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Robot-assisted versus thoracoscopic esophagectomy for esophageal cancer: long-term oncological and functional
Koshiro Ishiyama1, Ryoko Nozaki1, Ryota Kakuta1
1Division of Esophageal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan.
Background:
Robot-assisted esophagectomy (RE) has been increasingly adopted as an alternative to thoracoscopic esophagectomy (TE) for esophageal cancer. While RE has shown perioperative advantages, its long-term oncological and functional outcomes remain unclear. This study compared short- and long-term outcomes, as well as postoperative changes in body composition and pulmonary function.
Methods:
We retrospectively reviewed 639 patients who underwent esophagectomy for thoracic esophageal cancer between 2018 and 2022. After excluding non-standard procedures, 205 underwent RE and 434 TE. Propensity score matching was performed based on demographic, nutritional, functional, and oncological factors, yielding 122 matched pairs. Surgical outcomes, complications, overall survival (OS), relapse-free survival (RFS), skeletal muscle index (SMI), and pulmonary function (FEV1) were compared.
Results:
In the matched cohort, RE was associated with reduced blood loss, lower inflammatory response, and shorter ICU stay, with comparable complication rates to TE. The 3-year OS was higher in RE than TE (78.1% vs 68.1%, p = 0.01), particularly in cStage III (71.8% vs 57.5%, p = 0.044), whereas RFS was similar. Univariate analysis identified TE, pT > 3, pStage > III, and lymphovascular invasion as adverse prognostic factors, while multivariate analysis confirmed pStage > III as the only independent predictor (HR 5.20, 95% CI 2.54-10.40, p < 0.001). SMI remained above the sarcopenia threshold (7 kg/m2) in RE but consistently below in TE, despite no statistical difference. The decline in FEV1 at 4 months was smaller in RE (-3.6% vs -8.4%, p = 0.004). Survival analysis stratified by early FEV1 decline (ΔFEV) showed superior outcomes in patients with preserved function, with the RE ΔFEV low group showing the most favorable prognosis compared with the TE ΔFEV high group (3-year OS: 81.8% vs 58.5%, p = 0.005).
Conclusions:
RE was associated with improved perioperative recovery and early functional preservation compared with TE. The observed differences in OS were not confirmed in multivariable analysis.
