Esophagectomy is the standard treatment for potentially resectable thoracic esophageal cancer [
3]. It typically consists of transthoracic esophageal resection and transabdominal gastric mobilization for esophageal replacement. However, because it includes a wide surgical excision, esophagectomy is associated with a higher risk of postoperative morbidity and mortality than those in other cancer surgeries [
4,
5]. Postoperative pulmonary complications (PPCs) are the most common causes of serious morbidity after esophagectomy and can result in a poor prognosis in esophagectomized patients [
6‐
8]. Therefore, PPC prevention is crucial to improve the survival of patients with esophageal cancer.
Thoracoscopic esophagectomy was first introduced in 1992 [
9] and has been extensively performed in recent years [
10]. This approach minimizes the extent of chest trauma. Several studies, including those from our group, have reported that it decreases PPC frequency [
11‐
14]. However, it remains unclear whether PPC frequency is further decreased by combining this thoracoscopic esophagectomy with laparoscopic gastric mobilization because previous prospective studies have only evaluated the combined impact of the two approaches [
13,
14]. The present study uses data from our prospective multicenter trial, the Japan Clinical Oncology Group Study 0502 (JCOG0502), to determine the effect of laparoscopy on the prevention of PPCs after thoracoscopic esophagectomy and the factors playing a role in this prevention.
Results
A total of 379 patients with clinical stage IA (T1bN0) thoracic esophageal cancer from 37 institutions were enrolled in JCOG0502 between December 2006 and February 2013. Excluding one patient who withdrew consent postoperatively, 210 of 379 patients underwent transthoracic esophagectomy (Fig.
1). These patients were enrolled from 30 institutions, and the median number of patients from each institution was 5 (range, 1–28). Gastric pull-up reconstruction was performed in the majority of patients (
n = 206) with the colon being used as a conduit in the remaining patients (
n = 4). Cervical anastomosis was performed in 198 patients, whereas intrathoracic anastomosis was performed in 12 patients. Of the 210 patients, 102 underwent thoracotomic esophagectomy with laparotomy, 7 underwent thoracotomy with laparoscopy, 43 underwent thoracoscopy with laparotomy, and 58 underwent thoracoscopy with laparoscopy (Fig.
1).
Impact of thoracoscopy on PPC prevention
First, we compared thoracotomy (
n = 109) and thoracoscopy (
n = 101) to confirm the effect of thoracoscopic approach on PPC prevention. As shown in Table
1, there were no significant differences in the baseline characteristics of patients between the two approaches. Operative data showed that the thoracoscopic approach reduced blood loss but prolonged the operating time. Postoperatively, patients undergoing thoracoscopy had a lower PPC frequency than those undergoing thoracotomy [thoracoscopy 16 (15.8%), thoracotomy 33 (30.3%);
p = 0.015], particularly atelectasis [thoracoscopy 11 (10.9%), thoracotomy 24 (22.0%);
p = 0.041] (Table
2). There were no significant differences in the incidences of other complications and postoperative stay duration between the two approaches.
Table 1
Baseline characteristics and operative factors
Baseline characteristics |
Age (years) |
Median (range) | 61.5 (41–75) | 67 (58–72) | 63 (52–75) | 62.5 (48–75) | 0.522 | 0.765 |
Gender |
Male | 87 (85.3) | 6 (85.7) | 33 (76.7) | 49 (84.5) | 0.462b
| 0.441b
|
Female | 15 (14.7) | 1 (14.3) | 10 (23.3) | 9 (15.5) | | |
Performance statusc
|
0 | 102 (100) | 7 (100) | 43 (100) | 57 (98.3) | 0.481b
| 1.00b
|
1 | 0 (0) | 0 (0) | 0 (0) | 1 (1.7) | | |
Body mass index |
Median (range) | 22.4 (13.4–28.9) | 20.2 (18.6–26.0) | 22.9 (17.1–28.4) | 22.5 (18.3–28.3) | 0.934 | 0.718 |
Preoperative PaO
2
d
|
Median (range) | 87.7 (70.0–116.7) | 89.6 (73.6–114.0) | 86.0 (71.0–112.0) | 88.2 (71.1–155.0) | 0.963 | 0.163 |
Tumor location |
Upper thoracic | 10 (9.8) | 1 (14.3) | 6 (14.0) | 9 (15.5) | 0.183b
| 1.00b
|
Mid-thoracic | 63 (61.8) | 3 (42.9) | 29 (67.4) | 38 (65.5) | | |
Lower thoracic | 29 (28.4) | 3 (42.9) | 8 (18.6) | 11 (19.0) | | |
Tumor size |
≤4 cm | 72 (70.6) | 4 (57.1) | 29 (67.4) | 41 (70.7) | 1.00b
| 0.828b
|
>4 cm | 30 (29.4) | 3 (42.9) | 14 (32.6) | 17 (29.3) | | |
Operative factors |
Body position during thoracoscopy |
Prone | NA | NA | 17 (39.5) | 23 (39.7) | NA | 0.990b
|
Lateral decubitus | NA | NA | 26 (60.5) | 35 (60.3) | | |
Lymphadenectomy |
Two-field | 37 (36.3) | 4 (57.1) | 17 (39.5) | 23 (39.7) | 0.779b
| 1.00b
|
Three-field | 65 (63.7) | 3 (42.9) | 26 (60.5) | 35 (60.3) | | |
Lymph nodes harvested |
Median (range) | 48 (19–120) | 44 (28–54) | 53 (21–120) | 57 (18–120) | 0.063 | 0.690 |
Blood loss (mL) |
Median (range) | 448 (80–1833) | 240 (45–350) | 351 (0–4225) | 283.5 (10–2020) | <0.001 | 0.282 |
Operating time (min) |
Median (range) | 405 (222–638) | 338 (280–420) | 476 (310–791) | 533.5 (355–871) | <0.001 | 0.014 |
Table 2
Postoperative pulmonary complications and other outcomes
Pulmonary complications (PPCs) | 32 (31.4) | 1 (14.3) | 7 (16.3) | 9 (15.5) | 0.015 | 1.00 |
Pneumonia | 17 (16.7) | 1 (14.3) | 2 (4.7) | 6 (10.3) | 0.063 | 0.461 |
Atelectasis | 23 (22.5) | 1 (14.3) | 6 (14.0) | 5 (8.6) | 0.041 | 0.521 |
ARDSb
| 0 (0) | 0 (0) | 0 (0) | 1 (1.7) | 0.481 | 1.00 |
Recurrent nerve palsy | 16 (15.7) | 1 (14.3) | 6 (14.0) | 9 (15.5) | 1.00 | 1.00 |
Anastomotic leak | 14 (13.7) | 1 (14.3) | 2 (4.7) | 5 (8.6) | 0.120 | 0.696 |
Postoperative mortality | 1 (1.0) | 0 (0) | 0 (0) | 1 (1.7) | 1.00 | 1.00 |
Postoperative stay duration (days) |
Median (range) | 22 (10–162) | 17 (17–32) | 22 (9–114) | 24 (12–185) | 0.472c
| 0.514c
|
Impact of laparoscopy on PPC prevention
Next, we determined whether PPC frequency was further decreased when combined with laparoscopy. Among the 101 patients who underwent thoracoscopic esophagectomy, 43 underwent laparotomy and 58 underwent laparoscopy (Fig.
1). As shown in Table
1, there were no significant differences in the baseline characteristics of the patients between the two approaches. Operative data showed that laparoscopy prolonged the operating time. Postoperatively, there were no significant differences in PPC frequency [laparoscopy 9 (15.5%), laparotomy 7 (16.3%);
p = 1.00] and other postoperative complications/outcomes between the two approaches (Table
2).
Among the 109 patients who underwent thoracotomic esophagectomy, PPCs occurred in 32 patients (31.4%) in the laparotomy group and in 1 patient (14.3%) in the laparoscopy group. There was no significant difference between the two groups (p = 0.673).
Preventive factors for PPCs
Finally, we comprehensively analyzed the data from all 210 patients to determine if laparoscopy could aid in the prevention of PPCs. In univariable analysis, both thoracoscopy (shown above) and less blood loss (< 350 mL 16.3%, ≥350 mL 30.2%;
p = 0.022) were associated with PPC prevention (Table
3), whereas laparoscopy showed a borderline significant reduction in PPC frequency (laparoscopy 15.4%, laparotomy 26.9%;
p = 0.079). Multivariable analysis identified both thoracoscopy (Odds ratio, 0.40; 95% confidence interval, 0.16–1.04;
p = 0.059) and preoperative partial pressure of O
2 (PaO
2) in arterial blood (Odds ratio, 0.50; 95% confidence interval, 0.24–1.02;
p = 0.057) as preventive factors with borderline significance. Stepwise regression analysis showed that both thoracoscopy (Odds ratio, 0.46; 95% confidence interval, 0.23–0.92;
p = 0.028) and less blood loss (Odds ratio, 0.50; 95% confidence interval, 0.25–0.99;
p = 0.048) were associated with PPC prevention.
Table 3
Preventive factors for pulmonary complications
Baseline characteristics |
Age (years) |
<65 | 129 | 29 (22.5) | 0.739 | 1 | | | |
≥65 | 81 | 20 (24.7) | | 1.28 (0.60–2.71) | 0.524 | | |
Gender |
Female | 35 | 9 (25.7) | 0.669 | 1 | | | |
Male | 175 | 40 (22.9) | | 0.75 (0.27–2.10) | 0.586 | | |
Body mass index |
<25 | 168 | 40 (23.8) | 0.840 | 1 | | | |
≥25 | 42 | 9 (21.4) | | 0.63 (0.21–1.60) | 0.334 | | |
Tumor location |
Upper thoracic | 26 | 6 (23.1) | 0.970 | 1 | | | |
Mid-thoracic | 133 | 32 (24.1) | | 0.99 (0.33–2.99) | 0.985 | | |
Lower thoracic | 51 | 11 (21.6) | | 0.76 (0.20–2.91) | 0.689 | | |
Tumor size |
≤4 cm | 146 | 31 (21.2) | 0.291 | 1 | | | |
>4 cm | 64 | 18 (28.1) | | 1.48 (0.70–3.13) | 0.311 | | |
Preoperative laboratory data |
WBC count |
<5800/μL | 102 | 24 (23.5) | 1.000 | 1 | | | |
≥5800/μL | 108 | 25 (23.1) | | 1.09 (0.50–2.34) | 0.836 | | |
Hemoglobin |
<13.5/12.5d g/dL | 67 | 16 (23.9) | 1.000 | 1 | | | |
≥13.5/12.5d g/dL | 143 | 33 (23.1) | | 0.78 (0.35–1.73) | 0.538 | | |
Platelet count |
<22.1 × 104/μL | 105 | 23 (21.9) | 0.744 | 1 | | | |
≥22.1 × 104/μL | 105 | 26 (24.8) | | 1.25 (0.62–2.52) | 0.539 | | |
Total protein |
<7.0 g/dL | 105 | 21 (20.0) | 0.328 | 1 | | | |
≥7.0 g/dL | 105 | 28 (26.7) | | 1.28 (0.85–3.70) | 0.497 | | |
Total bilirubin |
<0.7 mg/dL | 104 | 19 (18.3) | 0.103 | 1 | | 1 | |
≥0.7 mg/dL | 106 | 30 (28.3) | | 1.77 (0.85–3.70) | 0.129 | 1.77 (0.90–3.52) | 0.101 |
Serum creatinine |
<0.77 mg/dL | 107 | 26 (24.3) | 0.747 | 1 | | | |
≥0.77 mg/dL | 103 | 23 (22.3) | | 0.86 (0.39–1.88) | 0.703 | | |
PaO
2
e
|
<87.9 mmHg | 105 | 29 (27.6) | 0.192 | 1 | | 1 | |
≥87.9 mmHg | 105 | 20 (19.0) | | 0.50 (0.24–1.02) | 0.057 | 0.53 (0.27–1.04) | 0.065 |
Operative factors |
Thoracic approach |
Thoracotomy | 109 | 33 (30.3) | 0.015 | 1 | | 1 | |
Thoracoscopy | 101 | 16 (15.8) | | 0.40 (0.16–1.04) | 0.059 | 0.46 (0.23–0.92) | 0.028 |
Abdominal approach |
Laparotomy | 145 | 39 (26.9) | 0.079 | 1 | | | |
Laparoscopy | 65 | 10 (15.4) | | 0.90 (0.33–2.44) | 0.842 | | |
Lymphadenectomy |
Two-field | 81 | 19 (23.5) | 1.000 | 1 | | | |
Three-field | 129 | 30 (23.3) | | 0.94 (0.42–2.13) | 0.887 | | |
Blood loss |
<350 mL | 104 | 17 (16.3) | 0.022 | 1 | | 1 | |
≥350 mL | 106 | 32 (30.2) | | 1.27 (0.54–2.98) | 0.587 | 2.01 (1.01–4.03) | 0.048 |
Operating time |
<452 min | 105 | 25 (23.8) | 1.000 | 1 | | | |
≥452 min | 105 | 24 (22.9) | | 2.00 (0.91–4.39) | 0.083 | | |
Discussion
The present study demonstrated that the laparoscopic approach had limited effect on PPC prevention after thoracoscopic esophagectomy. To the best of our knowledge, this is only the second study using data from a prospective multicenter trial that evaluated the effect of laparoscopy on PPC prevention after esophagectomy. The first phase III multicenter trial (MIRO trial) was conducted by Mariette et al. [
15]. They reported that laparoscopy decreased PPC frequency to a greater extent than that by laparotomy under the condition of thoracotomy (laparoscopy 17.7%, laparotomy 30.1%;
p = 0.037) [
16]. This result is similar to that of the present study comparing laparoscopy with laparotomy following thoracotomic esophagectomy (laparoscopy 14.3%, laparotomy 31.4%), although the difference was not significant (
p = 0.673) due to the lack of power. Therefore, our results are consistent with those of the MIRO trial, and laparoscopy is recommended to prevent PPCs under the condition of thoracotomy.
Another prospective randomized trial (TIME trial) reported that a combination of thoracoscopic and laparoscopic approaches decreased the frequency of pneumonia to a great extent compared with thoracotomy with laparotomy (thoracoscopy–laparoscopy: 9%, thoracotomy–laparotomy: 29%;
p = 0.005) [
13]. However, the extent to which each minimally invasive approach contributes to this reduction is still unclear. The present study demonstrated that laparoscopy showed a borderline significant reduction in PPC frequency, whereas thoracoscopy showed an independent and significant reduction in PPC frequency. Therefore, it is likely that the impact of thoracoscopy on the prevention of pneumonia in the TIME trial was more than that of laparoscopy.
It is well known that laparoscopic surgery maintains better postoperative respiratory function than open abdominal surgery [
17,
18], thus potentially affecting PPC prevention after thoracoscopic esophagectomy. However, whether laparoscopy contributes to better postoperative respiratory function [
19,
20] and reduction of PPC frequency [
8,
19,
20] remains controversial. In the present study, laparoscopy failed to show any substantial effect on PPC prevention under this condition. We speculated that this is because the preventive effect of thoracoscopy was so dominant that it masked that of laparoscopy. Under the condition of thoracotomy, a laparoscopic approach could potentially have a substantial effect on PPC prevention.
Another possible explanation for laparoscopy failing to show a substantial preventive impact after thoracoscopic esophagectomy is the presence of a minilaparotomy. In the MIRO trial, surgeons created a gastric conduit intracorporeally using a pure laparoscopic approach without any minilaparotomy, and specimens were removed via the thoracotomic incision [
15]. In contrast, gastric conduits in the laparoscopic group of the present study were created extracorporeally through a minilaparotomy, and specimens were removed via this incision. We speculate that the pain and discomfort caused by the minilaparotomy diminished the preventive effect of laparoscopy on PPCs. A laparoscopic approach without minilaparotomy may be required to further decrease PPC frequency after thoracoscopic esophagectomy.
The prone position with artificial pneumothorax is reported to have an advantage over the lateral decubitus position by avoiding total lung collapse, thereby decreasing the incidence of PPCs [
21]. In the present study, the body positions were equally distributed between the laparotomy and laparoscopy groups as shown in Table
1. Therefore, it is not likely that the body position during thoracoscopic esophagectomy affected the results in the present study.
Multivariable analysis in the present study indicated that thoracoscopy and less blood loss were significant PPC preventive factors. It has previously been reported that less blood loss is associated with PPC prevention after esophagectomy [
7,
22,
23]. Total blood loss during surgery is one of the parameters to estimate surgical stress in surgical risk scoring systems [
24,
25], and the calculated risk score is well correlated with the postoperative morbidity and mortality rates after gastrointestinal surgery [
26]. Therefore, it is likely that less blood loss is one of the PPC preventive factors after esophagectomy.
The median body mass index (BMI) in the present study (22.5) was lower than that in trials conducted in Western countries (24.0–25.0) [
13,
16]. It has been reported that patients with a high BMI do not have increased risk of PPCs after esophagectomy compared with those with a normal BMI [
27,
28]. Likewise, the present study showed no significant increase in PPC frequency in the BMI ≥25 group (Table
3). The pneumonia and PPC frequencies in the thoracotomy–laparotomy (control) group were reported to be 29 and 30.1% in the TIME and MIRO trials, respectively [
13,
16], which are comparable with that of the present study (31.4%). Thus, it is not likely that the lower BMI affected the results in the present study.
The present study had some limitations. First, because it was designed as a non-randomized comparison with a limited number of patients, the results may have been affected by patient selection bias and low statistical power. Second, there are omitted preoperative patient variables of pulmonary function tests, smoking history, and comorbidities, which may influence PPC frequency. Third, esophagectomy was only performed for patients with stage IA esophageal cancers. Therefore, the results may not be generalized to advanced esophageal cancers, which require preoperative therapy and more invasive surgical manipulation. Finally, the results may have been influenced by different surgical techniques and perioperative patient care styles because they were carried out depending on the standards of each participating institution.
Our new randomized phase III trial, JCOG1409 (MONET trial), is currently underway to compare the efficacy and safety of thoracoscopic esophagectomy and thoracotomic esophagectomy. In the MONET trial, patients are further stratified based on whether they undergo laparotomy or laparoscopy for gastric mobilization, performed according to the standard of each participating institution [
29]. We expect that the data from JCOG1409 will strengthen the conclusions of the present study.
In conclusion, the present study demonstrated that the thoracoscopic approach and less blood loss were significant factors in the prevention of PPCs after esophagectomy, whereas the laparoscopic approach had minimal effect on the prevention of PPCs after thoracoscopic esophagectomy.