Esophagectomy In Prone Position Research Articles

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.

Our first experience in thoracoscopic esophagectomy in prone position

Our first experience in thoracoscopic esophagectomy in prone position

Lateral position could provide more excellent hemodynamic parameters during video-assisted thoracoscopic esophagectomy for cancer

Thoracoscopic esophagectomy is a feasible technique that has been shown to be safe for the treatment of esophageal cancer. There continues to be controversy about the optimal position during thoracoscopic esophagectomy. In this study, we compared the intraoperative hemodynamic parameters, clinical pathological characteristics, as well as postoperative complications in patients who underwent thoracoscopic esophagectomy in the prone position (PP) or left-lateral decubitus position (LDP). Between January 2011 and June 2011, 23 patients underwent thoracoscopic esophagectomies for cancer of the esophagus in LDP (group A). Since February 2011, we have performed thoracoscopic esophagectomies for cancer of the esophagus in PP for 21 patients (group B). The demographics and clinicopathologic factors, as well as the intraoperative hemodynamic parameters, of the two groups were analyzed. No postoperative death occurred in these 44 patients. Overall morbidity was similar in the two groups. No significant difference in the length of operation or number of retrieved mediastinal nodes between the two groups was observed, but the intraoperative blood loss in group A was significantly higher than in group B (P=0.0228). There was no significant difference of the intraoperative mean arterial pressure, central venous pressure, heart rate, and stroke volume variation between the two groups and various positions. In group A, the cardiac output (CO), cardiac index (CI), as well as stroke volume index (SVI) did not exhibit significant difference after altering patients' position from LDP to SP. However, patients who underwent thorascopic esophagectomy in PP had lower CO, CI, and SVI than in LDP during the thoracoscopic stage. Compared with the PP, the LDP could provide more excellent hemodynamic parameters during thoracoscopic esophagectomy. However, the various hemodynamic statuses did not exert significant influence on the occurrence of postoperative complications.

Thoracolaparoscopic Esophagectomy: Is the Prone Position a Safe Alternative to the Decubitus Position?

During the last few years, prone thoracoscopic esophagectomy has been increasingly adopted for thoracolaparoscopic esophagectomy (TLE). However, evidence for the prone position (PP) over the decubitus position (DP) during TLE is currently not strong enough to reach conclusions. From May 2009 to December 2010, we conducted thoracoscopic esophagectomies in the DP and then PP on consecutive patients admitted to our institution. TLE in DP was conducted from May 2009 to February 2010 and in PP from March 2010 to December 2010. Clinical features and operation characteristics of all patients were collected and compared to determine differences between the 2 groups. A total of 93 consecutive esophageal cancer patients were enrolled; Forty-one had their operations in DP and 52 in PP. There was no significant difference found between the 2 groups in age, sex, body mass index, tumor location, histological type, and TNM stage. When compared with DP, thoracoscopic esophagectomy in PP had a shorter operation duration (67 vs 77 minutes; p = 0.013), horter overall hospital stay (17.4 vs 11.4 days; p = 0.011), and yielded a larger number of lymph nodes (11.6 ± 4.0 vs 8.9 ± 4.9 on average; p = 0.005). Complication rates were similar between the 2 groups, with anastomotic leak developing in a significantly smaller number of patients in PP (7.7% vs 22.0%; p = 0.049). TLE in the PP is a feasible and safe alternative to DP and is potentially associated with fewer complications. Additional randomized studies are required to discuss the long-term prognostic value of this procedure.

Minimally Invasive Esophagectomy: Thoracoscopic Mobilization of the Esophagus and Mediastinal Lymphadenectomy in Prone Position—Experience of 130 Patients

To evaluate outcomes after minimally invasive or thoracolaparoscopic esophagectomy (TLE) with thoracoscopic mobilization of the esophagus and mediastinal esophagectomy in prone position. Esophagectomies are being performed increasingly by a minimally invasive route with decreased morbidity and shorter hospital stay compared with conventional esophagectomy. Most series report thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in the left lateral position with respiratory complications up to 8% and prolonged operative time, probably because of inadequate stance of the surgeon during the thoracoscopic part. This study shows the potential of the thoracoscopic part of the procedure in prone position to ease these difficulties. From January 1997 through April 2005, TLE was performed in 130 patients. All patients had histologically proved squamous cell carcinoma of the middle third of the esophagus. Only one (0.77%) patient received neoadjuvant chemotherapy. The thoracoscopic part of the procedure was performed in prone position with excellent ergonomics, translating into less operative time and better respiratory results. We performed a minilaparotomy to retrieve the specimen owing to bulky tumors. Feeding jejunostomy and pyloromyotomy were performed in all patients. There were 102 men and 28 women. Median age was 67.5 years (range 38 to 78 years). There was no conversion to open method. Median ICU stay was 1 day (range 1 to 32 days) and median hospital stay was 8 days (range 4 to 68 days). Perioperative mortality was 1.54% (n = 2). Anastomotic leak rate was 2.31% (n = 3). There was no incidence of tracheal or lung injury and a very low incidence of postoperative pneumonia. At mean followup of 20 months (range 2 to 70 months), stage-specific survival was similar to open and other minimally invasive series. TLE with thoracoscopic part in prone position is technically feasible, with a low incidence of respiratory complications and less operative time required. It provides comparable outcomes with other techniques of minimally invasive esophagectomy and most open series. In our experience, we observed a low mortality rate (1.54%), hospital stay of 8 days, and low incidence of postoperative pneumonia. It has the potential to replace conventional and other techniques of minimally invasive esophagectomy.