Esophagectomy by thoracoscopy with patient in prone position, laparoscopy and cervicotomy (technique)

Background: Authors describe the technique of esophagectomy by thoracoscopy with the patient in the prone position, followed by laparoscopy and cervicotomy in supine position. Methods: Between October 30, 2002 and August 31 2005, 15 patients (12 males and 3 females) underwent this procedure for esophageal cancer. The median age was 60.4 years (37-86). At the preoperative work-up the tumor was localized at the cervical esophagus in 1 patient, at the mid-esophagus in 3 patients, at the lower esophagus in 6 patients, and at the eso-gastric junction in 5 patients. Preoperative histological examination demonstrated squamous cell carcinoma in 7 patients, adenocarcinoma in 7 patients, and high-grade dysplasia with carcinoma in situ in 1 patient. None of the patients underwent neo-adjuvant therapy. Results: Average total operative time was 377.1 minutes (300-540). Average total perioperative bleeding was 889.3 ml (125-2400). Perioperative complications comprised a conversion to thoracotomy in one patient and an associate splenectomy in another. Postoperative medical morbidity was 1 respiratory failure, 1 deep venous thrombosis, 1 pneumonia, 2 tracheal necroses, and 3 temporary laryngeal paralysis. Postoperative surgical morbidity included 4 leaks at esophagogastrostomy, 1 colic leak, 2 giant hiatal hernias. The median intensive care stay was 5 days and the median total hospital stay was 14 days. Upon histological examination, the margins of all specimens were free and the average number of lymph nodes identified was: 5,1 mediastinal/periesophageal (2-13), 12.2 celiac/perigastric (3-22). Early mortality was 0%. After a mean follow-up of 19.1 months (8-34), total survival rate is 61.5% of patients, whom 87.5% free of disease and 37.5% on adjuvant therapy. No gastroesophageal reflux was registered and in 4 patients we observed stenosis of the esophagogastrostomy. Conclusions: Thoracoscopic and laparoscopic esophagectomy with extended lymphadenectomy is technically feasible and safe. Thoracoscopy performed with the patient in the prone position improves the quality of the esophageal dissection and the mediastinal lymphadenectomy.