Uniportal-VATS vs. open McKeown esophagectomy: Surgical and long-term oncological outcomes

{"Background": "Esophagectomy is a critical treatment for resectable esophageal cancer but open surgery carries high morbidity and mortality. Minimally invasive esophagectomy (MIE) has shown superiority in short-term outcomes, but the role of Uniportal-VATS esophagectomy remains debated with limited data on long-term oncological outcomes. This study aimed to compare surgical and long-term oncological outcomes of Uniportal-VATS versus open McKeown esophagectomy.", "Methods": "Prospectively collected data from 75 consecutive patients who underwent McKeown esophagectomy at a single Thoracic Surgery Department from January 2012 to August 2022 were retrospectively analyzed. Nineteen patients underwent open thoracotomy (January 2012\u2013November 2016) and 56 underwent Uniportal-VATS (December 2016\u2013August 2022). All patients had gastric tubulization (laparoscopic or mini-laparotomic) and cervical anastomosis per Orringer's technique. Patients with IIB\u2013IIIB stage (AJCC 8th edition) received neoadjuvant chemoradiotherapy. Statistical analysis used t-tests, Mann-Whitney U, Chi-squared, Kaplan-Meier survival, and Cox regression. CUSUM analysis defined the learning curve.", "Key Results": "Groups were comparable in age (63.38\u00b110.17 vs 63.95\u00b112.15 years, p=0.841), histology (adenocarcinoma 71.4% vs 57.9%, p=0.274), and neoadjuvant therapy (58.9% vs 31.6%, p=0.079). Mean operative thoracic time was similar (102.34\u00b115.21 vs 115.56\u00b123.12 min, p=0.646). No conversions occurred in the VATS group. Mediastinal node retrieval was comparable (13.40\u00b18.12 vs 15.00\u00b16.86, p=0.275). The learning curve for Uniportal-VATS was completed after 34 cases, mastery after 40. Re-operation for major complications was significantly lower in the VATS group (3.6% vs 21.0%, p=0.04). Chest tube duration (11.89\u00b19.55 vs 25.82\u00b124.37 days, p=0.003) and postoperative stay (15.63\u00b111.69 vs 25.53\u00b123.33 days, p=0.018) were significantly shorter with VATS. Thirty-day mortality was higher in the open group (15.7% vs 0%, p=0.002). Pain on postoperative day 1 was lower with VATS (1.89\u00b11.60 vs 4.68\u00b12.91, p<<0.001). Minor complications (pneumonia, atelectasis, atrial fibrillation, anastomotic leak, vocal cord palsy, chylothorax) were comparable. For the whole series, 2-, 5-, and 8-year OS was 72%, 50%, and 33%. Combined 2- and 5-year OS was 76% and 47% (VATS) vs 62% and 62% (open) (Log-rank p=0.286; Breslow-Wilcoxon p=0.036). Five-year DFS was 86% (VATS) vs 72% (open) (p=0.298). In stage III, 5-year OS was superior with VATS (58% vs 29%, p=0.040). At multivariate analysis, only pathological stage independently affected OS (HR 0.127, 95% CI 0.022\u20130.723, p=0.02), not surgical approach (HR 0.588, 95% CI 0.226\u20131.529, p=0.276).", "Clinical Implications": "Uniportal-VATS McKeown esophagectomy appears safe and feasible with equivalent surgical radicality and long-term oncological outcomes compared to open thoracotomy, while offering faster recovery, less pain, shorter hospital stay, and lower early mortality. The learning curve is relatively short (34 cases for completion, 40 for mastery). These findings support Uniportal-VATS as a viable minimally invasive option for esophageal cancer surgery, though prospective randomized trials are needed for confirmation."}