Thoracoscopic vs open esophagectomy: Short-term efficacy with laparoscopic gastric tube

Abstract

BACKGROUND

Esophagectomy remains the cornerstone of curative treatment for resectable esophageal cancer (EC). Traditional open surgery is associated with significant surgical trauma, slow postoperative recovery, and high complication rates. With rapid advancements in minimally invasive techniques, video-assisted thoracoscopic surgery combined with laparoscopic gastric mobilization has been increasingly adopted for tubular stomach creation. The short-term efficacy and recovery advantages of this minimally invasive approach compared to conventional open esophagectomy remain debatable.

AIM

To compare the short-term outcomes of thoracoscopic and open esophagectomy approaches in patients with EC.

METHODS

A retrospective analysis was conducted on patients who underwent radical esophagectomy for EC. Patients were divided into a thoracoscopic group (laparoscopic gastric mobilization with tubular stomach reconstruction + thoracoscopic esophagectomy + cervical anastomosis, n = 58) and an open surgery group (laparoscopic gastric mobilization with tubular stomach reconstruction + open esophagectomy + cervical anastomosis, n = 40). Perioperative variables, postoperative recovery parameters, pain scores, inflammatory and stress responses, postoperative complications, and quality of life were compared between the two groups.

RESULTS

Intraoperative blood loss, chest drainage duration, time to first ambulation, postoperative hospital stay, bowel sound recovery, and time to liquid diet tolerance were all significantly lower in the thoracoscopic group vs open surgery. The thoracoscopic group had a lower total complication rate in the (24.1% vs 47.5%; P < 0.05). One month postoperatively, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 scores for overall health status, physical functioning, and role functioning were significantly higher after thoracoscopic surgery. Postoperative pain scores and C-reactive protein and interleukin-6 levels were significantly lower in the thoracoscopic group at all time-points compared with the open surgery group.

CONCLUSION

Thoracoscopic esophagectomy combined with laparoscopic gastric mobilization and tubular stomach reconstruction offers significant advantages, contributes to an improved postoperative quality of life and should be further promoted in clinical practice.

Key Words: Esophageal neoplasms; Thoracoscopic surgery; Open surgery; Laparoscopy; Short-term efficacy

Core Tip: This retrospective study demonstrated that minimally invasive thoracoscopic esophagectomy, when combined with laparoscopic gastric mobilization, provides superior short-term outcomes compared to conventional open surgery for esophageal cancer. It minimizes surgical trauma and accelerates recovery, reduces postoperative pain, systemic inflammation, and stress response, and ultimately enhancing patients’ early postoperative quality of life. These findings support broader clinical adoption of this minimally invasive surgical approach.

INTRODUCTION

Esophageal cancer (EC) is one of the most common malignant tumors of the digestive tract. China has a particularly high incidence, with both morbidity and mortality remain stubbornly high that pose a serious threat to patients’ lives and health[1,2]. Comprehensive therapy centered on surgical resection remains the principal treatment. Conventional open esophagectomy provides an excellent operative field and working space, ensuring radical oncologic resection; however, it is associated with substantial surgical trauma, a long thoracic incision, and extensive chest wall tissue damage, often leading to severe postoperative pain, impaired respiratory function, pulmonary complications, and delayed recovery[3,4]. In recent years, with the rapid evolution of minimally invasive concepts and techniques, video-assisted thoracoscopic surgery (VATS) has been widely adopted in thoracic surgery owing to smaller wound size, reduced postoperative pain, and faster recovery[5,6]. As a novel approach, thoracoscopic esophagectomy reduces the incision size and minimizes injury to the chest wall muscles and nerves, promising less intraoperative bleeding, diminished postoperative pain, better preservation of pulmonary function, and fewer complications, and is gradually becoming a strong alternative to open surgery[7,8]. We retrospectively analyzed the clinical data of patients who underwent either thoracoscopic or open esophagectomy combined with laparoscopic gastric mobilization and tubular stomach reconstruction at our hospital, and compared the short-term efficacy of the two approaches to provide an evidence base for surgical decision-making.

MATERIALS AND METHODS

Study population

After approval by the hospital Ethics Committee, we retrospectively collected clinical data of patients who underwent radical esophagectomy at the Department of Thoracic/General Surgery, Characteristic Medical Center of the Strategic Support Force, from January 2017 to December 2023.

Inclusion criteria: Diagnosis of EC confirmed by gastroscopy and histopathology; indications for radical esophagectomy; age, 18-75 years; complete medical records; and informed consent for the surgical plan obtained from patients and relatives.

Exclusion criteria: Previous major thoracic or abdominal surgery; intraoperative discovery of unresectable tumor or performance of palliative resection; concomitant other malignancies; preoperative neoadjuvant chemoradiotherapy; conversion to another surgical approach; and incomplete clinical data.

A total of 98 patients were enrolled and divided into the VATS (n = 58) and open surgery (n = 40) groups. Baseline characteristics were comparable between the two groups (P > 0.05; Table 1).

Table 1 Comparison of general data between the two groups, n (%)/mean ± SD.

Group	n	Sex		Age (years)	BMI (kg/m2)	cT grade			cN grade
		Male	Female			T1	T2	T3	N0	N1
Thoracoscopic group	58	42 (72.4)	16 (27.6)	62.5 ± 8.1	22.8 ± 2.5	10 (17.2)	25 (43.1)	23 (39.7)	35 (60.3)	23 (39.7)
Open surgery group	40	32 (80.0)	8 (20.0)	64.2 ± 7.6	23.1 ± 2.7	8 (20.0)	16 (40.0)	16 (40.0)	22 (55.0)	18 (45.0)
χ2/t		0.784		1.052	0.573	0.211			0.327
P value		0.376		0.296	0.568	0.900			0.567

BMI: Body mass index.

Surgical methods

All open and minimally invasive esophagectomies were performed by the same surgical team. The procedural sequence was total laparoscopic gastric mobilization and tubular-stomach construction, followed by thoracic procedure according to group assignment, and then cervical anastomosis. During the study period, both thoracoscopic and open esophagectomies were routinely performed without a predefined time-based allocation strategy, and the choice of surgical approach was not deliberately clustered within specific years.

Laparoscopic gastric mobilization and tubular-stomach construction: The patient was placed supine, with legs apart, and under general anesthesia. A 10-mm infraumbilical longitudinal incision was made as the camera port, and a CO₂ pneumoperitoneum was established at 12-14 mmHg. Under laparoscopic vision, 5- or 12-mm ports were inserted along the mid-clavicular line below the costal margin (main working ports) and along the lateral border of the rectus abdominis at the umbilical level (assistant ports) in a “U” distribution. The gastrocolic ligament was opened 2 cm outside the gastroepiploic arch using an ultrasonic scalpel, starting from the infrapyloric area toward the splenic hilum. The right gastroepiploic vascular arch was preserved, and all short gastric vessels were divided until the gastric fundus and gastrophrenic ligament were fully freed. The stomach was lifted to expose the lower sac. The common hepatic artery was identified to the left of the hepatoduodenal ligament, and station 8a lymph nodes were dissected along their surface until the root of the left gastric artery (LGA) was exposed. The proximal LGA was clipped, and its distal end was divided with an ultrasonic scalpel; the left gastric vein was treated similarly. The hepatogastric ligament was divided on the right side of the cardia. The lymph nodes around the celiac trunk, anterior to the common hepatic artery, and LGA were systematically removed. A 2-3-cm longitudinal pyloromyotomy was performed to promote postoperative gastric emptying.

Using a 60-mm linear stapler, the gastric body was sequentially divided from the angular incisure toward the cardia along the inner side of the right gastroepiploic arch, excising lesser-curvature fat and lymphatic tissue and fashioning a 4-5-cm-wide gastric tube. The apex of the tube was left intact for subsequent transhiatal delivery into the posterior mediastinum.

VATS group - thoracoscopic esophagectomy: Left lateral decubitus positioning was used, with double-lumen intubation, and single-lung ventilation. A 1.5-cm incision at the 7^th or 8^th intercostal space along the right mid-axillary line served as the camera port (10-mm trocar). Under VATS vision, 12-mm and 5-mm ports were placed at the 4^th intercostal space anterior axillary line (main working port), 5^th intercostal space posterior axillary line (assistant port), and 9^th intercostal space scapular angle line (assistant port). The mediastinal pleura over the azygos arch was opened using an L-hook or ultrasonic scalpel. The azygos vein was dissected, clipped proximally and distally and divided. The inferior pulmonary ligament was divided, and the esophagus was freed upward. The pericardial reflection was opened anteriorly; posteriorly, the dissection proceeded to the inferior border of the aortic arch, protecting the contralateral pleura. The bilateral recurrent laryngeal nerves (RLNs) were identified along the vagal trunk. The right RLN-chain nodes were meticulously dissected in the space between the superior vena cava and trachea with gentle caudal retraction of the esophagus to avoid thermal nerve injury. The left RLN was located in the ligamentum arteriosum and was dissected cranially to the thoracic apex. The subcarinal nodes were removed en bloc between the bilateral main bronchi and pericardium. The lower paraesophageal and perihilar nodes were then cleared. After completing all the intrathoracic steps, the esophagus was divided at the thoracic apex using a linear stapler, and the distal specimen was temporarily left in the posterior mediastinum.

Open-surgery group - open esophagectomy: With the patient in the left-lateral decubitus position, a standard right posterolateral thoracotomy, 20-25 cm long, was performed through the 5^th intercostal space; the 5^th rib posterior end of the fifth rib was divided if necessary, and a rib spreader was used to obtain adequate exposure. Esophageal mobilization and lymph-node dissection were identical in scope and principle to the VATS group, following en bloc and skeletonization concepts under direct vision. Conventional long electrocautery, an ultrasonic scalpel, or LigaSure (Medtronic, Minneapolis, MN, United States) was used for division and hemostasis.

Delivery of gastric tube and cervical anastomosis: The patient was repositioned supine; the neck and abdomen were re-prepped and draped. A 5-6-cm oblique incision was made along the anterior border of the left sternocleidomastoid muscle to expose the cervical esophagus. The abdominal team sutured the apex of the gastric tube to the distal esophageal stump. The cervical team gently pulled the esophagus and gastric tube through the posterior mediastinum to the neck to ensure that there was no torsion or tension on the vascular arcade. After resecting the esophageal lesion for pathologic examination, a gastrotomy matching the esophageal stump diameter was created at the top of the gastric tube, and a two-layer (full-thickness plus seromuscular) interrupted end-to-side anastomosis was performed. A nasogastric tube was placed into the gastric tube, and a drainage tube was placed beside the anastomosis. The cervical incision was then closed. Laparoscopic port sites were sutured; in the open group, the chest was closed in a standard fashion with a thoracic drainage tube left in place.

Outcome measures

Peri-operative variables: Data on total operative time; intraoperative blood loss; and number of right upper mediastinal, subcarinal, perigastric, and total dissected lymph nodes were collected.

Postoperative recovery: Data included duration of chest drainage, time to first ambulation, length of postoperative hospital stay, time to bowel sound recovery, and time to oral fluid tolerance.

Pain intensity: Visual analog scale (VAS) scores at rest were recorded on the day before surgery and on postoperative days 1, 3, 5, and 7 (0 = no pain, 10 = worst imaginable pain).

Inflammatory and stress response: Serum C-reactive protein (CRP) and interleukin-6 (IL-6) levels were measured the day before surgery and on postoperative days 1, 3, 5, and 7.

Complications: All complications occurring within 30 days of surgery, including pulmonary infection, arrhythmia, anastomotic leak, RLN injury, chylothorax, and wound infection, were recorded.

Quality of life: The European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core-30 (EORTC QLQ-C30)[9] was administered on the day before and 30 days after surgery. The scores range from 0 to 100, with higher values indicating a better quality of life.

Statistical analysis

Continuous variables are presented as mean ± SD or median (interquartile range) and compared using the independent-samples t-test or Mann-Whitney U-test. Categorical variables are expressed as n (%) and compared using the χ² test or Fisher’s exact test. Repeated-measures ANOVA was used for VAS scores, and CRP and IL-6 levels to assess group, time, and interaction effects. All analyses were performed using SPSS 26.0 (IBM, Armonk, NY, United States); statistical significance was set at P < 0.05.

RESULTS

Comparison of peri-operative variables

Intraoperative blood loss was significantly lower in the VATS group than in the open surgery group (P < 0.05). No significant differences were observed in any of the other peri-operative parameters (Table 2).

Table 2 Comparison of perioperative indicators between the two groups, mean ± SD.

Group	Total operation time (minutes)	Intraoperative blood loss (mL)	Total lymph nodes dissected (n)	Right upper mediastinal lymph nodes (n)	Sub-carinal lymph nodes (n)	Perigastric lymph nodes (n)
Thoracoscopic group	285.6 ± 45.3	150.5 ± 50.2	22.4 ± 6.1	4.5 ± 1.8	3.2 ± 1.1	7.8 ± 2.5
Open surgery group	275.8 ± 50.1	320.8 ± 85.7	21.8 ± 5.9	4.2 ± 1.6	3.0 ± 1.3	7.5 ± 2.4
t-value	1.012	-12.345	0.491	0.867	0.821	0.596
P value	0.314	< 0.001	0.625	0.388	0.414	0.553

Comparison of postoperative recovery

The durations of chest drainage, time to first ambulation, postoperative hospital stay, time to bowel sound recovery, and time to oral fluid tolerance were shorter in the VATS group than the open surgery group (P < 0.05; Table 3).

Table 3 Comparison of postoperative recovery between the two groups, mean ± SD.

Group	Chest-tube duration (days)	Time to first ambulation (days)	Postoperative hospital stay (days)	Return of bowel sounds (hours)	Time to oral fluid tolerance (days)
Thoracoscopic group	5.1 ± 1.5	2.5 ± 0.8	12.5 ± 3.2	28.5 ± 6.8	5.8 ± 1.2
Open surgery group	7.2 ± 2.1	2.8 ± 1.0	15.8 ± 4.5	35.2 ± 9.5	6.9 ± 1.8
t-value	-5.678	-1.234	-4.123	-4.012	-3.567
P value	< 0.001	0.220	< 0.001	< 0.001	0.001

Comparison of pain intensity

Repeated-measures ANOVA showed that the VAS scores at every postoperative time-point were significantly lower in the VATS group than the open surgery group (group effect, time effect, and interaction, all P < 0.05; Figure 1A).

Figure 1 Comparison between the two groups at 1 day pre-operation, 1 day post-operation, 3 days post-operation, 5 days post-operation and 7 days post-operation. A: Visual analog scale pain score trends; B: C-reactive protein levels; C: Interleukin-6 levels. VAS: Visual analog scale; CRP: C-reactive protein; IL-6: Interleukin-6.

Comparison of inflammatory and stress markers

CRP and IL-6 levels at every postoperative time-point were significantly lower in the VATS group than the open surgery group (group effect, time effect, and interaction, all P < 0.05; Figure 1B and C).

Comparison of complications

The overall complication rates within 30 days were 24.1% in the VATS group vs 47.5% in the open surgery group (P < 0.05; Table 4).

Table 4 Comparison of postoperative recovery between the two groups, n (%).

Group	Pulmonary infection	Arrhythmia	Anastomotic leak	Recurrent laryngeal nerve injury	Chylothorax	Wound infection	Total complications
Thoracoscopic group	5 (8.6)	6 (10.3)	3 (5.2)	4 (6.9)	1 (1.7)	2 (3.4)	14 (24.1)
Open surgery group	10 (25.0)	7 (17.5)	2 (5.0)	5 (12.5)	1 (2.5)	4 (10.0)	19 (47.5)
χ2 value							5.876
P value							0.015

Comparison of quality of life

Global health status, physical functioning, and role functioning scores on the EORTC QLQ-C30 at 1 month were significantly higher in the VATS group than the open surgery group (P < 0.05; Table 5).

Table 5 Comparison of postoperative recovery (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 scores) between the two groups, mean ± SD.

Group	General health		Somatic function		Role features
	Preoperative	Postoperative 1 month	Preoperative	Postoperative 1 month	Preoperative	Postoperative 1 month
Thoracoscopic group	68.5 ± 9.8	65.8 ± 10.2	76.2 ± 10.5	72.5 ± 11.6	74.8 ± 11.2	68.9 ± 12.1
Open surgery group	67.9 ± 10.3	58.3 ± 12.5	75.8 ± 11.1	65.1 ± 13.8	73.9 ± 12.4	60.5 ± 14.2
t	0.302	3.345	0.185	2.894	0.376	3.112
P value	0.763	0.001	0.854	0.005	0.708	0.002

DISCUSSION

Minimally invasive surgery has profoundly changed the management of thoracic diseases. As a hallmark of minimally invasive techniques, VATS has evolved from simple procedures such as bullectomy and pleural biopsy to a mainstream approach capable of handling complex conditions, including EC[10-12]. Minimally invasive esophagectomy (MIE) involves oncologic resection and gastrointestinal reconstruction through several small ports, offering reduced trauma, faster recovery, and less pain[13,14]. The present study demonstrates the significant advantages of the thoracoscopic approach in perioperative and recovery domains.

Patients who underwent VATS exhibited markedly lower intraoperative blood loss and shorter chest drainage time, earlier ambulation, shorter hospital stay, faster return of bowel sounds, and earlier tolerance to oral fluids than those in the open surgery group. These findings indicate that VATS not only reduces hemorrhage but also accelerates postoperative recovery. Diminished bleeding is attributable to the avoidance of a large thoracotomy and intercostal vessel injury, coupled with magnified visualization that permits meticulous vascular control[15,16]. Fujita et al[17] similarly reported that magnified fine dissection in MIE allows the precise identification and management of vessels, thereby decreasing blood loss. Accelerated recovery reflects reduced surgical insult and preserved physiologic reserve[18,19], consistent with the meta-analysis by Booka et al[20] showing that laparoscopic gastric mobilization combined with thoracoscopic esophagectomy significantly lowers pulmonary morbidity and facilitates early recovery.

Repeated-measures analysis revealed that patients undergoing VATS experienced lower VAS pain scores, as well as reduced CRP and IL-6 levels at every observation point than the open surgery group (all interactions, P < 0.05), indicating both subjective and objective attenuation of surgical stress. Akimoto et al[21] observed higher postoperative oxygenation indices and milder inflammatory responses after VATS, which paralleled our CRP and IL-6 data. Smaller incisions and reduced chest wall retraction lessen neural and muscular damage, and decrease pain and neurohumoral stress, thereby stabilizing systemic homeostasis[22,23].

The overall complication rate was significantly lower and the 1-month EORTC QLQ-C30 scores for global health, physical functioning, and role functioning were significantly higher in the VATS group, confirming that MIE reduces morbidity and improves quality of life. Fewer complications translate into fewer additional treatments and a faster reintegration into daily life[24,25]. Using a nationwide Japanese database, Takeuchi et al[26] found that thoracoscopic esophagectomy with laparoscopic gastric mobilization did not increase pulmonary complications; rather, smaller wounds and reduced pain conferred advantages for complication control. Superior QLQ-C30 scores reflect better physical and psychosocial recovery, facilitating return to societal roles[27-29]. Similarly, Goto et al[30] reported that VATS was associated with better long-term quality of life, particularly in the physical and social domains, offering a more humane therapeutic option.

Although this study demonstrated the significant advantages of thoracoscopic esophagectomy in terms of perioperative recovery, postoperative morbidity, inflammatory response, and short-term quality of life, its influence on long-term oncological outcomes requires further consideration. Overall survival, disease-free survival, and local recurrence are critical endpoints for evaluating the overall efficacy of minimally invasive esophagectomies. Evidence from prospective studies and large-scale analyses suggests that thoracoscopic or MIE can achieve long-term oncological outcomes comparable to those of open surgery when oncological principles, including adequate lymph node dissection and radical tumor resection, are strictly followed. Nevertheless, the present study primarily focused on short-term outcomes, and long-term survival and recurrence data were not comprehensively analyzed owing to the limited follow-up duration and sample size. Therefore, definitive conclusions regarding the long-term oncological efficacy cannot be drawn from our cohort. All patients underwent standardized long-term follow-up according to institutional protocols, and future analyses based on extended follow-up and multicenter prospective randomized studies are warranted to further clarify the long-term oncological value of thoracoscopic esophagectomy.

This study had some limitations that warrant careful consideration when interpreting the results. First, as a single-center retrospective study, the choice of surgical approach was not randomly assigned but was determined by the surgical team based on multiple factors within clinical practice, potentially introducing a selection bias. Although no statistically significant differences were observed between the groups in terms of baseline characteristics (age, sex, body mass index, and clinical stage), the influence of potential confounding factors cannot be entirely ruled out. For instance, the choice of open thoracotomy for some patients may have been influenced by tumor location or extent of local invasion, tumor stage, prior thoracoabdominal surgery history, cardiopulmonary function status, degree of pleural adhesions, or the surgeon’s subjective assessment of surgical safety and technical feasibility. These factors are challenging to quantify and to adjust for in retrospective analyses. Second, although all procedures were performed by the same experienced surgical team, thereby minimizing operator variability, the implementation of different surgical approaches inevitably reflects learning curves and technical proficiency. This may also interfere with perioperative outcomes. Moreover, the relatively small sample size and short follow-up period, primarily focusing on short-term efficacy, precludes a comprehensive comparison of the two approaches regarding long-term survival, tumor recurrence, and long-term quality of life. Given these limitations, future multicenter, large-sample, prospective, randomized controlled trials are warranted. Stricter randomization of surgical approaches, standardized control of tumor characteristics, patient functional status, and perioperative management should be employed to further validate the safety, efficacy, and long-term benefits of thoracoscopic esophagectomy.

CONCLUSION

Thoracoscopic esophagectomy combined with laparoscopic gastric mobilization and tubular stomach reconstruction is associated with reduced intraoperative bleeding, faster postoperative recovery, fewer complications, diminished pain and inflammatory responses, and an improved quality of life. This minimally invasive strategy merits a wider adoption.