title: Technical and perioperative outcomes of minimally invasive esophagectomy in the prone position.
abstract: BACKGROUND
  Minimally invasive esophagectomy (MIE) is performed through various approaches, including using video-assisted thoracoscopic surgery for mediastinal esophageal dissection. The prone technique allows for gravity-aided retraction of the lung. The aim of this study was to examine perioperative outcomes after prone MIE in relation to patient preoperative comorbidities.
  
  
  METHODS
  A retrospective cohort study from our single tertiary-care center is presented. Between January 2007 and August 2010, a total of 42 patients underwent three-field prone MIE. The majority of patients were male (37 vs. 5 female), with an average age of 68 years (range = 37-87). The diagnoses for patients who underwent MIE were 35 adenocarcinoma, four Barrett's esophagus with high-grade dysplasia, two achalasia, and one squamous cell carcinoma. Neoadjuvant chemotherapy with or without radiotherapy was administered to 16 (38 %) patients. Preoperative comorbidities were quantified using the Modified Charlson Comorbidity Index; low risk was defined as a score of 0-2 (23 patients), moderate risk 3-4 (14 patients), and high risk 5 or higher (five patients). Postoperative complications were stratified using the Clavien Classification Scale; minor complications were grades 1 and 2 and major complications were grades 3-5.
  
  
  RESULTS
  Median length of hospital stay was 8 days (range = 6-51) and median ICU stay was 2 days (range = 1-26). Average prone surgical time was 108 min (range = 67-198). Thirty-seven of 42 patients (88 %) were extubated on the day of operation. Postoperatively, all five high-risk patients had a complication, three of which were major. Eight of the 14 moderate-risk patients had a complication and three were major, and 17 of the 23 low-risk group had a complication with nine being major. There was a total of 15 major complications. Predominant complications were arrhythmias (15) and pneumonia (five), with four anastomotic leaks and two postoperative 30-day mortalities.
  
  
  CONCLUSIONS
  This series supports using prone MIE. Despite a clinical pathway, including immediate extubation postoperatively, there is still a risk of pulmonary complications that appears to correlate with higher preoperative comorbidity scores.
authors.affiliation: Department of Surgery, Mayo Clinic-Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA. rossfgoldberg@gmail.com
authors.forename: Ross F
authors.initials: RF
authors.lastname: Goldberg
authors.forename: Steven P
authors.initials: SP
authors.lastname: Bowers
authors.forename: Michael
authors.initials: M
authors.lastname: Parker
authors.forename: John A
authors.initials: JA
authors.lastname: Stauffer
authors.forename: Horacio J
authors.initials: HJ
authors.lastname: Asbun
authors.forename: C Daniel
authors.initials: CD
authors.lastname: Smith
mesh_terms: D000368:Aged; D015331:Cohort Studies; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D056888:Patient Positioning / Q000379:methods; D016684:Prone Position; D012189:Retrospective Studies; D016896:Treatment Outcome