Journal Article: Kinjo, Y., Kurita, N., Nakamura, F., et al (2011) in press
Title: Effectiveness of combined thoracoscopic-laparoscopic esophagectomy: comparison of
postoperative complications and mid-term oncological outcomes in patients with esophageal
cancer
Journal Category: B. Esophagus
3. Neoplasms benign and malignant
Key Words: Esophagectomy, thoracoscopy, esophageal cancer
Article objective: Following completion of this activity, the participant will gain a greater
understanding of the surgical treatment of esophageal cancer including different surgical
approaches with their potential differences in short-term post-operative complications and
oncologic outcomes.
1. The article describes three different treatment groups and their clinical outcomes for
esophageal cancer over an eight-year period (2002 – 2010). This study design is best
described as:
a. Prospective, randomized clinical trial
b. Cross-sectional study
c. Case-control study
d. Longitudinal cohort study
e. Case series
2. The term Minimally Invasive Esophagectomy (MIE) typically implies the combined use
of thoracoscopic and laparoscopic techniques for esophageal resection. In the article
presented by Kinjo et al, the thoracoscopic approach refers to which of the following:
a. Thoracoscopic mobilization of the esophagus and regional lymphadenectomy
b. Thoracoscopic mobilization of the esophagus only
c. Thoracoscopic regional lymphadenectomy only
d. Thoracoscopic transection of the esophagus
e. Thoracoscopic-assisted esophageal anastomosis
3. In the article presented by Kinjo et al, the authors compared outcomes of patients
undergoing combined thoracoscopic-laparoscopic esophagectomy (TLE), thoracoscopic
esophagectomy (TE), and open esophagectomy (OE). When compared to OE and TE,
which of the following statements regarding TLE is/are TRUE?:
a. TLE is associated with a retrieval of fewer lymph nodes
b.
c.
d.
e.
TLE is associated with a longer LOS than OE or TE patients
TLE is associated with fewer respiratory and overall complications
TLE is associated with a greater mean operative EBL
TLE is associated with shorter operative times than TE or OE
4. Indications and technical differences between the three surgical approaches were
described and the variability of approach could explain some of the differences in
outcomes. With regards to clinical or pathological characteristics reported in the article
by Kinjo et al, which of the following statements is/are TRUE?
a. Patients in the TLE group were less likely to have undergone neoadjuvant
chemotherapy than TE or OE patients
b. Patients in the TLE group had a lower percentage of early (T1 or T2) tumors than
patients in the TE or OE groups
c. Patients in the TLE group had equivalent use of either stomach or colon as
conduits to those in TE or OE groups
d. Patients in the TLE group had a higher percentage of patients with a thoracic
anastomosis than TE or OE group patients
e. Patients in the TLE group had a higher percentage of patients with hand-sewn
anastomosis than TE or OE group patients
Answers with Explanations:
1. The article describes three different treatment groups and their clinical outcomes for
esophageal cancer over an eight-year period (2002 – 2010). This study design is best
described as:
a. Prospective, randomized clinical trial
The patients’ data was collected longitudinally over an eight year period
(2002-2010), but the study did not prospectively enroll patients, nor were
they randomized to one treatment arm over another.
b. Cross-sectional study
A cross-sectional study compares population groups at one specific point
in time.
c. Case-control study
Because three different treatment groups (with no control) were analyzed,
this would not qualify as a case-control study or a case series.
d. Longitudinal cohort study
The decision(s) as to which type of esophagectomy patients received
changed over the course of the study – prior to September 2005, all
patients received an open transthoracic (OE) approach. Beginning in
September 2005, the thoracoscopic approach was introduced and
patents either received TE or TLE, but these were restricted to T1 to
T3 tumors. OE remained a treatment option for those with previous
chemoradiation, previous esophageal resection, or T4 tumors.
Although data were analyzed retrospectively, the best methodological
description of this study would be a longitudinal cohort study.
2. The term Minimally Invasive Esophagectomy (MIE) typically implies the combined use
of thoracoscopic and laparoscopic techniques for esophageal resection. In the article
presented by Kinjo et al, the thoracoscopic approach refers to which of the following:
a. Thoracoscopic mobilization of the esophagus and regional lymphadenectomy
In the article, the authors specifically define their thoracoscopic
approach as “thoracoscopic mobilization of the esophagus and
regional lymphadenectomy without the use of mini-thoracotomy”. In
all but a few cases, this technique was used and the esophageal
transection and anastomoses were performed in the neck.
b. Thoracoscopic mobilization of the esophagus only
The application of thoracoscopic technique likely varies from one surgeon
(or institution) to another, but the authors were specific on the technique
most consistent with an MIE procedure to also include regional
lymphadenectomy as well as mobilization of the esophagus.
c. Thoracoscopic regional lymphadenectomy only
The application of thoracoscopic technique likely varies from one surgeon
(or institution) to another, but the authors were specific on the technique
most consistent with an MIE procedure to also include mobilization of the
esophagus as well as lymphadenectomy.
d. Thoracoscopic transection of the esophagus
The application of thoracoscopic technique likely varies from one surgeon
(or institution) to another, but the authors were specific on the technique
most consistent with an MIE procedure which included cervical
transection of the esophagus.
3. In the article presented by Kinjo et al, the authors compared outcomes of patients
undergoing combined thoracoscopic-laparoscopic esophagectomy (TLE), thoracoscopic
esophagectomy (TE), and open esophagectomy (OE). When compared to OE and TE,
which of the following statements best represents TLE?
a. TLE is associated with a retrieval of fewer lymph nodes
TLE was also found to have a greater mean retrieval of (thoracic) lymph
nodes compared to TE and OE (28 vs. 24 and 18 respectively; p<0.002).
b. TLE is associated with a longer LOS than OE or TE patients
TLE patients had a much shorter hospital stay than TE and OE patients
(23d vs. 32d and 53d respectively; p<0.001).
c. TLE is associated with fewer respiratory and overall complications
The primary outcome measures for this study were the 30-day
incidence of respiratory and overall complications, and patients in the
TLE group were found to have fewer complications in both categories
compared to TE and OE patients (13% vs. 38% and 39%; p=0.001;
47% vs. 58% and 68% respectively; p=0.031). Also, on multivariate
analysis, having respiratory complications was associated with having
undergone OE rather than TLE (AOR = 0.22; 95% CI 0.09 to 0.53;
p=0.001) and having undergone TLE was associated with a lower
adjusted odds of overall complications (AOR = 0.47; 95% CI 0.23 to
0.94; p=0.034).
d. TLE is associated with a greater mean operative EBL
TLE was associated with a lower intra-operative EBL than TE or OE
(320mL vs. 536mL and 680mL; p<0.001).
4. Indications and technical differences between the three surgical approaches were
described and the variability of approach could explain some of the differences in
outcomes. With regards to clinical or pathological characteristics reported in the article
by Kinjo et al, which of the following statements is TRUE?
a. Patients in the TLE group were less likely to have undergone neoadjuvant
chemotherapy than TE or OE patients
Overall, the clinical and pathological characteristics were fairly similar
between the three treatment groups (Table 1), with the notable exception
that TLE patients were more likely to have undergone neoadjuvant
chemotherapy than TE or OE patients (57% vs. 38% and 14%
respectively; p<0.001).
b. Patients in the TLE group had a lower percentage of early (T1 or T2) tumors than
patients in the TE or OE groups
The distribution of early (T1 or T2) and advanced (T3 or T4) tumors was
similar between all three groups.
c. Patients in the TLE group had equivalent use of either stomach or colon as
conduits to those in TE or OE groups
All TLE patients received stomach conduits.
d. Patients in the TLE group had a higher percentage of patients with handsewn anastomosis than TE or OE group patients
The majority of the anastomoses (92%) were hand-sewn. Patients in
the OE group were more likely to have stapled anastomoses (89%).
References
1. Adams TD, Gress RE, Smith SC, et al. (2007). Long-term mortality after gastric bypass
surgery. N. Engl. J. Med. 357 (8): 753–61.
2. Smithers BM, Gotley DC, Martin I. (2007). Comparison of the Outcomes between Open
and Minimally Invasive Esophagectomy. Ann Surg 245 (2); 232-240.
3. Sgourakis G, Gockel I, Radtke A, et al. (2010) Minimally Invasive Versus Open
Esophagectomy: Meta-Analysis of Outcomes. Dig Dis Sci (55): 3031-3040.
4. Pham TH, Perry KA, Dolan, JP, et al. (2010). Comparison of Perioperative Outcomes
after Combined Thoracoscopic-Laparoscopic Esophagectomy and Open Ivor-Lewis
Esophagectomy. Am J Surg 199: 594-598.