title: Perioperative outcomes of laparoscopic transhiatal inversion esophagectomy compare favorably with those of combined thoracoscopic-laparoscopic esophagectomy.
abstract: OBJECTIVE
  Wide acceptance of laparoscopic esophagectomy has been hampered by the technical difficulty of the procedure and inconsistent improvements in morbidity and mortality. Most case series have utilized a combined thoracoscopic-laparoscopic approach (TLE), but laparoscopic inversion esophagectomy (LIE), a method of transhiatal esophagectomy, has been proposed as an alternative. Inversion esophagectomy simplifies retraction and improves exposure during the mediastinal dissection; however, no previous studies have directly compared LIE outcomes with those of the combined approach.
  
  
  METHODS
  Between July 2003 and March 2008, 70 consecutive patients underwent minimally invasive esophagectomy by LIE (N = 40) or TLE (N = 30). Data for all patients were collected prospectively and stored in a relational database. Recorded outcome measures included operative time, blood loss, length of hospital stay, intensive care unit stay, and perioperative complications.
  
  
  RESULTS
  There were no significant differences in patient age, gender, body mass index (BMI), or American Society of Anesthesiologists (ASA) class between the groups, but LIE patients had lower stage of esophageal cancer, and were less likely to have received induction chemoradiotherapy than TLE patients. Patients undergoing LIE had significantly lower operative time (398 vs. 537 min, p < 0.001), intraoperative blood loss (100 vs. 200 ml, p < 0.001), and overall length of stay (9 vs. 14 days, p = 0.003) compared with TLE patients. LIE yielded a median of 10 lymph nodes removed compared with 13 for TLE (p = 0.016). Atrial arrhythmia and postoperative pneumonia were less common in LIE patients than in TLE patients, occurring in 17.5% vs. 27.1% (p = 0.036), and in 7.5% vs. 15.7% of cases (p = 0.029), respectively.
  
  
  CONCLUSIONS
  LIE provides safe and effective approach to minimally invasive esophagectomy for patients with early esophageal cancer and high-grade dysplasia. Compared with TLE, inversion esophagectomy requires less operative time and has lower operative blood loss and length of hospital stay. LIE may also result in fewer perioperative cardiac and pulmonary complications compared with TLE. Based on these results, we reserve TLE for more advanced esophageal cancer and those undergoing preoperative radiochemotherapy.
authors.affiliation: Department of Surgery, Oregon Health and Science University, OHSU M/C L223A, 3181 Sam Jackson Park Road, Portland, OR 97239, USA. perryky@ohsu.edu
authors.forename: Kyle A
authors.initials: KA
authors.lastname: Perry
authors.forename: C Kristian
authors.initials: CK
authors.lastname: Enestvedt
authors.forename: Brian S
authors.initials: BS
authors.lastname: Diggs
authors.forename: Blair A
authors.initials: BA
authors.lastname: Jobe
authors.forename: John G
authors.initials: JG
authors.lastname: Hunter
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods; D001145:Arrhythmias, Cardiac / Q000453:epidemiology / Q000209:etiology; D016063:Blood Loss, Surgical; D003131:Combined Modality Therapy; D004938:Esophageal Neoplasms / Q000188:drug therapy / Q000532:radiotherapy / Q000601:surgery; D016629:Esophagectomy / Q000379:methods* / Q000639:trends; D005260:Female; D006801:Humans; D015994:Incidence; D007432:Intraoperative Period; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay / Q000706:statistics & numerical data; D008197:Lymph Node Excision / Q000379:methods; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D011014:Pneumonia / Q000453:epidemiology / Q000209:etiology; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D017792:Surgical Stapling; D013906:Thoracoscopy / Q000379:methods*; D016896:Treatment Outcome; D014826:Vocal Cord Paralysis / Q000453:epidemiology / Q000209:etiology