Single-sterilization modified-position robotic-assisted McKeown esophagectomy versus minimally invasive approach after neoadjuvant chemoimmunotherapy for locally advanced esophageal squamous cell carcinoma.

BACKGROUND

Surgical resection remains a key component of multimodal therapy for patients with resectable or locally advanced esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoimmunotherapy (nCIT). This study compared the safety and efficacy of single-sterilization modified-position robotic-assisted esophagectomy (SM-RAE) with conventional minimally invasive esophagectomy (MIE), focusing on perioperative outcomes, composite adverse events, electronic patient-reported outcomes (ePROs), and short-term oncologic results.

METHODS

This single-center retrospective study included 137 ESCC patients who underwent McKeown esophagectomy after nCIT between January 2022 and December 2024. Of them, 36 received SM-RAE and 101 received MIE. Baseline characteristics, perioperative indicators, composite adverse events (operative time ≥330 min, intraoperative blood loss ≥400 mL, conversion to open, non-R0 resection, or Clavien-Dindo grade ≥ III complications), ePROs (pain, cough, distress, dysphagia, and dyspnea), and short-term survival outcomes were analyzed. Propensity score matching (PSM) was applied to balance baseline variables, and comparisons were repeated after matching.

RESULTS

Compared with MIE, SM-RAE resulted in shorter operative time (270 vs. 295 min, P<0.001) and neck drain duration (4 vs. 6 days, P<0.001), a higher yield of recurrent laryngeal nerve (RLN) lymph nodes (4.5 vs. 2.0, P<0.001), and fewer composite adverse events (16.67% vs. 41.58%, P=0.007). Multivariate analysis confirmed SM-RAE as an independent protective factor for composite adverse events [odds ratio (OR) =0.28, 95% confidence interval (CI): 0.11-0.74; P=0.01]. SM-RAE was not an independent predictor of major pathological response (MPR) or recurrence. ePROs showed lower postoperative symptom scores in weeks 1-8 (P<0.001), indicating faster recovery. Findings remained consistent after PSM. No significant differences were observed in R0 resection rate, overall complications, ward cost, pathological complete response (pCR)/MPR rates, recurrence, or short-term survival.

CONCLUSIONS

SM-RAE is a safe, effective, and feasible surgical option for ESCC patients after nCIT. For selected patients with locally advanced disease, SM-RAE offers a non-inferior alternative to standard MIE, with advantages in perioperative efficiency, RLN lymphadenectomy, and patient-reported recovery.