title: Minimally invasive oesophagectomy in prone versus lateral decubitus position: A comparative study.
abstract: BACKGROUND
  Thoracoscopic oesophageal mobilisation during a minimally invasive oesophagectomy (MIE) is most commonly performed with the patient placed in the lateral decubitus position (LDP). The prone position (PP) for thoracoscopic oesophageal mobilisation has been proposed as an alternative.
  
  
  METHODS
  This was a retrospective, comparative study designed to compare early outcomes following a minimally invasive thoracolaparoscopic oesophagectomy for oesophageal cancer in LDP and in PP.
  
  
  RESULTS
  During the study period, between January 2011 and February 2014, 104 patients underwent an oesophagectomy for cancer. Of these, 42 were open procedures (transhiatal and transthoracic oesophagectomy) and 62 were minimally invasive. The study group included patients who underwent thoracolaparoscopic oesophagectomy in LDP (n = 23) and in PP (n = 25). The median age of the study population was 55 (24-71) years, and there were 25 males. Twenty-one (21) patients had tumours in the middle third of the oesophagus, 24 in the lower third, and 3 arising from the gastro-oesophageal junction. The most common histology was squamous cell cancer (85.4%). The median duration of surgery was similar in the two groups; however, the estimated median intraoperative blood loss was less in the PP group [200 (50-400) mL vs 300 (100-600) mL; P = 0.01)]. In the post-operative period, 26.1% patients in the LDP group and 8% in the PP group (8%) developed respiratory complications. The incidence of other post-operative complications, including cervical oesophagogastric anastomosis, hoarseness of voice and chylothorax, was not different in the two groups. The T stage of the tumour was similar in the two groups, with the majority (37) having T3 disease. A mean of 8 lymph nodes (range 2-33) were retrieved in the LDP group, and 17.5 (range 5-41) lymph nodes were retrieved in the PP group (P = 0.0004). The number of patients with node-positive disease was also higher in the PP group (19 vs 10, P = 0.037).
  
  
  CONCLUSIONS
  MIE in the PP is an effective alternative to LDP. The exposure obtained is excellent even without the need for a complete lung collapse, thereby obviating the need for a double-lumen endotracheal tube. A more meticulous dissection can be performed resulting in a higher lymph nodal yield.
authors.affiliation: Department of Gastrointestinal Surgery, GB Pant Hospital and MAM College, Delhi University, New Delhi, India.
authors.forename: Amit
authors.initials: A
authors.lastname: Javed
authors.affiliation: Department of Gastrointestinal Surgery, GB Pant Hospital and MAM College, Delhi University, New Delhi, India.
authors.forename: John Mathew
authors.initials: JM
authors.lastname: Manipadam
authors.affiliation: Department of Gastrointestinal Surgery, GB Pant Hospital and MAM College, Delhi University, New Delhi, India.
authors.forename: Amit
authors.initials: A
authors.lastname: Jain
authors.affiliation: Department of Gastrointestinal Surgery, GB Pant Hospital and MAM College, Delhi University, New Delhi, India.
authors.forename: R
authors.initials: R
authors.lastname: Kalayarasan
authors.affiliation: Department of Gastrointestinal Surgery, GB Pant Hospital and MAM College, Delhi University, New Delhi, India.
authors.forename: Rajeev
authors.initials: R
authors.lastname: Uppal
authors.affiliation: Department of Gastrointestinal Surgery, GB Pant Hospital and MAM College, Delhi University, New Delhi, India.
authors.forename: Anil K
authors.initials: AK
authors.lastname: Agarwal
keywords: Esophagectomy; esophageal cancer; minimally invasive surgical procedures