The semi-Prone position for thoraco-laparoscopic esophagectomy is safe and effective: A single institution experience

Hue Central Hospital Journal of Clinical Medicine - No. 62/2020 1 THE SEMI-PRONE POSITION FOR THORACO-LAPAROSCOPIC ESOPHAGECTOMY IS SAFE AND EFFECTIVE: A SINGLE INSTITUTION EXPERIENCE Ho Huu Thien1 DOI: 10.38103/jcmhch.2020.62.5 ABSTRACT Background: Prone position for thoraco-laparoscopic esophagectomy (TLE) 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. However, urgent conversion to thoracotomy with the patient in the prone position is theorically more complicated than on the left. Some authors reported the semi-prone position on the thoracoscopic stage to overcome this problem. The objective of this study is to evaluate the outcomes of TLE with the patient in a semi-prone position in a Multidisciplinary public hospital. Methods: We conducted a prospective, nonrandomized, observational study in Hue central hospital, which is one of the biggest hospitals in Vietnam from January 2016 to April 2019. This study included the esophageal cancers that were diagnosed by endoscopy and confirmed by pathology. Esophageal cancer with cT1b-3N0M0 using chest CT, ultrasound-endoscopy, abdominal CT was indicated for resection initially, while esophageal cancer with cT4N0M0 or T3N(+)M0 was indicated for resection after neoadjuvant therapy. The patients had the ASA I-III. All the data were analyzed statistically using SPSS software (SPSS, Inc, Chicago, IL). Results: From January 2016 to April 2019, 35 consecutive patients were operated by the semi-prone TLE technique. The male/female ratio was 30/5. The mean age was 57.3±6.3 years, and the mean BMI was 20.5±3.3 kg/m2. The preoperative location of the esophageal cancer was the upper one-third in two (5.7%), the middle one-third in 15 (42.9%), and the lower one- third in 18 (51.4%). For 15 patients (42.9%), the malignancy was squamous cell carcinoma. The remaining 20 patients (57.1%) had adenocarcinomas. The majority of our patients had cTNM stage II (48.6%). Only seven patients (20%) had cTNM stage III, whereas 11 patients (31.4%) had cTNM stage I. Of the 35 patients, seven (20.0%) received short-courses neoadjuvant therapy, two (5.7%) received long-courses neoadjuvant therapy, and the remaining was operated immediately. The operative time was 311.2±45.9 minutes. We did not record either conversion or intraoperative events. The mortality and the morbidity rate were 2.8% and 34.4%, respectively. Hospital stay was 15.6±7.2 days. The median follow-up time was 22±1.5 months, and the overall survival rate at one year was 84.7%. 1. Department of Abdominal Emergency and Paediatric Surgery, Hue Central Hospital Corresponding author: Ho Huu Thien Email: thientrangduc@gmail.com Received: 8/5/2020; Revised: 17/5/2020 Accepted: 20/6/2020 Bệnh viện Trung ương Huế 2 Journal of Clinical Medicine - No. 62/2020 The semi-prone position for t oraco-laparoscopic... Conclusion: Thoraco-laparoscopic esophagectomy for esophageal cancer with the patient in semi-prone position is safe and effective, including the lower morbidity rate and the shorter operative time while preserving the longterm outcomes. Keywords: Esophageal cancer; Thoraco-laparoscopic esophagectomy I. INTRODUCTION Esophageal cancer is one of the leading causes of cancer-related death worldwide. Esophageal cancer is currently the seventh most common malignant tumor in men in Vietnam, and the vast majority of esophageal cancers are squamous cell carcinomas [1]. Esophagectomy plays a significant role in the treatment strategy for resectable thoracic esophageal cancer. However, esophagectomy is a highly invasive procedure that can lead to severe postoperative complications [2]. TLE with the patient in the left lateral decubitus position firstly reported by Luketics et al. in 2003. This technique showed several advantages comparing with open esophagectomy such as lower blood loss, less postoperative pain, a lower percentage of pleuropulmonary complications, faster postoperative recovery with reduction of hospital stay [3]. Prone position for TLE 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 [4-8]. However, urgent conversion to thoracotomy with the patient in the prone position is probably more complicated than on the left, in some cases needed. Subsequently, some authors reported the semi-prone position on the thoracoscopic stage to overcome this problem [9], [10]. In our hospital, semi-prone TLE was introduced in 2016. The objective of this study is to evaluate the outcomes of this technique in a Multidisciplinary public hospital with 3,000 beds in central Vietnam. II. METHODS We conducted a prospective, nonrandomized, observational study in Hue central hospital, which is one of the biggest hospitals in Vietnam from January 2016 to April 2019. The Hospital ethics committee approved the study protocol and all modifications during the study. The written informed consent was obtained from all patients. This study included the esophageal cancers that were diagnosed by endoscopy and confirmed by pathology. Esophageal cancer with cT1b-3N0M0 using chest CT, ultrasound-endoscopy, abdominal CT was indicated for resection initially, while esophageal cancer with cT4N0M0 or T3N(+)M0 was indicated for resection after neoadjuvant therapy [11]. Gastrostomy always indicated for patients receiving long-term neoadjuvant therapy. The patients had the ASA I-III that were preoperatively determined by an anesthetist. Exclusion criteria were a history of thoracic or abdominal surgery, which may affect the study, pleural adhesion, or unable to selective tracheal intubation. Surgical techniques The semi-prone TLE, including thoracoscopic, laparoscopic, and cervical phase, was performed by the same thoracoscopic, laparoscopic, and cervical team, respectively. Thoracoscopic stage After endotracheal selective intubation anesthesia (Carlene tube) for right lung exclusion, we initiated all procedures by thoracoscopy on the right with the patient on tilted left 300. The surgeon and assistant stand to the right of the patient and the monitor on the opposite. The first 10 mm trocar was placed in the 6th intercostal space on the medial axillary line Hue Central Hospital Journal of Clinical Medicine - No. 62/2020 3 for a 300 Optique, the second 5 mm trocar was in ninth intercostal space on posterior axillary line (surgeon’s left hand) and the third 5 mm trocar in the 4th intercostal space on the anterior axillary line (surgeon’s right hand). After pneumothorax with the pressure of 12 mm Hg and assessment the location, tumor invasion, lymph nodes as well as the ability of resection, Azygos vein was firstly dissected and cut between two hemolocks 5 mm. The mediastinal pleura was then opened on both sides of the esophagus, altogether remove the thoracic esophagus from the diaphragmatic orifice to the cervical base, avoid damaging the thoracic tube and recurrent nerve, extensive lymphadenectomy surrounding the esophageal tumor and bronchial lymph nodes. At the end of the thoracic stage, a drain of 24 Fr was positioned, checking for bleeding, pulmonary re- expansion, and closed the trocars. Laparoscopic stage: The patient then was positioned in dorsal decubitus, the head tilted right, the legs apart, and replaced the double-lumen tracheal tube by a conventional. The monitor was on the patient’s left. The surgeon stood between the legs and the assistant on the patient’s right. A 10 mm trocar for Optique 300 was placed infra-umbilically. A 10 mm trocar in the left mammillary line above 3 cm the umbilical line (surgeon’s right hand) and 5 mm trocar in the right mamillary line above 2 cm umbilical line (surgeon’s left hand). The fourth trocar was placed under xiphoid 3 cm (assistant’s hand). After the exploration of the abdominal cavity, the stomach was mobilized by resection the gastrocolic ligament and short gastric vessels with Thunderbeat device (Olympus Medical Systems) while preserving the gastroepiploic arcade. Then, left gastric vessels were sectioned between hemolocks. The hiatus opened broadly by partially sectioning the left and right diaphragm pillar after radical lymphadenectomy, including 8,9,7,1,2,3 groups. Then, the fourth trocar site was enlarged 5-6 cm longitudinally and covered by a protective bag. The specimen and the stomach pulled out en bloc. The gastric tube of 3 cm was prepared outside the abdominal cavity with 4-5 GIA 60 mm, with reinforcement of the entire Clipping line with a continuous suture of Vicryl 4.0. The gastric tube was then pulled up through the posterior mediastinum to anastomose with the cervical esophagus. The abdominal stage was completed with the pyloroplasty and feeding jejunostomy. Cervical stage: The left anterolateral cervicotomy 5 cm was performed simultaneously with the laparoscopic stage following the anterior border of the sternocleidomastoid muscle, isolating the cervical esophagus. The esophagus was sectioned, and the distal end was sutured with a 24 Fr drain to aid in the pulling up the gastric tube. After performing the cervical anastomosis by the end to side technique, a cervical drain was placed. In the latter study, cervical anastomosis was changed to side to side with GIA with the agreement of the institutional ethics committee to avoid the cervical anastomotic stricture. Statistical data and analysis All data were collected from the medical record of our hospital for further analysis. The following variables were analyzed: Demographics and preoperative variables (age, BMI, tumor location, histopathology, neo-adjuvant treatment); intraoperative (conversion, operative time, intraoperative complication); postoperative (mortality, morbidity, respiratory complications, cervical fistula, thoracic duct injury, gastric tube leaks, hoarseness); and follow-up (cervical anastomotic stenosis, recurrence, metastasis). All the data were analyzed statistically using SPSS software (SPSS, Inc, Chicago, IL), and expressing data values as percentages, mean, standard deviation, or median values as per data type (qualitative or Bệnh viện Trung ương Huế 4 Journal of Clinical Medicine - No. 62/2020 The semi-prone position for t oraco-laparoscopic... quantitative). Overall survival was analyzed by the Kaplan–Meier method calculated from the date of operation until the date of death. III. RESULTS From January 2016 to April 2019, 35 consecutive esophageal cancer patients were operated with the semi-prone TLE technique. In the whole cohort, there were 30 men (85.7%) and five women (14.3%); mean age was 57.3±6.3 (44-69) years and mean BMI 20.5±3.3 (16.3-24.8) kg/m2. The preoperative location of the esophageal cancer was the upper one-third in two (5.7%), the middle one- third in 15 (42.9%), and the lower one-third in 18 (51.4%). For 15 patients (42.9%), the malignancy was squamous cell carcinoma. The remaining 20 patients (57.1%) had adenocarcinomas. The majority of our patients had cTNM stage II (48.6%). Only seven patients (20%) had cTNM stage III, whereas 11 patients (31.4%) had cTNM stage I. Of the 35 patients, seven (20.0%) received short-courses neoadjuvant therapy, two (5.7%) received long- courses neoadjuvant therapy, and the remaining was operated immediately. The operative time was 311.2±45.9 minutes. We did not record either conversion to open or intraoperative events. No blood transfusion was needed in all cases. This study recorded one death (3.7%) due to gastric tube leakage. The thoracic drain and nasogastric tube were removed and feeding through jejunostomy on the 5th day. On the 8th postoperative day, coughing appeared, chest X-ray showed an image of pleural effusion. Two days after the patient had breathing difficulty. Esophageal contrast radiography and endoscopic esophagoscopy located the leakage in the lower of the gastric tube. The cause of the leakage was suspected as the torsion of the gastric tube. The thoracic drainage and the nasogastric tube were repositioned, but the symptoms were not improved. The patient was re-operated on the tenth postoperative day by the cervical esophageal diversion. The patient died on the 14th postoperative day due to septicemia and multi-organ failure. Postoperative complications were experienced by 12 patients (34.3%), with postoperative pneu- monia developing in four (11.4%), who required conservative treatment. The cervical fistula was detected in three patients. The fistula was managed conservatively. Four patients (11.4%) experienced hoarseness, which resolved without any treatment. The hospital stay was 15.6±7.2 days (7-25). The surgical complications were detailed in table 1. Table 1: Surgical complications and Clavien’s classification Complication n % Clavien’s classification Pneumonia Cervical fistula Gastric tube leakage Hoarseness 4 3 1 4 11.4 8.6 2.8 11.4 Grade II Grade II Grade III (death) Grade I Fourteen patients (40%) were sent to the oncology center for adjuvant chemotherapy due to positive lymph nodes. Of these, five patients (35.7%) received short-course radiotherapy preoperatively. The median follow-up time was 22±1.5 months. There were nine (25.7%) anastomotic stenosis, which were all resolved by endoscopic dilatation from one to several times. Of those without anastomotic stenosis, we noted all five cases of which the cervical side to side anastomoses were performed. We recorded three regional recurrences (8.6%) and three (8.6%) distal metastasis (one lung, one oral base, one multi-organ). Overall survival rate Hue Central Hospital Journal of Clinical Medicine - No. 62/2020 5 Figure 1: Overall survival rate according to Kaplan-Meier IV. DISCUSSION The first large series of TLE with the patient on the left lateral decubitus position was report- ed by Luketich et al. [3]. This technique showed several advantages comparing with open esopha- gectomy such as lower blood loss, less postop- erative pain, faster postoperative recovery with reduction of hospital stay. However, these initial reports showed high rates of conversion to open thoracotomy and postoperative respiratory compli- cations, and therefore did not show a convincing advantage of the TLE with the patient on the left [3], [12]. In 2006, Palanivelu performed TLE in the prone position, given a lower rate of morbidity [4]. The conversion to open in the thoracoscopic phase of prone TLE was reported with a lower rate [4-10]. The conversion rate was 10% in the series of Seesing et al. [9] and 7.4% in the series of Ja- ved et al. [6]. The conversion to a thoracotomy is theoretically more difficult in the prone than the left lateral position. However, in Seesing’s study, no severe difficulties were encountered during conversion to thoracotomy in a prone position. All at one year and two years was 84.7% and 73.9%, respectively (Figure 1). conversions were performed due to reduced acces- sibility of the thorax because of adhesions, and no emergency conversion was needed. When conver- sion to thoracotomy is needed during TLE in the prone position, the patient needs to be repositioned and draped. However, since no emergency conver- sion was necessary for his series, he did not experi- ence practical problems [9]. In our study, we did not record any conversion so that we could not evaluate the advantages of this technique for thoracotomy. However, there were few complications as well as death related to the pa- tient’s semi-prone position, demonstrating the feasi- bility and the safety of this method. Overall morbid- ity and pulmonary complications were 34.3% and 11.4%, respectively. These results were comparable to those of the TLE group but lower in OE group [9], [10], [13-18]. There was one death (2.8%), secondary to a me- diastinal fistula at the end of the gastric tube with the suspected cause of gastric tube torsion. This death rate was comparable with that in the literature ( 0%9 - 2.9%) [13-18]. In our series, the stomach tube was prepared ex- tracorporeally by making a small abdominal inci- sion required for specimen delivery, pyloroplasty, and feeding jejunostomy. Laparoscopy could use even in two cases with the previous gastrostomy without any difficulty. Most authors strongly sup- port the need to perform a pyloromyotomy for gas- tric tubularization, believing they can improve the rate of gastric emptying [3], [4]. Luketich et al. [3] also performed laparoscopic gastric mobilization, but he formed an intracorporeal stomach tube using Endo-GI staplers (Johnson and Johnson, Cincinna- ti). This technique increased the total operative time (median, 7.5 h). One drawback of the semi-prone position is that the patients were intubated with a double- lumen endotracheal tube while the prone position only required a single-lumen endotracheal tube. However, the benefit of single-lumen tube ventilation is minor because we changed into a single-lumen endotracheal tube in the laparoscopic stage. Bệnh viện Trung ương Huế 6 Journal of Clinical Medicine - No. 62/2020 Regarding the operative time, there is no difference between our study and other studies in which the semi-prone TLE was used [9], [10]. The good surgical field having by the semi-prone position and extracorporeal gastric tube preparation might be the reasons for the shortness. Our study noted the high rate of cervical anastomotic stenosis (9 cases, 25.7%), which were successfully treated with endoscopic dilatation. We believe that side to side using the linear stapler helps to reduce the incidence of anastomotic stenosis, as shown in this latter study. We also noted three cervical anastomotic fistulas related to cervical anastomotic stenosis. Related to longterm results, although the study was far from ideal, the overall survival rate of one year was 84.7% was similar to that of the systemic review of Dantoc et al. [19] as well as the study of Lazzarino [20]. V. CONCLUSION Thoraco-laparoscopic esophagectomy for esophageal cancer with the patient in a semi- prone position is a method with many advantages, including the lower morbidity rate, shorter the operative time, while preserving the longterm outcomes. However, a more significant number of patients need to be studied for an accurate evaluation of long-term results. Conflicts of Interest: The authors have no conflicts of interest to declare. Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by the ethics commitee of Hue Central Hospital. Written informed consent was obtained from all patients. REFERENCE 1. Viet nam-globocal observatory 2018 2. Takeuchi H, Miyata H, Gotoh M, et al. A risk model for esophagectomy using data of 5354 patients included in a Japanese nationwide web- based database. Ann Surg 2014; 260:259-66. 3. Luketich JD, Alvelo-Rivera M, Buenaventura PO, Christie NA, McCaughan JS, Litle VR, et al. Min- imally invasive esophagectomy: outcomes in 222 patients. Ann Surg. 2003 Oct; 238(4): 486–94. 4. Palanivelu C, Prakash A, Senthilkumar R, Sent- hilnathan P, Parthasarathi R, Rajan PS, et al. Minimally invasive esophagectomy: thoraco- scopic mobilization of the esophagus and me- diastinal lymphadenectomy in prone position— experience of 130 patients. J Am Coll Surg. 2006 Jul; 203(1): 7–16. 5. Kubo N., Ohira M., Yamashita Y. et al. Thora- coscopic Esophagectomy in the Prone Position Versus in the Lateral Position for Patients With Esophageal Cancer: A Comparison of Short- term Surgical Results. Surgical laparoscopy, en- doscopy & percutaneous techniques. V 24.doi - 10.1097/SLE.0b013e31828fa6d7 6. Javed A, Manipadam JM, Jain A, Kalayarasan R, Uppal R, Agarwal AK. Minimally invasive oesophagectomy in prone versus lateral de- cubitus position: A comparative stud. J Minim Access Surg. 2016 Jan-Mar;12(1):10-5. doi: 10.4103/0972-9941.171954. 7. Sheraz R. Markar, Tom Wiggins, Stefan Antono- wicz, Emmanouil Zacharakis, George B. Hanna. Minimally invasive esophagectomy: Lateral de- cubitus vs. prone positioning; systematic review and pooled analysis. Surgical Oncology. 2015 Sept, 24 (3); 212-9 8. Carlos Bernado Cola, Flavio Duarte Sabino, Carlos Eduardo Pinto et al. Thoraco-laparoscop- ic esophagectomy: thoracic stage in prone posi- tion. Rev Col Bras Cir 2017; 44(5): 428-434. 9. Seesing MF, Goense L, Ruurda JP, Luyer MD, Nieuwenhuijzen GA, van Hillegersberg R. Mini- mally invasive esophagectomy: a propensity score-matched analysis of semiprone versus prone position. Surg Endosc. 2018 Jun; 32(6): 2758-65. The semi-prone position for t oraco-laparoscopic...