Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position—experience of 130 patients

Chinnusamy Palanivelu, Anand Prakash, Rangaswamy Senthilkumar, Palanisamy Senthilnathan, Ramakrishnan Parthasarathi, Pidigu Seshiyer Rajan, S Venkatachlam
Journal of the American College of Surgeons 2006, 203 (1): 7-16

BACKGROUND: 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.

STUDY DESIGN: 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.

RESULTS: 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.

CONCLUSIONS: 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.

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