title: Thoracoscopic esophagectomy while in a prone position for esophageal cancer: a preceding anterior approach method.
abstract: BACKGROUND
  In 2009, the rate of thoracoscopic esophagectomy for esophageal cancer was about 20% in Japan. This low rate may be due to the difficulty in maintaining a good surgical field and the meticulous procedures that are required. The purpose of this study was to establish and evaluate a new procedure for performing a thoracoscopic esophagectomy while the patient is in a prone position using a preceding anterior approach to make the esophagectomy easier to perform.
  
  
  METHODS
  We have performed thoracoscopic esophagectomy using our new procedure in 60 patients with esophageal cancer. Each patient was placed in a prone position and five trocars were inserted; only the left lung was ventilated and a pneumothorax was maintained. The esophagus was mobilized from the anterior structure during the first step and from the posterior structure during the second step. The lymph nodes around the esophagus were also dissected anteriorly and posteriorly. The patients were sequentially divided into two groups and their clinical outcomes were evaluated.
  
  
  RESULTS
  The mean operative time for the thoracoscopic procedure for the latter 30 cases (203 min) was shorter than that for the former 30 cases (260 min) (P = 0.001). Among the 52 cases without pleural adhesion, the mean blood loss in the latter 26 cases (18 mL) was also less than that in the former 26 cases (40 mL) (P = 0.027). There were no conversions to a thoracotomy and no operative deaths in this series. Postoperative complications related to the thoracoscopic procedure occurred in 8 cases (27%) in the former group and in 4 cases (13%) in the latter group.
  
  
  CONCLUSIONS
  Thoracoscopic esophagectomy with the patient in the prone position using a preceding anterior approach is a safe and feasible procedure. As experience performing the procedure increases, the performance of the procedure stabilizes. This method seems to make the esophagectomy easier to perform.
authors: Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan. sozawa@tokai.ac.jp
authors: Soji
authors: S
authors: Ozawa
authors: Eisuke
authors: E
authors: Ito
authors: Akihito
authors: A
authors: Kazuno
authors: Osamu
authors: O
authors: Chino
authors: Minoru
authors: M
authors: Nakui
authors: Soichiro
authors: S
authors: Yamamoto
authors: Hideo
authors: H
authors: Shimada
authors: Hiroyasu
authors: H
authors: Makuuchi
mesh_terms: D016063:Blood Loss, Surgical / Q000401:mortality; D061887:Conversion to Open Surgery / Q000401:mortality; D004938:Esophageal Neoplasms / Q000401:mortality / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D008197:Lymph Node Excision / Q000401:mortality; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D016684:Prone Position; D013906:Thoracoscopy / Q000379:methods* / Q000401:mortality; D016896:Treatment Outcome