Abstract
BACKGROUND: The surgical approach to esophageal cancer is evolving. Open (OE) and hybrid esophagectomy (HE) have been standard treatments for years but minimally invasive (MIE) and robotic-assisted esophagectomy (RAMIE) have recently emerged with promising perspectives. PURPOSE: Compare short-term outcomes among different techniques for transthoracic esophagectomy. METHODS: Systematic review and random effect Frequentist network meta-analysis. Included were randomized controlled trials (RCTs) reporting short-term outcomes for transthoracic OE, HE, MIE, and RAMIE in adult patients undergoing esophagectomy for cancer. Primary outcomes were anastomotic leak, pulmonary complications (PCs), and in-hospital mortality. Risk ratio (RR), standardized mean difference, and 95% confidence intervals (CIs) were used as pooled effect size measures. PROSPERO (CRD42025645818). RESULTS: Eight RCTs (1776 patients) were included. Overall, 493 patients (27.8%) underwent OE, 494 (27.9%) HE, 447 (25.3%) MIE, and 338 (19.2%) RAMIE. Adenocarcinoma was diagnosed 65.8% of patients while neoadjuvant therapy was completed in 64.1%. Ivor Lewis or McKeown esophagectomy was performed in 43.3% and 56.7% of patients, respectively. MIE and RAMIE were associated with a reduced risk of PCs compared to OE (RR = 0.46; 95% CI 0.29-0.71 and RR = 0.48; 95% CI 0.33-0.71) and HE (RR = 0.54; 95% CI 0.34-0.86 and RR = 0.57; 95% CI 0.37-0.87). Additionally, MIE and RAMIE showed significantly reduced intraoperative blood loss and hospital length of stay compared to OE and HE. Among surgical approaches, anastomotic leak, in-hospital mortality, together with the other perioperative and oncological outcomes were equivalent. CONCLUSIONS: MIE and RAMIE were associated with significantly reduced postoperative PCs, intraoperative blood loss and shorter hospital stays compared to OE and HE. MIE and RAMIE showed equivalent perioperative outcomes and oncological radicality.