The hybrid position is superior to the prone position for thoracoscopic esophagectomy with upper mediastinal lymphadenectomy

Background: Thoracoscopic esophagectomy (TE) is becoming a common surgical method for esophageal cancer. TE is performed with the patient the left lateral decubitus position, prone position, or hybrid position combining the left lateral decubitus and prone positions. However, only few studies have compared the clinical utility of these TE positions. In our institute, we introduced TE in the prone position (prone TE) in 2014, and have performed TE in the hybrid position (hybrid TE) since March 2017. The present study compared the short-term outcomes of prone TE versus hybrid TE. Methods: One-hundred-and-three patients with esophageal or esophagogastric junction cancer who underwent TE between March 2014 and December 2019 were included. Patients were divided into those who underwent prone TE (prone TE group; n=43) and those who underwent hybrid TE (hybrid TE group; n=60). Clinicopathological data were retrospectively reviewed and compared between groups. Results: There were no differences between groups in age, tumor histology, and tumor location. The proportion of females was significantly higher in the prone TE group than the hybrid TE group (23.3% vs. 8.3%, P=0.034). Compared with the hybrid TE group, the prone TE group had a smaller tumor depth (P<0.001), lower grade of lymph node metastasis (P=0.003), and less severe tumor stage (P=0.001). The operation time for the thoracoscopic procedure was shorter in the hybrid TE group than the prone TE group (318.9 vs. 249.2 min, P=0.002). There were no significant differences between the two groups in the reconstruction organ and route, bleeding volume, and number of dissected mediastinal lymph nodes. Although several factors can affect postoperative complications, the rate of recurrent laryngeal nerve paralysis (Clavien-Dindo grade I–III) was significantly lower in the hybrid TE group than the prone TE group (41.9% vs. 11.7%, P<0.001), whereas there were no differences between groups in the rates of anastomotic leakage, atelectasis, or pneumonia. Conclusions: In hybrid TE, the upper mediastinal procedures were performed in the left lateral decubitus position. Therefore, the most significant differences between prone TE and hybrid TE involved the upper mediastinal procedures. Because the assistant stands opposite to the operator in hybrid TE, the motion of the assistant’s forceps causes less interference with the operative field compared with prone TE in which the assistant stands next to the operator. Furthermore, in hybrid TE, the angle at which the operator's forceps approach the upper mediastinal lymph nodes and the recurrent laryngeal nerve enables the maintenance of appropriate traction. These advantages resulted in a shorter operation time and less recurrent laryngeal nerve paralysis in hybrid TE compared with prone TE.