Single-incision versus multi-incision minimally invasive esophagectomy with different reconstruction routes for esophageal cancer: a retrospective propensity-weighted analysis

Introduction

Esophageal cancer remains one of the most challenging malignancies in the world, and due to its substantial morbidity and mortality, optimal surgical strategies are required for resectable cases (1). The progression from open esophagectomy to minimally invasive techniques has fundamentally transformed perioperative outcomes, with minimally invasive esophagectomy (MIE) now established as the preferred approach for most patients (2,3). However, within the rapidly evolving landscape of minimally invasive surgery, significant variation exists in both surgical access strategies and reconstruction pathways, generating an array of technical combinations with potentially different clinical implications.

Uniportal video-assisted thoracic surgery (VATS) represents a paradigm shift from conventional multiport thoracoscopy, as it can concentrate chest wall trauma to a single 3–4 cm intercostal incision, which is in contrast to ports at multiple sites (4,5), theoretically minimizing intercostal nerve damage and neuralgia. Recent evidence demonstrates that uniportal VATS significantly reduces postoperative complications (28.8% vs. 10.1%) and pneumonia rates (23.2% vs. 7.3%) compared with multiport approaches (6), while achieving superior pain control with lower visual analog scale (VAS) scores throughout the first postoperative week and reduced analgesic requirements (7). Moreover, the concentration of thoracic wall trauma allows for better preservation of intercostal muscle integrity and reduced inflammatory response, contributing to enhanced recovery kinetics (8). Similarly, single-port laparoscopy via a solitary umbilical incision, as opposed to traditional five-port approaches (9,10), has demonstrated reduced postoperative pain, accelerated recovery, and improved cosmetic outcomes while maintaining oncological adequacy (11). The integration of enhanced recovery protocols with single-port techniques has further emphasized the benefits of minimizing access trauma in complex abdominal procedures (12).

The choice of the reconstruction pathway for esophagectomy introduces additional complexity to surgical decision-making, as it bears significant anatomical and physiological implications. Retrosternal reconstruction provides the most direct conduit pathway and a shorter anatomical distance as compared to posterior mediastinal reconstruction, potentially reducing cardiac and pulmonary complications during anastomosis (13,14). Recent studies suggest that retrosternal reconstruction offers superior respiratory function preservation and reduced anastomotic stricture rates than do posterior mediastinal approaches (15), whereas posterior mediastinal reconstruction, despite following natural anatomy, requires greater conduit length and may increase anastomotic tension, particularly following extensive lymphadenectomy (16,17). The integration of uniportal VATS with single-port laparoscopy and retrosternal reconstruction represents a unified minimalist strategy that concentrates operative trauma to minimal access points, theoretically optimizing inflammatory response modulation and preserving thoracoabdominal wall integrity (18)—critical considerations for the elderly population predominantly affected by esophageal cancer (19,20). However, comprehensive comparative evidence between these integrated strategies remains fragmented across small series and single-center experiences, necessitating systematic analysis of critical perioperative endpoints including pneumonia, pain trajectories, pulmonary function recovery, gastric emptying, and functional restoration to inform evidence-based surgical decision-making.

The aim of this study was thus to conduct a comprehensive propensity score (PS)—matched retrospective analysis comparing single-incision laparo-thoracoscopic MIE with retrosternal reconstruction (SIMIE-RS) to multi-incision MIE with posterior mediastinal reconstruction (MIMIE-PM) in the treatment of esophageal cancer. By focusing specifically on perioperative and short-term functional outcomes, this investigation provides targeted evidence for optimizing integrated surgical strategies in contemporary esophageal cancer care. The study’s methodological rigor, innovative approach, and technical evaluation can provide high-quality evidence for clinical decision-making in the era of personalized surgical medicine, ultimately contributing to improved patient outcomes and enhanced recovery pathways in esophageal cancer surgery. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2317/rc).

Methods

Study design and patients

A retrospective cohort study was performed at the Department of Thoracic Oncology Surgery of Fujian Cancer Hospital from January 2018 to December 2024. This study was approved by the Ethics Committee of Fujian Cancer Hospital (approval No. SQ2024-020). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all patients.

The inclusion criteria were as follows: (I) age 18–75 years; (II) histopathologically confirmed esophageal cancer; (III) Eastern Cooperative Oncology Group (ECOG) performance status 0–1; (IV) adequate cardiopulmonary function; (V) completion of curative McKeown esophagectomy; and (VI) availability of complete clinicopathological data. Meanwhile, the exclusion criteria were as follows: (I) incomplete medical records; (II) concurrent malignancies; (III) distant metastases; (IV) conversion to open surgery; and (V) previous esophageal or gastric surgery.

Surgical approaches

All surgical procedures were carried out by the same experienced surgical team. The choice of surgical approach was determined according to surgeon’s preference and patient’s characteristics after multidisciplinary team discussion. All patients underwent McKeown esophagectomy. At our institution, the McKeown procedure was selected as the routine surgical approach for patients with resectable esophageal cancer involving the upper, middle, or lower thoracic esophagus who had adequate cardiopulmonary reserve and no distant metastases. This three-field approach enables comprehensive lymphadenectomy and cervical anastomosis, which facilitates safer management of potential anastomotic complications.

Procedure for MIMIE-PM

MIMIE-PM was performed as described in a previous study (21). Briefly, four thoracoscopic ports were established, and five laparoscopic ports were used for abdominal mobilization. The gastric conduit was positioned through the posterior mediastinal route via the original esophageal bed.

Procedure for SIMIE-RS

During SIMIE-RS, patients were placed in left lateral decubitus for the thoracic segment. A 4–5 cm utility incision was made at the fifth intercostal space on the anterior axillary line. All thoracoscopic procedures were implemented via this single access. For the abdominal segment, patients were repositioned supine with a single transumbilical incision (3–4 cm) created via a single-port access device. The gastric conduit was constructed following standard surgical protocols. The retrosternal tunnel was carefully formed under direct laparoscopic visualization through careful blunt dissection between the posterior aspect of the sternum and pericardium.

Cervical phase

In both groups, a 4–5 cm transverse incision was created along the anterior border of the right sternocleidomastoid muscle. The cervical esophagus was gently mobilized, with meticulous preservation of the recurrent laryngeal nerves. End-to-side esophagogastric anastomosis was performed via a circular stapler.

Data collection and definitions

Comprehensive perioperative data were collected, including patient demographics, tumor characteristics, operative details, and postoperative outcomes. The eighth edition of the American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system was employed. Postoperative complications were defined according to the Esophagectomy Complications Consensus Group criteria and graded using the Clavien-Dindo classification system. Functional outcomes included VAS-determined pain scores, oxygen saturation levels, reflux symptoms, and cosmetic satisfaction scores at follow-up.

Statistical analysis

Continuous variables were presented as mean ± standard deviation (SD). After confirming approximate normal distribution using Shapiro-Wilk tests and visual inspection, differences between groups were assessed using Student’s t-test for independent samples. Categorical variables are expressed as frequency and were analyzed with the Fisher’s exact test. Patient characteristics between the SIMIE-RS and MIMIE-PM groups were balanced via inverse probability of the treatment weighting (IPTW) based on a PS. The PS was estimated via logistic regression, which included the following covariates: age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, ECOG performance status, primary tumor location, clinical T and N categories, clinical TNM stage, and comorbidities. Statistical significance was set at P<0.05. All analyses were performed with R software version 4.2.0 (The R Foundation for Statistical Computing).

Results

Patient characteristics

The baseline characteristics of patients are summarized in Table 1. Among the initially included patients, 339 underwent McKeown esophagectomy, with 231 patients treated with MIMIE-PM and 108 with SIMIE-RS. Prior to IPTW adjustment, the SIMIE-RS group had a significantly higher proportion of older patients (P=0.048), while the MIMIE-PM group had a significantly greater proportion of females (P=0.004). There were no significant differences between groups in terms of BMI, ASA grade, ECOG performance status, preoperative pulmonary function, primary tumor location, clinical T and N categories, clinical TNM stage, or comorbidities.

After IPTW adjustment, there were 201 patients in the MIMIE-PM group and 105 in the SIMIE-RS group, with the patient characteristics being well-balanced between the two groups.

Perioperative and functional outcomes

There were both similarities and differences between two groups in terms of perioperative outcomes (Table 2). Operative efficiency remained comparable between the MIMIE-PM and SIMIE-RS groups, with no significant difference in total operative time (207.0±38.3 vs. 206.8±28.6 min; P=0.96) or intraoperative blood loss (68.6±15.1 vs. 70.1±15.5 mL; P=0.41), indicating similar procedural safety profiles.

In contrast, notable differences emerged in postoperative recovery parameters. Patients undergoing SIMIE-RS, as compared to those subjected to MIMIE-PM, demonstrated significantly lower VAS pain scores at both 24 hours (3.1±1.0 vs. 7.5±1.1; P<0.001) and 72 hours post-surgery (1.6±1.1 vs. 3.3±1.2; P<0.001), as well as significantly higher incision aesthetic scores (8.2±1.3 vs. 5.4±1.3; P<0.001). Early postoperative respiratory function, as measured by oxygen saturation on postoperative day 1, was significantly better preserved in the SIMIE-RS group than in the MIMIE-PM group (94.5%±1.3% vs. 93.4%±1.6%; P=0.005), although this difference was not apparent by postoperative day 7 (96.1%±1.4% vs. 95.9%±1.9%; P=0.34). Drainage analyses revealed significantly reduced volumes in the SIMIE-RS group as compared to MIMIE-PM group for both chest tube output (256.2±111.8 vs. 440.2±80.9 mL; P<0.001) and nasogastric drainage (681.2±31.9 vs. 917.1±25.2 mL; P<0.001). Oncological adequacy was maintained between the SIMIE-RS group and MIMIE-PM groups, with comparable total lymph node harvest (33±11.1 vs. 32.1±12.2; P=0.53) and similar yields from the thoracic (17.5±6.0 vs. 16.7±4.2; P=0.23) and abdominal (16.1±2.0 vs. 15.8±2.2; P=0.24) compartments. The combined benefits of reduced pain and improved early recovery translated into a significantly shorter postoperative hospital stay for patients treated with SIMIE-RS (7.0±1.6 vs. 9.7±1.5 days; P<0.001).

Postoperative complications

As shown in Table 3, pulmonary complications differed between the two surgical approaches. The pneumonia rate in the SIMIE-RS group was lower than that in the MIMIE-PM group (0.9% vs. 5.5%; P=0.02), while the pulmonary embolism rate was similar (0% vs. 0.5%; P=0.66).

There were both similarities and differences between the two groups in terms of surgery-related complications. The incidence of anastomotic leakage in the SIMIE-RS group was lower than that in the MIMIE-PM group, but not significantly (2.8% vs. 5.0%; P=0.55); the incidence of recurrent nerve paralysis was nearly identical between the two groups (0.9% vs. 1.0%, P>0.99); and the incidence of chylothorax in the SIMIE-RS group was lower than that in the MIMIE-PM group, but not significantly so (0.9% vs. 1.5%; P=0.66).

Functional outcomes demonstrated differences between the two groups. The forced expiratory volume in 1 second (FEV₁) at 1 month in the SIMIE-RS group was higher than that in the MIMIE-PM group (3.2±0.5 vs. 2.4±0.6; P<0.001), while the reflux symptom scores in the SIMIE-RS group were lower than those in the MIMIE-PM group (1.2±0.5 vs. 1.8±0.9; P<0.001).

Discussion

The persistent challenge of optimizing surgical outcomes in esophageal cancer has driven continuous innovation in minimally invasive techniques, with emerging evidence supporting the superiority of integrated minimalist approaches (1,2). Building upon the established benefits of MIE over open surgery, contemporary research has focused on refining specific technical combinations to maximize perioperative advantages while maintaining oncological integrity (3).

This study represents the first comprehensive analysis comparing SIMIE-RS with MIMIE-PM in esophageal cancer. The methodological rigor lies in the use of IPTW in cohort allocation, which effectively balanced the baseline characteristics, including age, comorbidities, and tumor staging, between the two groups, thereby minimizing selection bias and strengthening the validity of comparative outcomes. Our findings demonstrate that SIMIE-RS achieves superior perioperative safety profiles with significantly reduced pulmonary complications compared to MIMIE-PM, for instance, providing a lower incidence of pneumonia (0.9% vs. 5.5%; P=0.02). Furthermore, functional recovery parameters strongly favored the SIMIE-RS approach, with patients demonstrating superior lung function preservation at 1 month postoperatively (3.2±0.5 vs. 2.4±0.6; P<0.001) and significantly reduced reflux symptomatology (1.2±0.5 vs. 1.8±0.9; P<0.001) compared to their MIMIE-PM counterparts. Importantly, the safety profiles between the SIMIE-RS with MIMIE-PM groups were comparable, including in terms of surgery-related complications such as 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), confirming that SIMIE-RS maintains surgical quality while providing enhanced recovery benefits.

The significant reduction in pulmonary complications observed with SIMIE-RS aligns with established evidence supporting uniportal approaches over multiportal techniques. Xiao et al. reported that uniportal VATS, as compared to multiportal approaches, had a lower incidence of mild postoperative complications (28.8% vs. 10.1%) and pneumonia (23.2% vs. 7.3%) (6), which is in line with our finding of reduced pulmonary morbidity with a concentrated thoracic access. The chest wall trauma being confined to a single 3–4 cm incision theoretically minimizes intercostal nerve damage and preserves respiratory muscle function as compared to multiport techniques requiring four separate thoracoscopic ports (4,5). Our results demonstrate this concept practically, with the SIMIE-RS group achieving superior oxygen saturation at postoperative day 1 compared to the MIMIE-PM group (94.5%±1.3% vs. 93.4%±1.6%; P=0.005), in addition to substantially reduced chest tube drainage volume (256.2±111.8 vs. 440.2±80.9 mL; P<0.001). The superior postoperative pain control inherent to single-incision techniques was also evident in our analysis, with the SIMIE-RS group exhibiting significantly lower VAS 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), facilitating improved sputum clearance and early mobilization (7).

The advantages of retrosternal reconstruction were evident in our data for functional outcomes. The superior FEV₁ preservation in SIMIE-RS is in line with previous findings reported by Kikuchi et al., who found that retrosternal reconstruction resulted in better respiratory function preservation than did posterior mediastinal reconstruction (15). The retrosternal pathway provides the most direct conduit route and shorter anatomical distance, reducing conduit tension and minimizing compression of surrounding thoracic structures (13,14). This pathway avoids traversal of the posterior mediastinum, which requires greater conduit mobilization and may compromise pulmonary function through mechanical compression (16,17). The reduced reflux symptom scores in the SIMIE-RS group further support the physiological advantages of retrosternal reconstruction, which can be attributed to improved gastric conduit positioning and reduced anatomical disruption. Additionally, the significantly reduced nasogastric tube drainage volume in the SIMIE-RS group as compared to the MIMIE-PM group (681.2±31.9 vs. 917.1±25.2 mL; P<0.001) suggests improved gastric function and faster gastrointestinal recovery.

SIMIE-RS also demonstrated more favorable perioperative outcomes and comparable operative complexity to that of MIMIE-PM. The total operative time was not significantly different between the SIMIE-RS and MIMIE-PM groups (206.8±28.6 vs. 207.0±38.3 min; P=0.96), indicating that surgeons performing SIMIE-RS have overcome the initial learning curve in technical proficiency associated with single-incision approaches (22). This was accompanied by comparable intraoperative blood loss (70.1±15.5 vs. 68.6±15.1 mL; P=0.41), confirming that SIMIE-RS maintains surgical safety while providing enhanced recovery benefits. The reduced postoperative hospital stays (7.0±1.6 vs. 9.7±1.5 days; P<0.001) and improved incision aesthetic scores (8.2±1.3 vs. 5.4±1.3; P<0.001) of SIMIE-RS reflect the combined advantages of minimized access trauma and optimized reconstruction pathways (18).

As indicated by the lymph node yield, SIMIE-RS maintained oncological adequacy without compromising surgical quality. The total lymph node count, thoracic lymph nodes, and abdominal lymph nodes showed no significant differences between the two groups, confirming that this technical innovation does not compromise fundamental oncological outcomes. These findings align with recent evidence suggesting that minimally invasive techniques can achieve adequate lymphadenectomy while providing superior perioperative outcomes (23,24).

The comparable rates of surgery-related complications between the two groups are particularly encouraging for the widespread adoption of SIMIE-RS. The incidence of anastomotic leakage, recurrent laryngeal nerve paralysis, and chylothorax was not significantly different, confirming that technical innovation does not compromise fundamental surgical safety. These complication rates align with contemporary benchmarks established by international consensus groups (25), suggesting that both techniques maintain acceptable safety standards but that SIMIE-RS provides additional recovery advantages. The attainment of surgical quality despite the technical complexity involved supports the feasibility of single-incision approaches in centers with the requisite experience.

Several limitations to this study should be acknowledged. First, as we employed a retrospective design, no conclusions regarding causality can be made despite PS matching being performed. Specifically, the surgical approach was determined by surgeon preference and patient characteristics following multidisciplinary discussion. Although we balanced measured covariates, unmeasured confounders related to surgeon judgment—including perceived technical complexity, subtle anatomical variations, or patient frailty indicators not captured in our variables—may have influenced treatment allocation and outcomes. This limitation is intrinsic to non-randomized comparative studies and cannot be fully addressed through statistical adjustment alone. Second, SIMIE-RS was performed in a single center, reducing the generalizability of our findings, as technical proficiency significantly influences outcomes in complex minimally invasive procedures (26). Third, the study population primarily comprised patients with early-to-intermediate stage tumors, potentially limiting applicability to locally advanced cases requiring extensive lymphadenectomy. Recent evidence suggests that minimally invasive approaches may provide particular advantages in locally advanced disease (27), warranting future investigation of SIMIE-RS in this population. Fourth, for comprehensive comparative effectiveness to be established for long-term functional outcomes and oncological results, extended follow-up is required. Finally, the learning curve associated with SIMIE-RS might have influenced the outcomes, although our results represent mature surgical experience with standardized techniques.

The clinical implications of our findings are substantial for contemporary esophageal cancer care. SIMIE-RS represents an evolution toward a truly minimalist surgical philosophy, concentrating operative trauma to the fewest possible access points while optimizing reconstruction pathways (18). The significant improvements in pulmonary complications, functional recovery, pain control, and hospital length of stay, combined with the surgical safety and oncological adequacy, support broader adoption of this integrated approach. Moreover, the reduced postoperative pain scores and faster recovery kinetics align with enhanced recovery protocols and value-based healthcare initiatives (28). For carefully selected patients with resectable esophageal cancer, SIMIE-RS offers a compelling alternative to conventional multiport approaches, particularly in centers with established expertise in both single-incision laparoscopy and uniportal thoracoscopy.

Future research should include multi-institutional validation studies to establish a broader applicability across different surgical teams and patient populations. Randomized controlled trials comparing SIMIE-RS to standard approaches would provide definitive evidence for clinical decision-making. Long-term oncological outcomes, including survival and recurrence patterns, require systematic evaluation to confirm that the functional advantages do not compromise cancer control (29,30). Additionally, cost-effectiveness analyses examining hospital stays, complication rates, and resource utilization would inform healthcare policy and adoption strategies. Finally, examining the value of SIMIE-RS in patients with locally advanced esophageal cancer and those receiving neoadjuvant therapy may help expand the applicability of this innovative approach (31).

Conclusions

In conclusion, SIMIE-RS yielded superior perioperative outcomes as compared to MIMIE-PM. The significant reductions in pulmonary complications, improved functional recovery, enhanced pain control, and relative surgical safety support SIMIE-RS as an innovative option in esophageal cancer surgery. Our study provides valuable evidence for optimizing surgical strategies in the era of personalized and precision medicine, ultimately advancing patient care and outcomes in contemporary esophageal cancer treatment.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2317/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2317/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2317/prf

Funding: This work received funding from the Medical Innovation Project of Fujian Province (Nos. 2024Y9633 and 2024Y9632).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-aw-2317/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Ethics Committee of Fujian Cancer Hospital (approval No. SQ2024-020). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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