Minimally invasive or open esophagectomy for esophageal squamous cell carcinoma: a comprehensive systematic review of surgical and survival outcomes

Background: Esophageal squamous cell carcinoma (ESCC) remains a common malignancy with high mortality. Minimally invasive esophagectomy (MIE) was developed to reduce the morbidity of conventional open esophagectomy (OE), but comparative evidence specifically addressing oncologic adequacy and postoperative recovery in ESCC is limited. This systematic review synthesizes comparative data on MIE vs. OE in ESCC. Methods: = 5,342; 2,968 MIE, 2,374 OE) met inclusion criteria. Methodological quality was assessed using the Newcastle-Ottawa Scale. Prespecified endpoints included overall survival (OS), disease-free survival (DFS), lymph node yield, R0 resection rate, perioperative complications, intraoperative blood loss, and lengths of ICU and hospital stay. Results: Aggregate data indicate oncologic equivalence between MIE and OE: R0 resection rates were uniformly high (≥92%), and lymph node yields were comparable. Five out of nine studies (55.6%) reported no statistically significant differences in overall survival (OS) or disease-free survival (DFS) between MIE and OE. However, selected analyses favored MIE (e.g., 3-year OS HR 0.54, 95% CI 0.43-0.68). Perioperatively, MIE demonstrated consistent advantages, including reduced intraoperative blood loss, shorter hospital length of stay, and lower rates of pulmonary complications-particularly pneumonia-each of which was reported in seven of the nine included studies (77.8%). Anastomotic leak rates were similar; reports of recurrent laryngeal nerve injury were heterogeneous. Conclusion: In ESCC, MIE achieves oncologic outcomes comparable to OE while conferring reduced pulmonary morbidity, lower blood loss, and accelerated postoperative recovery, supporting its consideration as a standard surgical approach. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251158559, PROSPERO CRD420251158559.