SUPERIORITY OF THORACOSCOPIC ESOPHAGECTOMY IN THE HYBRID POSITION TO THE PRONE POSITION
Hirotoshi Kikuchi*1, Yoshihiro Hiramatsu1,2, Sanshiro Kawata1, Tomohiro Matsumoto1, Yusuke Ozaki1, Kinji Kamiya1, Yoshifumi Morita1, Takanori Sakaguchi1, Hiroyuki Konno3, Hiroya Takeuchi1
1Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan; 2Department of Perioperative Functioning Care and Support, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan; 3Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
Background: Thoracoscopic esophagectomy (TE) with mediastinal lymphadenectomy is becoming a major surgical method for esophageal cancer. There are several approaches for TE; left lateral decubitus position, prone position, and hybrid position combining the left lateral decubitus and prone positions. However, there are only few studies that compared clinical utility of those approaches. In our institute, we introduced TE in the prone position (prone TE) in 2014, and have performed TE in the hybrid position (hybrid TE) since 2017 March. In this study, we compared short-term outcomes of those two surgical procedures.
Patients and methods: Eighty patients who underwent TE with total mediastinal lymphadenectomy followed by gastric tube reconstruction between 2014 March and 2018 October for esophageal squamous carcinoma (n= 67), adenocarcinoma (n=12) or malignant melanoma (n=1) were enrolled. Clinicopathological data were retrospectively reviewed and compared between 41 and 39 patients who underwent prone TE and hybrid TE, respectively.
Results: There was no difference in age. Female rate was significantly higher in the prone TE (24.4% vs 5.1%, P=0.016). Tumor depth (cT), lymph node metastasis (cN) and tumor stage (cStage) were lower in the prone TE (P=0.001, 0.002 and 0.001, respectively) because only superficial cancers were indicated for TE in the introduction phase of prone TE. Operation time for the thoracoscopic procedure was shorter in the hybrid TE (321 vs 251 min, P<0.001). There were no significant difference in the number of mediastinal lymph nodes dissected between the two groups. Although several factors could affect postoperative complications, the rate of recurrent laryngeal nerve paralysis (Clavien-Dindo grade I-III) was significantly lower in the hybrid TE (43.9% vs 15.4%, P=0.005), whereas there were no difference in the rate of anastomotic leakage, atelectasis or pneumonia between the two procedures.
Discussions: In the hybrid TE, upper mediastinal procedures were performed in the left lateral decubitus position. Therefore, upper mediastinal procedures most significantly differ between the prone TE and hybrid TE. Because the assistant stands opposite to the operator in the hybrid TE, the motion of assistant forceps is less interfered that enables better operative field compared to the prone TE in which the assistant stands by the operator. Hybrid TE appears to have advantage in the approaching angle of operator's forceps to upper mediastinal lymph nodes and recurrent laryngeal nerve for appropriate traction.
Conclusions: Hybrid TE has advantages in the upper mediastinal approach that resulted in shorter operation time and less recurrent laryngeal nerve paralysis compared to the prone TE.
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