|Year : 2016 | Volume
| Issue : 1 | Page : 10-15
Minimally invasive oesophagectomy in prone versus lateral decubitus position: A comparative study
Amit Javed, John Mathew Manipadam, Amit Jain, R Kalayarasan, Rajeev Uppal, Anil K Agarwal
Department of Gastrointestinal Surgery, GB Pant Hospital and MAM College, Delhi University, New Delhi, India
|Date of Submission||08-Oct-2014|
|Date of Acceptance||12-May-2015|
|Date of Web Publication||17-Dec-2015|
Department of Gastrointestinal Surgery, 2nd Floor, Academic Block, GB Pant Hospital, JLN Marg, Delhi - 110 002
Source of Support: None, Conflict of Interest: None
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.
Keywords: Esophagectomy, minimally invasive surgical procedures, esophageal cancer
|How to cite this article:|
Javed A, Manipadam JM, Jain A, Kalayarasan R, Uppal R, Agarwal AK. Minimally invasive oesophagectomy in prone versus lateral decubitus position: A comparative study. J Min Access Surg 2016;12:10-5
|How to cite this URL:|
Javed A, Manipadam JM, Jain A, Kalayarasan R, Uppal R, Agarwal AK. Minimally invasive oesophagectomy in prone versus lateral decubitus position: A comparative study. J Min Access Surg [serial online] 2016 [cited 2019 Dec 7];12:10-5. Available from: http://www.journalofmas.com/text.asp?2016/12/1/10/171954
| ¤ Introduction|| |
Oesophagectomy remains the mainstay of treatment in patients with potentially resectable oesophageal cancer. The surgical trauma imposed by oesophagectomy is perhaps the greatest amongst the standard general surgical procedures, often involving simultaneous exploration of the abdomen, chest and neck. Minimally invasive oesophagectomy (MIE) was introduced in the 1990s in an effort to reduce the morbidity and mortality associated with the traditional open surgical approach. Since then, there have been several studies that have documented the advantages of the minimally invasive approach over the standard transthoracic and transhiatal oesophagectomy. These include shorter operative time, decreased blood loss and thus transfusion requirement, decreased pulmonary complications, less vocal cord palsy, and reduced intensive care and hospital stay. ,,, The MIE can be performed by a single-stage laparoscopic transhiatal approach, or by a staged thoracoscopic and laparoscopic approach. Thoracoscopic oesophageal mobilisation is most commonly performed with the patient placed in the lateral decubitus position (LDP). Prone position (PP) for thoracoscopic oesophageal mobilisation has been proposed as an alternative to the lateral approach by a few authors, citing potential benefits such as better surgeon ergonomics and operative exposure, shorter operative time and decreased pulmonary morbidity. ,,, The objective of our study was to compare the early outcomes of thoracolaparoscopic oesophagectomy in PP and in LDP.
| ¤ Materials and Methods|| |
A retrospective review was performed of all patients with oesophageal cancer who were managed surgically at the Department of Gastrointestinal Surgery at our centre, which is a tertiary referral teaching institution, between January 2011 and February 2014. The data were extracted from a prospectively maintained oesophageal disease database.
All patients with suspected oesophageal cancer underwent an upper gastro-intestinal endoscopy and biopsy. Staging and assessment of resectability was routinely done by a contrast-enhanced computed tomography (CT) scan of the chest and the abdomen and by bronchoscopy (for middle third tumours). Positron emission tomography (PET) scan and endoscopic ultrasound evaluation were done selectively. A chest X-ray, pulmonary function tests, electrocardiography (ECG), and cardiac evaluation were done in all patients. Patients with bulky, locally advanced, unresectable (T4/N1) tumours on contrast-enhanced CT scan of the thorax and abdomen were referred for neo-adjuvant chemoradiotherapy with cisplatin 75 mg/m 2 , 5-fluorouracil 1000 mg/m 2 and concurrent radiation of 50 Gy. Those with metastatic disease or those unfit for surgery underwent palliative treatment.
All patients with resectable tumours and those considered fit to undergo surgery were started on a pulmonary physiotherapy programme that included deep-breathing exercises, steam inhalation, antiseptic mouthwash gargles and incentive spirometry. Antibiotics and bronchodilators were used if indicated. In patients who were nutritionally depleted or had prolonged/complete dysphagia, a pre-operative nasogastric tube was inserted for nutritional build-up. All patients who underwent a thoracolaparoscopic oesophagectomy in either LDP or PP constituted the study group. During the early part of the study, oesophagectomy was performed in the LDP as it was the preferred approach in many of the earlier studies, including the large single-centre experience reported by Luketich et al.  However, with the emerging evidence favouring the PP, the procedure was performed in PP in the latter half of the study.  All procedures were performed by the same surgical team. Patients who underwent open oesophagectomies (transhiatal and transthoracic) and laparoscopic transhiatal oesophagectomy were excluded. Informed consent was obtained from all the patients.
The surgical approach included a staged MIE which started with thoracoscopic oesophageal mobilisation, with an en bloc lymph nodal dissection followed by laparoscopic gastric mobilisation and cervical oesophagogastric anastomosis. A staging laparoscopy in the supine position was performed as the initial procedure (prior to thoracoscopy) in patients with adenocarcinoma of the lower third oesophagus and gastro-oesophageal junction. Thoracoscopic oesophageal mobilisation was performed in either the LDP or the PP.
Thoracoscopic mobilisation in the LDP
In this approach the patient was first intubated in the supine position with a double-lumen endotracheal tube. The position was then changed to LDP, the right lung was collapsed and four ports were inserted: One camera port, two working ports for the operating surgeon and one port for the assistant. The surgeon and the cameraperson stood on the patient's right side, with the assistant and the monitor positioned on the left side. Pneumomediastinum was created using carbon dioxide insufflation up to a pressure of 6-8 mmHg, and the pleural adhesions of the lung were released. The inferior pulmonary ligament was divided and the inferior pulmonary vein was identified and safeguarded. Peri-oesophageal dissection began with an incision on the mediastinal pleura over the lower end of the oesophagus. The oesophagus was mobilised starting from the lower oesophagus and moving upwards. The entire peri-oesophageal lymph nodes were excised en bloc with the specimen. Moving from below up, the sub-carinal lymph nodes were dissected with the specimen, taking care not to injure the right bronchus which leads on to the carina and the left bronchus. The vagus nerve was divided below the carina, and the azygos vein was either suture-ligated, clipped (using a hem-o-lok ® ) or divided using a laparoscopic stapler with a vascular cartridge. Right and the left recurrent laryngeal nerves were identified and the lymph nodes along them carefully dissected. After completion of the oesophageal mobilisation and lymph nodal dissection, an intercostal chest drain was inserted and the anaesthetist was asked to inflate the collapsed right lung before withdrawal of the ports. [Figure 1] depicts the exposure obtained during the thoracoscopic mobilisation in the LDP.
|Figure 1: Thoracoscopic oesophageal mobilisation in the lateral position- (a) View obtained in the LDP with the right lung collapsed using a double-lumen endotracheal tube (note oesophagus in the most dependent position - yellow arrow); (b and c) Opening the mediastinal pleura over the oesophagus; (d) Excision of the peri-oesophageal lymph nodes en bloc with the oesophagus; (e) Division of the azygous vein with an Endo GIA stapler (Ethicon Endo Surgery); (f) Superior mediastinal dissection|
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Thoracoscopic mobilisation in the PP
Each patient was intubated with a single-lumen endotracheal tube in the supine position and then positioned prone on the operating table. The right hemi-thorax was accessed through three ports in the PP: One camera port and two working ports for the surgeon. In most patients the lung fell away naturally from the operative field under the influence of gravity, in some a transient carbon dioxide insufflation was used to create pneumomediastinum. The surgeon and the assistant stood on the patient's right side with the monitor positioned on the left. The oesophageal dissection was performed as described above. [Figure 2] depicts the exposure obtained during the thoracoscopic mobilisation in the PP.
|Figure 2: Thoracoscopic oesophageal mobilisation in the PP- (a) View obtained in the PP [note- oesophagus (yellow arrow) is not in the most dependent position]; (b) Excision of the peri-oesophageal lymph nodes en bloc with the oesophagus; (c) Azygous vein (blue arrow) mobilised, prior to its division; (d and e) Oesophagus dissected off the membranous trachea clearing the sub-carinal lymph nodes (black arrow); the entire trachea and right and left bronchi are visualised (yellow arrow); (f) Superior mediastinal lymph nodal dissection|
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Laparoscopic mobilisation and cervical oesophagogastric anastomosis
Following completion of the thoracoscopic phase, the patients were positioned supine. The double-lumen endotracheal tube was changed to a single-lumen tube in patients of the LDP group. The abdomen and neck were prepped and draped. The stomach was mobilised with preservation of the right gastro-epiploic and the right gastric vascular arcade. Lymph nodes along the hepatic artery, celiac axis and left gastric artery were dissected. The specimen was retrieved either through a small abdominal incision (if the tumour was bulky/reaching up to the adventitia) or via the cervical incision. In patients in whom the specimen was retrieved through a cervical incision, the gastric conduit was fashioned by serial firing of a laparoscopic linear cutter starting from the antral area and stopping short of the gastro-oesophageal junction. Care was taken to maintain continuity between the specimen and the conduit. An approximately 5-cm portion of the stomach in the region of the cardia and the fundus was left undivided. This facilitated the delivery of both the specimen and the conduit into the neck by applying gentle traction on the divided upper oesophageal end. Once the specimen had been delivered out through the cervical incision, the gastric conduit formation was completed by dividing the attached cardiac portion of the stomach using a linear cutting stapler.
The gastric tube was pulled up into the neck via the posterior mediastinal route. A side-side, stapled cervical oesophagogastric anastomosis was performed. A feeding jejunostomy was inserted.
Following surgery, all patients were shifted to the intensive care unit. The post-operative analgesia included epidural, intravenous opioids and non-steroidal anti-inflammatory drugs (NSAIDs). Patients were given deep vein thrombosis prophylaxis and were started on a physiotherapy programme. Chest tube outputs were monitored and were usually removed when the lung was fully expanded and the output decreased to ≤100 mL/day. Enteral feeds were started via the feeding jejunostomy catheter starting on day 2 and the oral diet was initiated by day 5-7.
The following parameters were analysed: Demographics and pre-operative variables (age, location of tumour, histopathology, neo-adjuvant treatment); intraoperative (duration of surgery, intraoperative blood loss, conversion rate to open); post-operative (mortality, morbidity- respiratory complications, cervical oesophagogastric anastomotic leaks, thoracic duct injury, hoarseness of voice); and histopathology (type of tumour, stage of disease and number of lymph nodes harvested). A major neck leak was defined as one which required a therapeutic intervention or discontinuation of oral intake. Patients with minor neck leaks were encouraged to take orally, with digital compression at the neck. Respiratory complications were defined as fever >38°C with radiographic evidence of pneumonia or atelectasis. Statistical analysis was performed using the statistical program GraphPad InStat version 4 (GraphPad Software, Inc., La Jolla, CA, USA). Categorical variables were compared using Fisher's exact test and continuous variables were compared using the Mann-Whitney test.
| ¤ Results|| |
During the study period, 104 patients underwent an oesophagectomy for oesophageal cancer. Of these, 42 were open procedures (transhiatal and transthoracic oesophagectomy) and 62 were minimally invasive. In 11 patients a laparoscopic transhiatal oesophagectomy was done, and these were not considered for the analysis. In 51 patients a thoracolaparoscopic oesophagectomy was attempted: For LDP, 24 and for PP, 27. In 3 of these patients (LDP-1 and PP-2), the procedure was converted to open in view of adherence to carina and left bronchus. However, conversion to thoracotomy helped only to confirm unresectability, and the tumour could not be resected in these patients. Consequently, the study group included LDP-n = 23 and PP-n = 25 respectively.
[Table 1] depicts the demographic and the pre-operative features in the study groups. The median age of the study population was 55 (24-71) years and was comparable in the two groups (P = 0.9). There were 25 males and 23 females. Twenty-one (21) patients had tumours located in the middle third of the oesophagus, 24 in the lower third, and 3 in the gastro-oesophageal junction. The most commonly observed histology was squamous cell cancer (85.4%), followed by adenocarcinoma (14.6%). The location of the tumour, histology, and the number of patients who received neo-adjuvant treatment were similar in the two groups [Table 1].
|Table 1: Demographic and tumour profile of the patients who underwent oesophagectomy in left LDP and in PP|
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The operative outcomes and post-operative complications are listed in [Table 2]. The median duration of surgery was similar in the two groups (P = 0.12). In 16 patients (LDP-9, PP-7) with intra-oesophageal, non-bulky tumours (not reaching up to the adventitia), the specimen was retrieved via the thoracic inlet through the cervical incision, while in the remaining 23 patients, a small abdominal incision was made to retrieve the specimen. The median blood loss was 300 (100-600) mL in the LDP group and 200 (50-400) mL in the PP group. This difference was statistically significant (P = 0.01).
|Table 2: Comparison of operative and post-operative outcomes of the patients who underwent oesophagectomy in left LDP and PP|
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In the post-operative period, 6 patients in the LDP group (26.1%) and 2 patients in the PP group (8%) developed respiratory complications, P = 0.25. Cervical oesophagogastric anastomosis leaks occurred in 4 patients (2 in each group, P = 1.0). All these patients were managed conservatively with drainage of the neck wound, enteral feeds via the jejunostomy catheter, and continued soft oral diet after digital compression. Hoarseness of voice was seen in 3 patients of LDP group and 2 patients of PP group, P = 0.66. It was transient in all but 1 patient, who required therapeutic intervention (Teflon injection). Thoracic duct injury during oesophageal dissection occurred in 3 patients (1 in LDP, 2 in PP). In all these patients, the injury was recognised intraoperatively by visualising the leaking chyle, and the thoracic duct could be clipped proximal to the site of the injury using a hem-o-lok ® clip. Post-operatively, all of them had low triglycerides in the intercostals drain. One of these patients had prolonged drainage from the intercostal drain, which gradually subsided, and the drain was removed on the 14th post-operative day. In the remaining patients, the drain could be removed at the usual time.
A majority of the patients (37) had a T3 disease. The T stage of the tumour was similar in the two groups. A mean of 8 lymph nodes (range 2-33) were retrieved in LDP group, and 17.5 (range 5-41) in the PP group. This difference was found to be statistically significant, at P < 0.0001. The number of patients with node-positive disease was also higher in the PP group (19 vs 10, P = 0.037).
| ¤ Discussion|| |
The mainstay of treatment for malignancy of the oesophagus and gastro-oesophageal junction has been oesophagectomy. The operation is usually performed in cancer patients who are typically older, have co-morbidities and are malnourished.  Therefore, despite improvements in anaesthesia, and better post-operative care, the rate of post-operative complications and mortality is significant, being higher than most other oncological operations. In specialised units, post-operative morbidity rates range 26-60% and mortality 4-12%. ,,
MIE was introduced in an attempt to minimise the morbidity and mortality associated with a standard oesophagectomy. The credit of pioneering MIE goes to Cuschieri  and DePaula et al.  Since then, there has been an increasing number of reports of MIE that have documented shorter operative time, decreased blood loss, fewer transfusions, decreased pulmonary complications, less vocal cord palsy, reduced intensive care and hospital stay, acceptable lymph node yield and low mortality. ,,, A very recent, multicenter, randomised trial by Biere et al. showed significantly decreased pulmonary infection, hospital stay, intraoperative blood loss and vocal cord palsy in the minimally invasive transthoracic oesophagectomy group when compared to the open transthoracic oesophagectomy group. In addition, the quality-of-life scores were also significantly better in the minimally invasive group. 
Various techniques have been described for performing a MIE. These include laparoscopic transhiatal oesophagectomy, two/three-staged thoracolaparoscopic oesophagectomy and various combinations of hybrid procedures. DePaula et al. reported a transhiatal oesophagectomy without thoracotomy using abdominal-mediastinal dissection conducted by video-laparoscopy in 12 patients.  Cuschieri on the other hand described a technique for endoscopic-assisted oesophagectomy using either a LDP or a PP for the oesophageal dissection. Of the 26 procedures, 20 were performed in the LDP and 6 in the PP. The author suggested that PP had technical advantages and reduced post-operative respiratory complications.  Despite this early report suggesting the benefits of thoracoscopic mobilisation, most centers continued to perform thoracoscopic oesophageal mobilisation in the left LDP; however, recently studies have validated the prone approach as a safe and effective alternative.
The primary benefit of the PP is derived from the anatomical exposure of the oesophagus the surgeon gets in this position. The lung falls away because of the effect of gravity and the oesophagus is well visualised. This enables performance of the operation without the need for collapsing the right lung using a double-lumen endotracheal tube. In the lateral position, the oesophagus is in a dependent position and any pooling of blood obscures the surgical field, whereas in the PP, the blood pools away from the operative field. In our study, an additional port was required in the LDP group for the assistant to retract the lung and to suction out the blood. In the PP group, only three ports were used and no extra assistant was needed. A similar benefit was reported by Fabian et al.  The better exposure in turn facilitates a more meticulous dissection. Kubo et al. noted significantly decreased blood loss when the thoracoscopic oesophageal dissection was done in the PP compared to the LDP.  Similarly, in our study, intraoperative blood loss was low, but it was significantly less in the PP group [200 (50-400) mL vs 300 (100-600) mL; P = 0.01].
We noted a significantly higher lymph node yield in PP (average 17.48 vs 8.05, P = 0.0004) than in the LDP group. The number of patients with positive lymph nodes also was significantly higher (19 vs 10, P = 0.037), thereby implying that improved lymph nodal dissection and yield facilitated in upstaging the disease. One possible reason for the low number of lymph nodes in the LDP group could be suboptimal exposure secondary to the dependent position of the oesophagus that facilitates the pooling of blood, obscuring the operative field. In addition, the surgeon, operating field and monitor are not in a straight line; the wrists are not in the neutral position with the forearm, which adds to fatigue during a long procedure in LDP. Noshiro et al., in their study to ascertain whether lymphadenectomy along the left recurrent laryngeal nerve is facilitated in the PP, concluded that compared with the left LDP, PP was associated with lower blood loss and better exposure of the operative field around the left recurrent laryngeal nerve. Although the lymph node yield in the PP was higher than in the LDP, the difference was not significant.  In another study, comparing the lymph node yield during a video-assisted thoracoscopic lobectomy, a better lymph node yield was obtained in the PP. This was due to the good surgical view obtained (without any lung traction), especially in the low mediastinum, as the lung and the blood did not obscure the operative field.  The higher lymph node yield in our study may be attributed to the improved exposure the PP offers. In addition, we used a single-lumen endotracheal tube for the PP that was much softer and shorter than a double-lumen tube. This allows for better lymph nodal dissection in the sub-carinal and superior mediastinum, especially along the recurrent laryngeal nerves. In fact, some authors routinely deflate the main cuff of a double-lumen endotracheal tube to perform an adequate lymph-nodal dissection. 
Pulmonary morbidity is shown to be reduced in the PP. Cuschieri et al. were the first to report decreased respiratory complications following endoscopic-assisted oesophagectomy in the PP.  Palanivelu et al. reported similar findings in their experience.  In a recent randomised trial comparing MIE with open oesophagectomy, the authors reported decreased pulmonary infections during the first 2 weeks and during the whole hospital stay.  The thoracoscopic oesophageal dissection in this study was performed in the PP using a single-lumen endotracheal tube. The authors attributed the decreased pulmonary morbidity to the PP wherein the chest and the abdomen were free of compression. A double-lumen tube and complete collapse of the right lung was not needed, and only a minimal carbon dioxide insufflation was needed. This allowed for intermittent ventilation of the right lung during the thoracoscopic procedure and maintained better oxygenation. In our study, although there were less post-operative pulmonary complications in the PP group, this did not achieve statistical significance.
The present study, being retrospective, suffers from the drawbacks that any retrospective study has, but this is one of the few studies comparing the two approaches of thoracoscopic oesophageal mobilisation. The exposure obtained in the PP is excellent and facilitates meticulous oesophageal and lymph nodal dissection.
| ¤ 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.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]