Thoracoscopy in prone position with two-lung ventilation compared to conventional thoracotomy during Ivor Lewis procedure: a multicenter case-control study

Background Intraoperative management based on thoracoscopy, prone position and two-lung ventilation could decrease the rate of postoperative pulmonary complications after esophagectomy. The aim of this study was to compare this multifaceted approach (MIE-PP) and conventional thoracotomy for Ivor Lewis procedure after a systematic laparoscopic dissection. Methods Data from 137 consecutive patients undergoing Ivor Lewis procedures between 2010 and 2017 at two tertiary centers was analyzed retrospectively. The outcomes of patients who underwent MIE-PP (n = 58; surgeons group 1) were compared with those of patients undergoing conventional approach (n = 79; surgeons group 2). Our primary outcome was major postoperative pulmonary complications. Our main secondary outcomes were anastomotic leak, quality of resection and mortality. Results Female patients were more prevalent in the MIE-PP group (p = 0.002). Other patient characteristics, cTNM staging and neoadjuvant treatment rate were not different between groups. Major postoperative pulmonary complications were significantly lower in the MIE-PP group compared to Conventional group (24 vs. 44%; p = 0.014). Anastomotic leak occurred in 31 versus 18% in MIE-PP group and Conventional groups, respectively (p = 0.103). Complete resection rate (98 vs. 95%; p = 0.303) and mean number of harvested lymph nodes (16 (4-40) vs. 18 (3-37); p = 0.072) were similar between the two groups. Postoperative mortality rates were 0 versus 2% at day 30 (p = 0.508) and 0 versus 7.6% at day 90 (p = 0.038). Conclusion Short-term outcomes of minimally invasive Ivor Lewis using thoracoscopy, prone position and two-lung ventilation are at least equivalent to the hybrid approach. Anastomotic leak after MIE-PP remains a major concern.