Essential Updates 2024-2025: Surgical Strategy for Esophageal Cancer Toward a New Paradigm in the Era of...

Esophageal cancer surgery is evolving from technical standardization to a paradigm of personalized, strategy-oriented care. Robotic-assisted techniques and enhanced perioperative protocols have improved safety, but the field is increasingly shaped by three forces: integration of immune checkpoint inhibitors (ICIs), population aging, and the rise of intelligent technologies such as artificial intelligence (AI) and extended reality. Adjuvant nivolumab after neoadjuvant chemoradiotherapy (nCRT) remains the standard for residual disease, while other regimens such as durvalumab or dual checkpoint blockade have not demonstrated consistent survival benefit. Neoadjuvant ICI strategies, particularly camrelizumab plus chemotherapy in esophageal squamous cell cancer (ESCC), achieve high pathological response rates without increasing surgical morbidity, and pooled analyses confirm their feasibility. Immune-related adverse events (irAEs) occur in approximately 20%-35% of patients but are usually manageable. Perioperative outcomes remain comparable to conventional regimens. Elderly and frail patients require individualized optimization. The integration of minimally invasive techniques, assessment of sarcopenia and nutritional risk, and adjustment of chemotherapy intensity have contributed to improved outcomes. Moreover, salvage surgery-once prohibitive-now offers meaningful long-term survival when performed in high-volume centers with specialized expertise. AI and machine learning are transforming risk stratification, intraoperative guidance, and surgical training. AI-assisted video analytics and VR/AR simulators enhance skill acquisition, credentialing, and standardization. Future progress will depend on multicenter validation, prospective registries, and integration of oncologic, physiologic, and technological variables. Ultimately, the future of esophageal cancer surgery will be defined not only by technical precision but also by the surgeon's ability to leverage data-driven innovation for personalized care.