title: Hand-assisted laparoscopic surgery (HALS) is associated with less-restrictive ventilatory impairment and less risk for pulmonary complication than open laparotomy in thoracoscopic esophagectomy.
abstract: BACKGROUND
  Esophagectomy with extended lymphadenectomy improves prognosis but it is associated with high morbidity and mortality. The thoracoscopic approach is associated with fewer pulmonary complications. Abdominal wall injury greatly affects pulmonary function and complication rates during the acute postoperative phase. In this study we aimed to compare the incidence of pulmonary complications and respiratory recovery after thoracoscopic esophagectomy in the prone position with hand-assisted laparoscopic surgery (HALS) versus open laparotomy (OL).
  
  
  METHODS
  This was a case-matched control study of patients with esophageal cancer who underwent thoracoscopic esophagectomy in the prone position. Thirty-two patients in the HALS group and 32 patients in the OL group were selected by the use of propensity score matching. Operative outcomes and perioperative changes in respiratory function were compared.
  
  
  RESULTS
  There was no operative mortality in either group. Estimated blood loss was less in the HALS group (P < .001). The incidence of postoperative pneumonia was 6.2% (4/64) overall; it was less in the HALS group (0%) than in the OL group (12.5%) (P = .016). There were no differences in preoperative vital capacity (VC) and percent predicted vital capacity (%VC). Each parameter, including the ratio of the postoperative to preoperative %VC (%VC ratio), reached its nadir on postoperative day 7 in both groups but was greater in the HALS group (VC, 2.91 ± 0.68 L vs 2.53 ± 0.53 L, P = .018; %VC, 90.62 ± 16.92% vs 78.91 ± 16.65%, P = .007; %VC ratio, 80.90 ± 9.87% vs 72.09 ± 11.95%, P = .002). At 1 and 3 months, respiratory recovery was seen in both groups but more so in the HALS group. At 6 months, further respiratory recovery was seen in both groups, without any significant intergroup differences.
  
  
  CONCLUSIONS
  During the acute phase after thoracoscopic esophagectomy in the prone position, HALS is associated with less-restrictive ventilatory impairment, fewer subsequent pulmonary complications, and less blood loss than OL. The combination of HALS and thoracoscopic esophagectomy in the prone position is less invasive on respiratory function.
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan. Electronic address: oshikiri@med.kobe-u.ac.jp.
authors.forename: Taro
authors.initials: T
authors.lastname: Oshikiri
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Yasuda
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan; Division of Surgery, Kobe Rosai Hospital, Hyogo, Japan.
authors.forename: Kentaro
authors.initials: K
authors.lastname: Kawasaki
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan.
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Harada
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Oyama
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Hasegawa
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan.
authors.forename: Tadayuki
authors.initials: T
authors.lastname: Ohara
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan.
authors.forename: Hiroyoshi
authors.initials: H
authors.lastname: Sendo
authors.affiliation: Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan.
authors.forename: Tetsu
authors.initials: T
authors.lastname: Nakamura
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan.
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Fujino
authors.affiliation: Department of Gastroenterological Surgery, Hyogo Cancer Center, Hyogo, Japan.
authors.forename: Masahiro
authors.initials: M
authors.lastname: Tominaga
authors.affiliation: Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan.
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Kakeji
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery; D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000601:surgery; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D058733:Hand-Assisted Laparoscopy; D006801:Humans; D007813:Laparotomy; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D056888:Patient Positioning; D011183:Postoperative Complications / Q000517:prevention & control*; D016684:Prone Position; D057216:Propensity Score; D012131:Respiratory Insufficiency / Q000209:etiology / Q000517:prevention & control*; D012189:Retrospective Studies; D013906:Thoracoscopy; D016896:Treatment Outcome