Uniportal versus Multiportal Video-Assisted Thoracoscopic Surgery for Minimally Invasive Esophagectomy in Esophageal Cancer: A GRADE-Assessed Systematic Review and Meta-Analysis.

BACKGROUND

Minimally invasive esophagectomy has become the preferred surgical approach for esophageal cancer, with uniportal video-assisted thoracoscopic surgery (uVATS) emerging as a potential refinement over conventional multiportal VATS (mVATS). However, comparative evidence remains limited to small single-centre studies. This systematic review and meta-analysis aimed to comprehensively evaluate perioperative and safety outcomes of uVATS versus mVATS in patients undergoing minimally invasive esophagectomy.

METHODS

A systematic search was conducted across PubMed/MEDLINE, Embase, Scopus, Cochrane Library, Web of Science, ClinicalTrials.gov, and CNKI from inception through April 2026. Studies directly comparing uVATS with mVATS in adults undergoing minimally invasive esophagectomy were eligible. Binary outcomes were pooled as odds ratios and continuous outcomes as mean differences under REML random-effects model. Heterogeneity was assessed using I² statistics. Certainty of evidence was evaluated using the GRADE framework.

RESULTS

Nine studies comparing uVATS and mVATS were included. uVATS was associated with significantly lower postoperative pain on day one (MD - 2.10, 95% CI - 3.63 to - 0.57; I² = 99.3%), reduced postoperative pneumonia (OR 0.41, 95% CI 0.22-0.76; I² = 43.5%), and shorter length of hospital stay (MD - 2.13 days, 95% CI - 3.64 to - 0.63; I² = 96.8%). No significant differences were observed between approaches for anastomotic leakage (OR 1.13, 95% CI 0.61-2.09), overall complications (OR 0.79, 95% CI 0.47-1.32), recurrent laryngeal nerve injury (OR 0.89, 95% CI 0.43-1.85), perioperative mortality (OR 0.53, 95% CI 0.16-1.81), intraoperative blood loss, or total operative time.

CONCLUSION

UVATS esophagectomy appears to be a feasible and safe alternative to mVATS, with potential advantages in postoperative pain, pulmonary morbidity, and hospital stay while maintaining comparable perioperative safety. The evidence base remains limited by high heterogeneity and predominance of observational studies. Multicenter randomized trials with standardized protocols and long-term oncologic follow-up are needed to consolidate these findings.