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Minimally Invasive Esophagectomy in Semi-Prone Position (Pawar Technique): Technical Aspects and Outcome in 224 PatientsFunding Nil.
Background and Objectives There are two patient positions described for minimally invasive esophagectomy (MIE) for esophageal cancer, viz., left lateral and prone positions. To retain the benefits and overcome the disadvantages of these positions, a semi-prone position was developed by us. Our objective was to analyze the feasibility of performing MIE in this position.
Materials and Methods A retrospective review of patients who underwent MIE at our center from January 2007 to December 2017 was done. A semi-prone position is a left lateral position with an anterior inclination of 45 degrees. Intraoperative parameters including conversion rate, immediate postoperative outcomes, and long-term oncological outcomes were analyzed.
Statistical Analysis Statistical Package for the Social Sciences version 19 (IBM SPSS, IBM Corp., Armonk, New York, United States) was utilized for analysis. Survival analysis was done using Kaplan-Meier graph. Quantitative data were described as mean or median with standard deviation, and qualitative data were described as frequency distribution tables.
Results Consecutive 224 patients with good performance status were included. After excluding those who required conversion (14 [6.6%]), 210 patients were further analyzed. Median age was 60 years (range: 27–80 years). Neoadjuvant treatment recipients were 160 (76%) patients. Most common presentation was squamous cell carcinoma (146 [70%]) of lower third esophagus (140 [67%]) of stage III (126 [60%]). Median blood loss for thoracoscopic dissection and for total operation was 101.5 mL (range: 30–180 mL) and 286 mL (range: 93–480 mL), respectively. Median operative time for thoracoscopic dissection alone was 67 minutes (range: 34–98 minutes) and for entire procedure was 215 minutes (range: 162–268 minutes). There was no intraoperative mortality. Median 16 lymph nodes were dissected (range: 5–32). Postoperative complication rate and mortality was 50% and 3.3%, respectively. Disease-free interval was 18 months (range: 3–108 months) and overall survival was 22 months (range: 6–108 months).
Conclusion MIE with mediastinal lymphadenectomy in a semi-prone position is feasible, convenient, oncologically safe, which can combine the benefits of the two conventional approaches. Further prospective and comparative studies are required to support our findings.
12 June 2021 (online)
© 2021. MedIntel Services Pvt Ltd. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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- 1 Orringer MB, Marshall B, Stirling MC. Transhiatal esophagectomy for benign and malignant disease. J Thorac Cardiovasc Surg 1993; 105 (02) 265-276, 276–277
- 2 Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 1999; 230 (03) 392-400, 400–403
- 3 Rindani R, Martin CJ, Cox MR. Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference?. Aust N Z J Surg 1999; 69 (03) 187-194
- 4 Nguyen NT, Roberts P, Follette DM, Rivers R, Wolfe BM. Thoracoscopic and laparoscopic esophagectomy for benign and malignant disease: lessons learned from 46 consecutive procedures. J Am Coll Surg 2003; 197 (06) 902-913
- 5 Smithers BM, Gotley DC, Martin I, Thomas JM. Comparison of the outcomes between open and minimally invasive esophagectomy. Ann Surg 2007; 245 (02) 232-240
- 6 Martin DJ, Bessell JR, Chew A, Watson DI. Thoracoscopic and laparoscopic esophagectomy: initial experience and outcomes. Surg Endosc 2005; 19 (12) 1597-1601
- 7 Senkowski CK, Adams MT, Beck AN, Brower ST. Minimally invasive esophagectomy: early experience and outcomes. Am Surg 2006; 72 (08) 677-683, 683
- 8 Luketich JD, Alvelo-Rivera M, Buenaventura PO. et al. Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg 2003; 238 (04) 486-494, 494–495
- 9 Cuschieri A. Thoracoscopic subtotal oesophagectomy. Endosc Surg Allied Technol 1994; 2 (01) 21-25
- 10 Palanivelu C, Prakash A, Senthilkumar R. et al. Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position–experience of 130 patients. J Am Coll Surg 2006; 203 (01) 7-16
- 11 Low DE, Alderson D, Cecconello I. et al. International consensus on standardization of data collection for complications associated with esophagectomy: Esophagectomy Complications Consensus Group (ECCG). Ann Surg 2015; 262 (02) 286-294
- 12 Cuschieri A, Shimi S, Banting S. Endoscopic oesophagectomy through a right thoracoscopic approach. J R Coll Surg Edinb 1992; 37 (01) 7-11
- 13 Fabian T, McKelvey AA, Kent MS, Federico JA. Prone thoracoscopic esophageal mobilization for minimally invasive esophagectomy. Surg Endosc 2007; 21 (09) 1667-1670
- 14 Markar SR, Wiggins T, Antonowicz S, Zacharakis E, Hanna GB. Minimally invasive esophagectomy: lateral decubitus vs. prone positioning; systematic review and pooled analysis. Surg Oncol 2015; 24 (03) 212-219
- 15 Cadière GB, Torres R, Dapri G, Capelluto E, Hainaux B, Himpens J. Thoracoscopic and laparoscopic oesophagectomy improves the quality of extended lymphadenectomy. Surg Endosc 2006; 20 (08) 1308-1309
- 16 Shen Y, Feng M, Tan L. et al. Thoracoscopic esophagectomy in prone versus decubitus position: ergonomic evaluation from a randomized and controlled study. Ann Thorac Surg 2014; 98 (03) 1072-1078
- 17 Pawar S. Thoracoscopic Esophagectomy in Dorsolateral Position: An Innovative Approach – the Pawar Technique. Society of American Gastrointestinal and Endoscopic Surgeons [Internet];13/07/2010; Landover, Maryland, USA. Los Angeles: SAGES 2013;47. Available from https://www.sages.org/meetings/annual-meeting/abstracts-archive/page/47/?meeting=2010. Accessed February 11 2021
- 18 Ma Z, Niu H, Gong T. Thoracoscopic and laparoscopic radical esophagectomy with lateral-prone position. J Thorac Dis 2014; 6 (02) 156-160
- 19 Lin J, Kang M, Chen C, Lin R. Thoracoscopic oesophageal mobilization during thoracolaparoscopy three-stage oesophagectomy: a comparison of lateral decubitus versus semiprone positions. Interact Cardiovasc Thorac Surg 2013; 17 (05) 829-834
- 20 Seesing MFJ, Goense L, Ruurda JP. Luyer MDP, Nieuwenhuijzen GAP, van Hillegersberg R. Minimally invasive esophagectomy: a propensity score-matched analysis of semiprone versus prone position. Surg Endosc 2018; 32 (06) 2758-2765
- 21 Puntambekar SP, Agarwal GA, Joshi SN, Rayate NV, Sathe RM, Patil AM. Thoracolaparoscopy in the lateral position for esophageal cancer: the experience of a single institution with 112 consecutive patients. Surg Endosc 2010; 24 (10) 2407-2414
- 22 Law S, Fok M, Chu KM, Wong J. Thoracoscopic esophagectomy for esophageal cancer. Surgery 1997; 122 (01) 8-14
- 23 Denewer A, Fathi A, Setit A. et al. Totally endoscopic (thoracoscopic and laparoscopic) radical esophagectomy with gastric tube reconstruction through a small neck incision: an early experience with thirty Egyptian patients. Surg Sci 2014; 5: 214-223
- 24 Puntambekar S, Kenawadekar R, Pandit A. et al. Minimally invasive esophagectomy in the elderly. Indian J Surg Oncol 2013; 4 (04) 326-331
- 25 Dexter SPL, Martin IG, McMahon MJ. Radical thoracoscopic esophagectomy for cancer. Surg Endosc 1996; 10 (02) 147-151