Robotic versus open esophagectomy: a propensity score-matched analysis from a tertiary cancer center in India

Robotic esophagectomy has gained prominence over open esophagectomy for resectable esophageal cancer. However, high-quality comparative data remain limited, particularly from the Indian subcontinent. This study compares perioperative and long-term outcomes between robotic and open esophagectomy using propensity score matching. We analyzed 209 patients who underwent McKeown's total esophagectomy between January 2014 and December 2024 at a tertiary cancer center in India. Patients were divided into robotic (n = 156) and open esophagectomy (n = 53) groups. In robotic, the thoracic component was performed robotically, while cervical and abdominal phases used conventional open techniques. All anastomoses were handsewn in a tensionless, two-layer manner. Propensity score matching created 48 matched pairs. Primary outcomes were overall survival (OS) and disease-free survival (DFS). After propensity matching, the robotic cohort demonstrated superior 5-year overall survival (64.7% vs 53.4%, p = 0.045). Robotic showed significant advantages in reduced blood loss (174 vs 237.7 ml, p < 0.003), hospital stay (11.7 vs 14.4 days, p = 0.013), extubation day (0.4 vs 0.8 days, p = 0.008), and ICU duration (2.2 vs 3.4 days, p = 0.001). Respiratory complications requiring ICU were lower in the robotic cohort (8.3% vs 22.9%, p = 0.049). Robotic esophagectomy offers survival advantages over open esophagectomy with superior perioperative outcomes. This appears driven by reduced perioperative morbidity rather than enhanced cancer control, supporting robot adoption in experienced centers.