Short- and long-term outcomes of conversion minimally invasive esophagectomy versus open approach following induction therapy in cT4b esophageal cancer.

Conversion surgery (CS) following induction therapy has emerged as a treatment option for patients with cT4b esophageal cancer previously considered unresectable. Minimally invasive approaches, including thoracoscopic and robot-assisted techniques, are increasingly applied in this setting. However, evidence comparing conversion minimally invasive esophagectomy (C-MIE) with conversion open esophagectomy (C-OE) remains limited. This single-center retrospective study included 66 patients with cT4b esophageal cancer who underwent CS after induction therapy between 2007 and 2023. Patients were classified into C-MIE (n = 41) or C-OE (n = 25) groups. Short-term outcomes, including operative time, blood loss, complications, and hospital stay, as well as long-term outcomes such as recurrence and survival, were compared. Prognostic factors were identified using multivariate Cox analysis. The C-MIE group showed markedly reduced intraoperative blood loss (79 vs. 470 mL, P < 0.001), lower incidence of anastomotic leakage (4.8 vs. 24%, P = 0.04), and shorter intensive care unit stay (3 vs. 4 days, P = 0.03) compared with the C-OE group. Three-year overall survival was higher in the C-MIE group (63.0 vs. 39.6%, P = 0.08), although not statistically significant. Multivariate analysis identified Clavien-Dindo grade ≥ IIIa (HR: 3.73, 95% CI: 1.81-7.67, P < 0.001) and ypStage ≥ III (HR: 3.51, 95% CI: 1.6-8.43, P = 0.001) as independent predictors of poorer survival. C-MIE showed a reduced risk but not significantly (HR: 0.79, 95% CI: 0.37-1.66; P = 0.537). C-MIE was associated with acceptable short-term outcomes and comparable long-term oncologic results to C-OE in patients with cT4b esophageal cancer responding to induction therapy.