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Minimally invasive versus open oesophagectomy for oesophageal cancer

2012; Elsevier BV; Volume: 380; Issue: 9845 Linguagem: Inglês

10.1016/s0140-6736(12)61497-4

1474-547X

C. Mariette, William B. Robb,

Lung Cancer Diagnosis and Treatment

The results of the randomised trial by Surya Biere and colleagues1Biere SSAY van Berge Henegouwen MI Maas KW et al.Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial.Lancet. 2012; 379: 1887-1892Summary Full Text Full Text PDF PubMed Scopus (1077) Google Scholar are of huge interest, but some qualifications need to be made about their robustness and reliability. Many non-studied variables, including malnutrition, previous and current smoking, pulmonary comorbidities, functional status, and clinical TNM (tumour, node, metastasis) staging, have all been shown to strongly affect the primary endpoint of this trial—postoperative pulmonary infection.2D'Journo XB Michelet P Avaro JP et al.Respiratory complications after oesophagectomy for cancer.Rev Mal Respir. 2008; 25: 683-694Crossref PubMed Scopus (26) Google Scholar The small sample size could lead to a non-equivalent repartition of these variables. Moreover, one-lung mechanical ventilation and the lateral decubitus position was used only in the open group. This manoeuvre has been shown to be associated with inflammatory lesions resulting in ventilator-induced lung injury, and correlates strongly with postoperative pulmonary complications.3Michelet P D'Journo XB Roch A et al.Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study.Anesthesiology. 2006; 105: 911-919Crossref PubMed Scopus (296) Google Scholar Whether selection of a primary outcome measure of 2-week and in-hospital pulmonary complications was the most appropriate means of assessing outcome after an operation that can induce such significant perioperative complications is open to question. A longitudinal assessment of quality of life might have been more scientifically sound. A fortiori, in a study with a small sample size, a multivariate analysis should be done to test the independent effect of minimally invasive surgery on postoperative course, adjusted for numerous preoperative and perioperative variables known to be of significance. We do not know from this trial whether the thoracoscopic approach is superior to a hybrid approach with laparoscopy. The hybrid technique avoids a cervical anastomosis, with its related morbidity (vocal-cord palsy, aspiration, higher anastomotic leak rate), and worldwide it might prove to be simpler, safer, and more reproducible than the thoracoscopic technique. The MIRO trial,4Briez N Piessen G Bonnetain F et al.Open versus laparoscopically-assisted oesophagectomy for cancer: a multicentre randomised controlled phase III trial—the MIRO trial.BMC Cancer. 2011; 11: 310Crossref PubMed Scopus (134) Google Scholar developed by our group and just closed for accrual at 200 patients, will answer this question. It will also offer a repeated measure of the effect of minimally invasive oesophagectomy on outcomes and quality of life. We declare that we have no conflicts of interest. Minimally invasive versus open oesophagectomy for oesophageal cancer – Authors' replyStephen Swisher and colleagues criticise the in-hospital pneumonia rate in the open oesophagectomy group in our trial (34% vs 12% in the minimally invasive group). They refer to the 23% chest complication rate in the trial by Burmeister and colleagues.1 Our reading of this paper is different: major pulmonary complications occurred in 25 (20%) of 128 patients in the neoadjuvant group and 36 (28%) of 128 in the surgery-alone group; the total surgery-related death rate was 5% (11 of 215). These results are surely comparable with those of the open group in our trial. Full-Text PDF