03093768

September 04, 2021, 10:26

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The authors compared the results of two different surgical methods (thoracoscopic-assisted surgery vs. transhiatal surgery) and concluded that thoracoscopic-assisted surgery has a better effect on early adenocarcinoma of the esophagus-gastric junction. There are some issues in the article that deserve attention. 1. The surgery data were collected from two medical centers, spanning 17 years, with a total of 147 operations. The average annual number of operations in each medical center is less than 5 cases. It is well known that the success rate of major surgery is related to the accumulation of surgical volume in medical units. For such a major operation, it is difficult to accumulate the surgeon's experience through this number of cases. It is difficult to guarantee the homogeneity of treatment in the two medical centers. 2. In most country, the application of thoracoscopy to the disease is later than transhiatal method. To a certain extent, the thoracoscopic technology is an improvement of transhiatal surgery. Because of better expose and more effective in mediastinal lymph nodes cleaning, more accurate tumor staging could be achieved. This can make the patient's subsequent adjuvant treatment selection more precise. If two different surgical methods are to be compared, the baseline data of the two groups of patients should be comparable. However, there is a significant difference in the age of the two groups of patients in the article, which shows that there is a serious selection bias in the treatment process. In addition, there is no data to prove that the tumor stages of the two groups of patients are comparable. The TNM staging of the tumor should be introduced. 3. In the introduction section of thoracoscopic surgery, there is no description of resection on the lymph nodes adjacent to the recurrent laryngeal nerve. In fact, the main cause of hoarseness is damage related with the recurrent laryngeal nerve. 4. The statistics on complications in the article are ambiguous. For example, atelectasis is statistically analyzed in respiratory complications and infections, which is unreasonable. 5. The data seem to be contradictory. The number of removed lymph nodes described in the article is inconsistent with that in Table 3. 6. The names of lymph nodes are confusing. In the outcome, there are named as resected lymph nodes (LDs) and lymph nodes affected (LA), which are changed to AL/DL in Table 3. By the way, the P value is also inconsistent with the table. 7. In the Long-term results section, the authors said "longer survival is observed in patients with earlier disease (up to stage 2B), undergoing thoracoscopic esophagectomy'. And they also said "The multivariable analysis demonstrated better results related to transhiatal access in early staging tumors, hazard ratio 1.73". This is contradictory. 8. The 10.9% incidence of respiratory complication in the discussion does not match the 14.8% in the table. 9. In the discussion, the complication of anastomotic fistula should actually be leakage, not fistula. Fistula and leakage are different. In addition, this complication does not require balloon expansion. Balloon dilatation is only considered for anastomotic stenosis. 10. The text and data in Table 4 are difficult to understand. It looks like two tables are merged to one.

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