|Year : 2019 | Volume
| Issue : 2 | Page : 98-102
The surgical outcome of minimally invasive pharyngo-laryngo-oesophagectomy in prone position
Mariko Ogino1, Yuma Ebihara1, Akihiro Homma2, Kimitaka Tanaka1, Yoshitsugu Nakanishi1, Toshimichi Asano1, Takehiro Noji1, Yo Kurashima1, Soichi Murakami1, Toru Nakamura1, Takahiro Tsuchikawa1, Keisuke Okamura1, Toshiaki Shichinohe1, Satoshi Hirano1
1 Department of Gastroenterological Surgery, Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
2 Department of Otolaryngology, Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
|Date of Submission||15-Nov-2017|
|Date of Acceptance||14-Feb-2018|
|Date of Web Publication||12-Mar-2019|
Dr. Yuma Ebihara
Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N15W7,Kita-ku, Sapporo, Hokkaido 060-8638
Source of Support: None, Conflict of Interest: None
Purpose: Pharyngo-laryngo-oesophagectomy (PLE) which is mainly indicated for cervical oesophageal cancer or synchronous double cancer of the thoracic oesophagus and the pharynx or larynx, is extremely invasive. Since minimally invasive oesophagectomy (MIE) using video-assisted thoracic surgery has become popular recently, the procedure can be adopted to PLE. Moreover, the use of the prone position (PP) in MIEs has been increasing recently because technical advantages and fewer post-operative complications were reported. To assess the validity of PP, this study compared surgical outcomes of minimally invasive PLE (MIPLE) in PP with that in the left lateral decubitus position (LLDP).
Patients and Methods: This study enrolled consecutive 15 patients that underwent MIPLE with LLDP (n = 7) or PP (n = 8) between January 1996 and October 2016. The patients' background characteristics, operative findings and post-operative complications were examined.
Results: Eligible diseases are 5 cases of cervical oesophageal cancer, 9 cases of synchronous double cancer of the thoracic oesophagus and head and neck and 1 case of cervical oesophageal recurrence of the head-and-neck cancer. The patients' background characteristics were not significantly different. During surgery, thoracic blood loss was significantly lower in PP than in LLDP (P = 0.0487). Other operative findings and post-operative complications were not significantly different between the two groups.
Conclusions: In MIPLE, the PP could reduce blood loss due to the two-lung ventilation under artificial pneumothorax and was associated with lower surgical stress than LLDP.
Keywords: Minimally invasive pharyngo-laryngo-oesophagectomy, prone position, video-assisted thoracic surgery
|How to cite this article:|
Ogino M, Ebihara Y, Homma A, Tanaka K, Nakanishi Y, Asano T, Noji T, Kurashima Y, Murakami S, Nakamura T, Tsuchikawa T, Okamura K, Shichinohe T, Hirano S. The surgical outcome of minimally invasive pharyngo-laryngo-oesophagectomy in prone position. J Min Access Surg 2019;15:98-102
|How to cite this URL:|
Ogino M, Ebihara Y, Homma A, Tanaka K, Nakanishi Y, Asano T, Noji T, Kurashima Y, Murakami S, Nakamura T, Tsuchikawa T, Okamura K, Shichinohe T, Hirano S. The surgical outcome of minimally invasive pharyngo-laryngo-oesophagectomy in prone position. J Min Access Surg [serial online] 2019 [cited 2019 Nov 12];15:98-102. Available from: http://www.journalofmas.com/text.asp?2019/15/2/98/228410
| ¤ Introduction|| |
In the early 1990s, thoracoscopic oesophagectomy was adopted. This procedure was originally performed in the left lateral decubitus position (LLDP). In 1994, Cuschieri  reported the thoracoscopic oesophageal mobilisation in the prone position (PP). Hence, since Palanivelu et al. reported excellent surgical results of PP thoracoscopic oesophagectomy using artificial pneumothorax under two-lung ventilation, many oesophageal surgeons were stimulated new interest in this approach.
In our institution, we performed minimally invasive pharyngo-laryngo-oesophagectomy (MIPLE) in LLDP (from 1996 to 2009) with one-lung ventilation, adopted in PP under the artificial pneumothorax with two-lung ventilation (from 2010). There are no reports about surgical outcomes of MIPLE in PP. This study shows short-term surgical outcomes based on our experience with 8 cases of this procedure, and retrospective comparison of PP versus LLDP.
| ¤ Patients and Methods|| |
From January 1996 to October 2016, 15 consecutive patients who underwent MIPLE in the Department of Gastroenterological Surgery II at Hokkaido University Hospital (Sapporo, Japan) were enrolled for this study. The operative approach was LLDP (from January 1996 to December 2009) or PP (from January 2010 to October 2016). During the study, no open PLEs were performed. All patients gave their informed consent to be included in the study. This study was carried out with the approval of the Hokkaido University Ethics Committee (No. 016-0458).
Hospital records were reviewed to determine patient age, sex, American Society of Anaesthesiology, pre-operative chemoradiotherapy, and those in surgical findings are time of thoracoscopic surgery, blood loss, blood transfusion, the number of retrieved lymph nodes in mediastinal, residual tumour, alimentary tract reconstruction, route of reconstruction, and those in post-operative complications are anastomotic failure, pneumoniae, the Clavien-Dindo (CD) classification, post-operative stay and operative mortality.
Among the post-operative complications, anastomotic leak was defined as leakage identified by contrast X-ray and requiring surgical treatment (≥CD Grade IIIa). Pneumonia was defined as an abnormal infiltrate on the chest X-ray associated with leucocytosis and fever for which administration of antibiotics was required (≥CD Grade II).
The patient was placed in the PP while under epidural and general anaesthesia, which used a single lumen flexible endotracheal tube for two-lung ventilation. The port positions were as follows [Figure 1]: A 12-mm port was first carefully inserted into the 9th intercostal space (ICS) on the scapular angle line, and CO2 was then insufflated at a pressure of 8–10 mmHg. Other three ports were inserted under thoracoscopic control: a 12-mm port in the 3rd ICS behind the posterior axillary line, and 5-mm ports in the 5th and 7th ICS on a little ventral side of the posterior axillary line. After starting the artificial pneumothorax, the lung was gradually collapsed, and the operative field was ensured because the collapsed lung is drawn ventrally by gravity. Intrathoracic procedures were as follows: right pulmonary ligament was divided, and the middle and lower oesophagus was mobilised with regional lymph nodes along the layer that exposed the pericardium and bronchus. The azygos vein was divided and the right bronchial artery was preserved. Then, the upper thoracic oesophagus, the right main branch of the vagal nerve and the right subclavian artery were exposed. The lymph nodes around the right recurrent nerve were dissected with the nerve due to laryngectomy. Then, the upper thoracic oesophagus was circumferentially mobilised, and divided. By pulling the oral side of stump, the tissue including the lymph nodes around the left recurrent nerve was dissected. The thoracic duct was divided if necessary. Next, in the case of coexistence of thoracic oesophageal cancer, the lymph nodes below the aortic arch were dissected and the bilateral oesophageal branches of the vagal nerve were divided while pulmonary branches were preserved. The thoracic oesophagus was completely mobilised circumferentially, and the para-oesophageal lymph nodes were dissected and maintained en bloc with the surgical specimen. We performed the left side mobilisation at the later part of thoracoscopic procedure because the ventilation condition was disturbed when bilateral pneumothorax caused by the injury of left-sided mediastinal pleural occurred.
|Figure 1: The port placement in the prone position. Procedure: A 12-mm port in the 3rd intercostal space behind the posterior axillary line, and in the 9th intercostal space on the scapular angle line. A 5-mm ports in the 5th and 7th intercostal space on a little ventral side of the posterior axillary line. SA: Scapular angle line, PA: Posterior axillary line|
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Left lateral decubitus position
The patient was placed in the LLDP while under epidural and general anaesthesia with selective left lung ventilation using a double-lumen endotracheal tube. The port positions were as follows: the 2nd ICS on the anterior axillary line, the 4th and 6th ICS on the middle axillary line, the 3rd, 5th and 8th ICS on the posterior axillary line. Often, the wrap protectors were used in port sites. Intrathoracic procedures were almost same as the PP procedure in terms of the lymphadenectomy concept. When the lymphadenectomy in superior mediastinum was performed, the operative field was ensured by the assistant's hand excluding the right lung.
The patient was changed to the supine position, and gastric conduit formation was performed by the laparoscopic surgery. Pharyngolaryngectomy and cervical lymphadenectomy were performed by the otorhinologist. Gastric conduit reconstruction was underwent through the posterior mediastinum route, and handsewed pharyngo-gastric anastomosis was performed.
Statistical analyses were performed with the Chi-square test and Mann–Whitney U-test. Overall survival curves were obtained using the Kaplan–Meier method. The values of P < 0.05 were considered to indicate significant difference.
| ¤ Results|| |
All factors of patients' backgrounds and post-operative complications were not significantly different between the two groups [Table 1]. Median blood losses of entire surgery and thoracic procedure were 910 ml and 180 ml in the LLDP group and 365 ml and 55 ml in the PP group, respectively. The PP group had significantly less thoracic blood loss than the LLDP group (P = 0.0487) [Table 2]. Other operative findings, including oncological efficacy, such as the number of dissected nodes and the R0 rate, were not significantly different between the two groups. The morbidity rates (≥CD Grade IIIa) of the patients in the LLDP and PP groups (57.1% vs. 37.5% P = 0.6193) were distributed equally between the two groups [Table 3]. Post-operative complications (≥CD Grade IIIa) were the necrosis of gastric conduit, anastomosis failure, pneumoniae and haemorrhage of anastomosis site in the LLDP group, and chylothorax, deep venous thrombosis and pleural effusion in the PP group. In the LLDP group, there was one case of operative mortality caused by pneumoniae. There were no significant differences in the overall survival curves between the LLDP group and the PP group (P = 0.9763) [Figure 2].
|Figure 2: Overall survival curves: There were no significant differences between the left lateral decubitus position group and the prone position group (P = 0.9763)|
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| ¤ Discussion|| |
This is the first report of the surgical outcomes of MIPLE comparing LLDP and PP. In our study, the PP group had significantly less blood loss during thoracic procedure than the LLDP group (P = 0.0487). The number of dissected lymph nodes and the R0 rate were not significantly different between the two groups.
Some reports indicated that minimally invasive esophagectomy for oesophageal cancer in the PP has advantages compared with the LLDP. As for ensuring of the operative field, it is advantageous for pressing down the trachea by using a single-lumen flexible endotracheal tube. In their study, Noshiro et al. reported that blood loss was significantly lower and the number of retrieved lymph nodes was more in the PP group than in LLDP group. A possible reason for lower blood loss in the PP group may include the better visual field, and easer manoeuvrability caused by the artificial pneumothorax and the bleeding reduction effect due to the pressure of the pneumothorax. In addition, the magnifying effect of video-assisted thoracic surgery made it possible to operate more finely. As a result, the decrease in blood loss and the accuracy of lymphadenectomy were induced. Saikawa et al. reported that the PP thoracoscopic surgery using artificial pneumothorax under two-lung ventilation was beneficial for maintaining stable haemodynamics and oxygenation, and hence, this method improved safety and simplicity in anaesthesia induction and maintenance. Furthermore, it is reported that the frequency of post-operative respiratory complications such as infection and pleural effusion is lower in the PP than in the LLDP.
We adopted MIPLE to PLE since 1996. So far, there are few reports of the MIPLE.,, In 2015, Homma et al. reported 10 cases MIPLE using laparoscopy and thoracoscopy in our institution from 2004 to 2013. This report was co-authored by our department, and cases were duplicated. This report discussed mainly that the local complications such as troubles of tracheostomy site were one of the most frequent problems in PLE, and those occurred similarly in minimally invasive surgery. On the other hand, MIPLE can reduce post-operative systemic complications such as pneumoniae, as a result, it can decrease the in-hospital mortality.
Most patients having locally advanced cervical oesophageal cancer or those with synchronous double cancer of the thoracic oesophagus and the pharynx or larynx prefer definitive chemoradiotherapy rather than surgery because of possible laryngeal preservation. Therefore, PLE is often applied to the patients after the chemoradiotherapy as a salvage surgery. Salvage surgery is almost only curative treatment option for patients with locoregional persistence or recurrence after definitive chemoradiotherapy. It is reported that post-operative complications such as anastomotic failure often occurred in salvage oesophagectomy. In terms of the operative difficulty of salvage surgeries, degeneration of the organs and surrounding tissues by chemoradiotherapy makes the procedure more difficult than that of upfront surgery and might increase the post-operative morbidity. Addition to this, the latent period between the completion of radiation and surgical resection may affect the extent of small-vessel radiation damage and potentially jeopardise gastric conduit viability. Nevertheless, 71.4% of the LLDP group and 62.5% of the PP group in our series were received pre-operative chemoradiotherapy and the post-operative courses of those cases underwent MIPLES in PP were relatively good, that is, less anastomotic failure and pneumoniae, no reoperation and no operative mortality. It might be due to less invasiveness of the procedure and advantages in operation performance provided by MIPLE in PP.
The present study reveals that MIPLE in PP is the recommended surgical approach because PP could achieve the surgery with less blood loss than LLDP without increasing morbidity nor decreasing curability. To evaluate the effectiveness of MIPLE in PP, the long-term prognosis should be compared between the procedures in two different operative positions.
| ¤ Conclusions|| |
In MIPLE, the PP could be better approach than LLDP because it reduces blood loss for the artificial pneumothorax under two-lung ventilation.
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Conflicts of interest
All authors state that they have no commercial associations that might pose a conflict in connection with the submitted article. Compliance with ethical standards.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]