Technical and Perioperative Outcomes of Minimally Invasive Esophagectomy Using Prone Vats

Ross F Goldberg, MD, Steven P Bowers, MD FACS, Michael A Parker, MD, John A Stauffer, MD, Horacio J Asbun, MD FACS, C Daniel Smith, MD FACS. Mayo Clinic – Florida

Introduction:

Minimally invasive esophagectomy (MIE) is performed through various approaches, including the use of video-assisted thoracoscopic surgery (VATS) for mediastinal esophageal dissection. Typically, VATS is performed with patients in the lateral decubitus position. To achieve esophageal exposure, lateral positioning VATS requires numerous trocars, specialized retractors, and a skilled assistant. A prone VATS technique enables gravity-aided esophageal exposure thereby facilitating the thoracic portion of MIE. This study’s aim is to review perioperative outcomes after prone MIE focusing on outcomes related to patient preoperative comorbidities.

Methods and Procedures:

An IRB-approved retrospective cohort study is presented. Between January 2007 and August 2010, 42 patients underwent 3-field MIE using prone positioning for the VATS portion. A 3-trocar technique was used (10 mm x 2 and 5 mm x 1) allowing for just one surgeon and one assistant. All of the patients were managed with a standardized care pathway.

Patients were predominantly male (37 vs. 5 female) and an average age of 68 years (range 37-87). The indications for MIE were: adenocarcinoma (35), Barrett’s with high-grade dysplasia (4), end-stage achalasia (2), and squamous cell carcinoma (1). Neoadjuvant chemo/radiotherapy was administered to 16 (38%) patients. Using an established preoperative co-morbidity index, 23 patients were categorized as low-risk, 14 as moderate-risk, and 5 as high-risk. Postoperative complications were stratified using the Clavien Classification Scale, with minor complications classified as Class 1-2 and major complications as Class 3-5.

Results:

Median length of stay was 8 days (range 6-51 days) and median ICU stay was 2 days (range 1-26 days). Average surgical time for prone VATS was 108 minutes (range 67-198 minutes) and average supine surgical time was 230 minutes (range 120-364 minutes). Average estimated blood loss was 183 cc (range 20-500 cc), and 37 out of 42 patients (88%) were extubated on the day of operation. Postoperatively, 5 out of 5 high-risk patients had a complication, 3 of which were major. Eight of the 14 moderate-risk patients had a complication, 3 of which were major; and 17 of the 23 low-risk group had a complication, 8 of those major. The predominant complications were arrhythmias (14) and pneumonia (7). There were a total of 5 anastomotic leaks, 1 in the high-risk group, 1 in the moderate-risk group and 3 in the low-risk group. Twelve of the 14 major complications occurred in patients with a history of tobacco use. There were a total of 2 postoperative 30-day mortalities, 1 in the high-risk group and 1 in the moderate-risk group.

Conclusions:

This series supports the use of the prone MIE approach. Prone VATS in MIE allows for fewer ports than non-prone MIE and eliminates the need for lung retractors. Despite the facilitation of the thoracic portion of the surgery, and a pathway allowing early extubation, cardiopulmonary complications remained common, although more so in the high-risk patient and those with a history of tobacco use.