Abstract
BACKGROUND: The treatment of esophageal cancer requires optimized surgical approaches to improve patient outcomes. Minimally invasive esophagectomy (MIE) has demonstrated advantages compared to open procedures, but the difference in efficacy of single-incision versus multi-incision techniques under various reconstruction routes remains unclear. This retrospective propensity-weighted study aimed to evaluate the perioperative outcomes and short-term functional recovery between single-incision laparo-thoracoscopic MIE with retrosternal reconstruction (SIMIE-RS) and multi-incision MIE with posterior mediastinal reconstruction (MIMIE-PM) in patients with esophageal cancer. METHODS: This retrospective study included 339 patients with esophageal cancer who underwent McKeown esophagectomy. The inverse probability of the treatment weighting (IPTW) approach was employed to assess outcome between SIMIE-RS and MIMIE-PM. The primary endpoints included postoperative complications, functional recovery parameters, and perioperative outcomes. Secondary endpoints included oncological adequacy, hospital length of stay, and quality of life indicators. RESULTS: Pulmonary complications were markedly reduced in the SIMIE-RS group as compared to the MIMIE-PM group, with a lower incidence of pneumonia (0.9% vs. 5.5%; P=0.02). Postoperative pain control was substantially improved in the SIMIE-RS group, who exhibited lower visual analog scale scores at 24 hours (3.1±1.0 vs. 7.5±1.1; P<0.001) and 72 hours (1.6±1.1 vs. 3.3±1.2; P<0.001) as compared to the MIMIE-PM group. SIMIE-RS also provided greater functional recovery, with superior forced expiratory volume in 1 second (FEV1) preservation at 1 month (3.2±0.5 vs. 2.4±0.6; P<0.001) and reduced reflux symptoms (1.2±0.5 vs. 1.8±0.9; P<0.001). Hospital length of stay was significantly shorter in the SIMIE-RS group than in the MIMIE-PM group (7.0±1.6 vs. 9.7±1.5 days; P<0.001). The safety profiles of the SIMIE-RS group and MIMIE-PM group were comparable in terms of surgery-related complications, including anastomotic leakage (2.8% vs. 5.0%; P=0.55), recurrent laryngeal nerve paralysis (0.9% vs. 1.0%; P>0.99), and chylothorax (0.9% vs. 1.5%; P=0.66). Oncological adequacy was maintained, with similar total lymph node yields between the groups (33±11.1 vs. 32.1±12.2; P=0.53). CONCLUSIONS: SIMIE-RS provides superior perioperative outcomes as compared to MIMIE-PM, with significant reductions in pulmonary complications, enhanced functional recovery, improved pain control, and shortened hospital stays, as well as comparable surgical safety and oncological adequacy. Our findings indicate that SIMIE-RS is a viable innovation in esophageal cancer surgery that concentrates operative trauma while optimizing reconstruction pathways.