Comparative evaluation of transmediastinal and minimally invasive McKeown esophagectomy for esophageal cancer: perioperative and oncologic outcomes.

BACKGROUND

Esophageal squamous cell carcinoma remains a major health burden in China, where surgical resection is the mainstay of curative therapy. The conventional minimally invasive McKeown esophagectomy (MIE-McKeown), although oncologically effective, entails transthoracic access and single-lung ventilation, often resulting in higher postoperative morbidity. Thoraco-laparoscopic transmediastinal esophagectomy has emerged as a novel alternative that may mitigate these risks while preserving oncologic integrity.

METHODS

A retrospective cohort study was conducted involving 268 patients with resectable middle or lower thoracic esophageal squamous cell carcinoma (clinical stage I-III), including 131 who underwent transmediastinal esophagectomy and 137 who received MIE-McKeown. Outcomes assessed included operative time, intraoperative blood loss, lymph node yield, complication profiles, recovery indicators, quality of life (EORTC QLQ-C30), and 6-month disease-free survival (DFS). Statistical comparisons were performed using t-tests, χ² tests, and multivariate logistic regression.

RESULTS

The transmediastinal esophagectomy group exhibited significantly shorter operative time (197.2 ± 25.9 286.5 ± 32.1 min, <0.001) and reduced blood loss (155.4 ± 40.2 260.7 ± 65.1 mL, <0.001). Time to oral intake (4.6 ± 1.1 6.2 ± 1.3 days, <0.001), drainage duration (3.8 ± 0.5 4.4 ± 0.7 days, <0.001), and hospital stay (9.3 ± 1.8 11.1 ± 2.2 days, <0.001) were all significantly improved in the transmediastinal esophagectomy group. The incidence of Clavien-Dindo grade ≥III complications was lower (7.6% 16.0%, =0.043), particularly pneumonia (7.6% 18.2%, =0.009) and recurrent laryngeal nerve injury (4.6% 11.7%, =0.031). Lymph node harvest was comparable (21.4 ± 6.2 22.1 ± 5.9, =0.344). Three-month quality-of-life scores were higher in the transmediastinal esophagectomy group for global health (73.4 ± 12.1 66.5 ± 13.4, =0.005), physical functioning (78.2 ± 11.8 70.6 ± 13.6, =0.008), and role functioning (72.1 ± 14.2 64.3 ± 15.1, =0.011). The 6-month DFS rates were similar between groups (93.1% 91.2%, log-rank =0.327).

CONCLUSIONS

Thoraco-laparoscopic transmediastinal esophagectomy is a safe, effective, and minimally invasive alternative to the McKeown approach in selected esophageal squamous cell carcinoma patients. It provides superior perioperative outcomes and enhanced recovery without compromising short-term oncologic efficacy.