dissected lymph nodes, and the incidence of adverse events were compared among the three period groups. Results As for long term outcome, 203 patients from each group, for a total of 406 patients, were completely selected and paired. The 5-year survival of the TE patients (66.8%) was better than that of the OE patients (56.4%) (P = 0.044). The thoracoscopic times were 226 min, 241 min, and 214 min (P &lt; 0.001), and the blood losses during the thoracoscopic procedure were 36.1 mL, 43.3 mL, and 18.0 mL (P &lt; 0.001), respectively, according to the period groups. The mean numbers of harvested lymph nodes in the chest were 22.2, 25.1, and 28.9 (P &lt; 0.001). The rates of recurrent laryngeal nerve palsy were 23.9%, 29.9%, and 8.6% (P &lt; 0.001). Conclusion The long-term outcome of TE patients might be better than that of OE patients. As for the short-term outcomes, intraoperative factors, quality of lymph node dissection, and reduction of adverse events were best in the third period group. Establishment of standard procedure and accumulation of surgical cases seemed to make TE a safe and effective procedure for esophageal cancer. Disclosure All authors have declared no conflicts of interest.

RA04.01: PRONE POSITION IN THORACOSCOPIC ESOPHAGECTOMY IMPROVES POSTOPERATIVE OXYGENATION AND REDUCES PULMONARY COMPLICATIONS

Abstract Background While thoracoscopic esophagectomy is a widely performed surgical procedure, only few studies regarding the influence of body position on changes in circulation and breathing, after the surgery, have been reported. This study aimed at evaluating the effect of body position, during surgery, on the postoperative breathing functions of the chest. Methods A total of 266 patients who underwent right-sided transthoracic esophagectomy for esophageal cancer from 2004 to 2012 were included in this study. Fifty-four of them underwent open thoracotomies in the left lateral decubitus position (Group O), 108 underwent thoracoscopic esophagectomy in the left lateral decubitus position (Group L) and 104 patients were treated by thoracoscopic esophagectomy in the prone position (Group P). Two patients in Group P, who presented with intra-operative bleeding and underwent thoracotomy, were subsequently excluded from the pulmonary function analysis. Results Two patients in Group P had to be changed from the prone position to the lateral decubitus position and underwent thoracotomy in order to control intra-operative bleeding. Despite the significantly longer chest operation period in Group P, total blood loss was significantly lower in this group when compared to Groups O and L. Furthermore, patients in Group P presented with significantly lower water balance during the perioperative period and markedly higher SpO2/FiO2 ratio after the surgery. The incidence of respiratory complications was significantly higher in Group O when compared to the other two groups; however, no significant differences were observed between the Groups L and P. Conclusion From a surgical point of view, artificial pneumothorax and gravity improves the operative field view in the prone position without any compression of the right lung, thereby resulting in no mechanical damage to the lungs. Prone position esophagectomy is a useful surgical technique, which appears to preserve the postoperative pulmonary function. The patients are able to endure the surgical procedure and present with less respiratory complications. Disclosure All authors have declared no conflicts of interest.

PS01.210: VIDEO-ASSISTED SALVAGE ESOPHAGECTOMY: SHORT- AND LONG-TERM OUTCOMES

Abstract Background Salvage surgery is only one therapeutic option which enable to cure intractable esophageal cancer after definitive chemo-radiotherapy. Although video-assisted esophagectomy (VAE) is now widely accepted as a standard operation for primary esophageal cancer, the application of VAE to salvage surgery is still controversial since salvage surgery is known as high-risk operation. In this study, we investigated 27 cases of salvage surgery and assessed the feasibility of the operation by analyzing their short and long-term outcomes. Methods VAE was applied to 26 cases and laparoscopic lymphadenectomy was applied to 1 case. The procedure of the VAE included prone position esophagectomy (n = 8), esophagectomy by hand-assisted thoracoscopic surgery (n = 10) and mediastinoscope-assisted transhiatal esophagectomy (n = 5). Our current operative procedure after year 2010 is PPE. The fields of lymph node dissection for salvage esophagectomy have been limited to the stations that had metastasis before CRT and the lymphatic stations which newly recognized as suspected metastasis. Postoperative complications were defined according to the Clavien-Dindo classification. Results Video assisted surgery was applied to 96% of patients including one case of laparoscopic abdominal lymphadenectomy. One case required open surgery for suspicious of direct invasion of tumor. R0 rate of the operations was scored 78%. Postoperative complication rate defined as ≥ C-D II plus any grade of anastomotic leakage and recurrent laryngeal nerve palsy was 63%. The rate of anastomotic leakage, respiratory complication, and RLN palsy were 23%, 15%, and 12%, respectively. Operative death was 0%, whereas in-hospital mortality was 3.7%. Overall survival of esophagectomy cases showed 24% in 3-year and 8% in 5-year. According to subgroup analysis by pathological R status after operation, the survival outcomes of pR0 group (n = 20) reached 32% in 3-year and 10% in 5-year OS, whereas no patient reached 3-year survival in pR1/2 group (n = 6; P = 0.02). Conclusion Although salvage VAE should be applied in high-experienced institutions under the careful consideration of indication, it appears to be balanced operation for safety, and less invasiveness, as well as curability. Disclosure All authors have declared no conflicts of interest.

Outcomes of thoracoscopic esophagectomy in prone position with laparoscopic gastric mobilization for esophageal cancer.

The aim of this study was to evaluate the short- and long-term outcomes of thoracoscopic esophagectomy performed in the prone position (TSE-PP) followed by laparoscopic gastric mobilization (LGM) compared with open thoracotomy and LGM, for esophageal cancers. We reviewed the records of 105 consecutive patients who underwent esophagectomy with LGM for esophageal cancer at Kochi Medical School. Among the study patients, 60 patients underwent TSE-PP, while 45 underwent open thoracotomy (OPEN group). The perioperative outcomes of the two groups were compared. Compared to the OPEN group, the TSE-PP group had lower blood loss (TSE-PP, 150mL; OPEN, 430mL; P < 0.001), longer operative time (TSE-PP, 609min; OPEN, 570min; P = 0.012), more lymph nodes dissected around the left recurrent laryngeal nerve (TSE-PP, 6; OPEN, 2; P < 0.001), and a shorter length of hospital stay (TSE-PP, 16.5days; OPEN, 35days; P < 0.001). The incidence of postoperative complications was similar in the two groups. Though the recurrence rate and overall survival were not significantly different in the two groups, the TSE-PP group had better overall survival rates than the OPEN group (P = 0.122). Patients who underwent TSE-PP with LGM for esophageal cancers recovered earlier after surgery compared to those who underwent open thoracotomy with LGM.

Robot-sewn Ivor-Lewis anastomosis: preliminary experience and technical details.

Robot-assisted minimally invasive esophagectomy with intra-thoracic anastomosis showed encouraging results but there is a lack of data to demonstrate the safety and feasibility. The aim of this study is to report our experience in RA-ILE (robotic-assisted Ivor-Lewis esophagectomy) with robotic hand-sewn anastomosis. This is a retrospective study of patients who underwent robotic-assisted esophagectomy in prone position with intrathoracic anastomosis for malignant neoplasm of the esophagus or esophago-gastric junction. From January 2012 to December 2014 we performed eight completely robot-assisted esophagectomy without intra-operative complication. The mortality rate at 30-day was zero. In two patients we observed a partial leakage of the gastric tube that required revision. The mean operative time was 499 ± 46 min including robotic set up and patient positioning. The median hospital-stay was 10 days. Complete (R0) resection was accomplished in all patients and the mean number of lymph nodes removed was 37.6 ± 14 .7. This preliminary experience suggests that robotic-assisted RA-ILE for malignant lesions is a real surgical option compared with conventional surgery with satisfactory results. Copyright © 2015 John Wiley & Sons, Ltd.

Comparison of the short-term postoperative results of prone positioning and lateral decubitus positioning during thoracoscopic esophagectomy.

IntroductionThe conventional approach during thoracoscopic esophagectomy was performed in the left lateral decubitus position (LLDP). Recently, thoracoscopic esophagectomy in the prone position (PP) has attracted the attention of surgeons.AimTo report institutional experience with thoracoscopic esophagectomy in PP and compare it with the conventional LLDP approach.Material and methodsWe reviewed 59 consecutive patients who had presented with esophageal cancer undergoing three-stage thoracoscopic/laparoscopic esophagectomy (TLE) from May 2011 to Dec 2013. The TLE was sequentially performed on enrolled patients in LLDP from May 2011 to Oct 2012 and in PP from Nov 2012 to Dec 2013. Immediate postoperative outcomes were collected and compared to determine differences between the 2 groups.ResultsThirty-eight patients had their operations in LLDP and 21 in PP. No differences in blood loss, respiratory condition during surgery, or postoperative pain scores were observed between the 2 groups. The PP had a shorter thoracic stage duration (3.4 vs. 3.9 h; p = 0.03) and shorter intensive care unit (ICU) stay (1.0 vs. 1.5 days; p = 0.03) but yielded a similar number of lymph nodes. Incidence of complications was similar between the 2 groups, except significantly lower incidence of pneumonia in PP (0% vs. 21.1%; p = 0.04) and higher incidence of hoarseness in PP (52.4% vs. 23.7%; p = 0.03). The symptoms resolved within 3 months in all patients except in the 2 patients with vocal cord palsy.ConclusionsIt is feasible and safe to perform thoracoscopic esophagectomy by adopting the prone position. Thoracoscopic esophagectomy in the prone position is potentially associated with fewer major complications and shorter ICU stay.

Efficacy and safety of artificial pneumothorax under two-lung ventilation in thoracoscopic esophagectomy for esophageal cancer in the prone position

Thoracoscopic esophagectomy for esophageal cancer performed using two-lung ventilation in the prone position has many advantages, such as convenient anesthesia induction and maintenance, and good oxygenation. We examined the safety of surgery and anesthetic management by following chronological changes in intraoperative respiration and hemodynamics. We focused on the most recent and consecutive 14 cases of thoracoscopic esophagectomy for esophageal cancer in the prone position performed from November 2010 until recently. We measured the following items by use of FloTrac system : cardiac index (CI), central venous pressure (CVP), mean arterial pressure, partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), peak airway pressure (APmax), and tidal volume. No major changes were observed in CI, systolic blood pressure, and TV after the start of pneumothorax (statically not significant). Conversely, CVP increased immediately after pneumothorax (p<0.05) and decreased almost to its original level thereafter. The mean APmax value was 18-20cm H2O [mean increase, 4.2cm H2O; (p<0.05)]. The mean P/F ratio and mean PaCO2 were 244.4 and 48.3mmHg, respectively, during artificial pneumothorax. No excessive increases in airway pressure or clear circulatory depressions were observed because of artificial pneumothorax under two-lung ventilation in thoracoscopic esophagectomy for esophageal cancer in the prone position. These results suggest that artificial pneumothorax under two-lung ventilation is beneficial for maintaining stable hemodynamics and oxygenation in thoracoscopic esophagectomy in prone position.