The authors report that the
complete resection rates (R0) were similar between patients who underwent
minimally invasive esophagectomy (MIE) and those who underwent an open
transthoracic esophagectomy (more than 94%). However, the number of lymph nodes
resected was significantly higher in the MIE group, which had fewer serious
complications and a shorter length of hospital stay. In their conclusion, the
authors highlight similar R0 resection rates, improved lymphadenectomy, and improved
perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some
important limitations. First, it is a retrospective comparison, not a
randomized study. The approaches were adopted in different time periods with
potential differences in practice patterns – such as pathologic evaluation of
specimens or policies regarding hospital discharge – that may have accounted
for some of the differences observed. Second, although the open and MIE groups
were matched for age and gender, there may be important differences between
them. Neoadjuvant chemoradiation was used nearly twice as often in the open
transthoracic group as in the MIE group, and this different rate might confound
the analysis because it may reflect a more advanced clinical stage and be
associated with an increase in perioperative complications.
The 8% mortality appears high, compared with other
recent series. For example, mortality was 2% in the multicenter MIE trial
conducted by the Eastern
Cooperative Oncology Group (ECOG 2202). Although the authors describe
oncologic efficacy in terms of completeness of resection, the lack of
longer-term outcome data on recurrence and survival is a major limitation.
Nonetheless the authors should be commended for their efforts.
Dr. James D. Luketich is Henry T.
Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical
Center.
