Single-port compared to multi-port video-assisted thoracoscopic esophagectomy: a propensity-matched study
Highlight box
Key findings
• The single-port video-assisted thoracoscopic esophagectomy demonstrated superior incision aesthetics, reduced pain, and shortened average hospitalization time compared to multi-port video-assisted thoracoscopic surgery (VATS). Briefly, the single-port video-assisted thoracoscopic esophagectomy is worthy of further promotion.
What is known and what is new?
• Compared with open surgery, minimally invasive esophagectomy (MIE) has advantages of a smaller surgical incision, better postoperative prognosis, a significantly reduced bleeding volume, and a lower incidence of postoperative complications.
• Compared to the multi-port thoracoscopic method, the single-port method requires fewer incisions, reducing intraoperative bleeding and postoperative pain for surgical patients.
What is the implication, and what should change now?
• For the thoracoscopic portion of esophageal cancer surgery, single-port thoracoscopic surgery is recommended.
Introduction
Esophageal cancer is the 7th most common malignancy with an incidence of 604,000 new cases each year (1). The incidence of esophageal cancer in East Asia is much higher than that in other regions (1). In China, esophageal cancer is the sixth most common cancer and represents 53.7% of the total number of esophageal cancer cases worldwide with 324,000 new cases each year (1,2). Despite the advances in chemotherapy, immunotherapy, and target therapy achieved in recent years, surgical resection including McKeown and Ivor-Lewis procedures remains the main treatment with curative intent for esophageal cancer. Compared with Ivor-Lewis surgery, McKeown procedure is associated with a lower recurrence rate for three-field lymph node dissection in the abdomen, chest, and neck (3). However, the systemic inflammatory response syndrome (SIRS) caused by surgical trauma after esophagectomy may lead to complications such as infection and organ failure (4). With the development of minimally invasive surgery (MIS), the surgical treatment of esophageal cancer has evolved from open to minimally invasive esophagectomy (MIE). Compared with open surgery, MIE is associated with a less surgical trauma and thus a significant reduction of postoperative morbidity and mortality, better aesthetic outcomes, yet with similar oncological results (5-8).
Thoracoscopic esophagectomy may be performed using a multi-port or a single-port approach. In theory, surgery through a single incision is less painful as only one intercostal nerve is injured, however the real advantage of single-port esophagectomy vs. multi-port esophagectomy is still under debate. Thus, to provide further evidence on this issue, we compared the surgical outcomes of patients undergoing single-port thoracoscopic McKeown esophagectomy with a control group to assess whether single-port esophagectomy presents significant clinical advantages compared to multi-port esophagectomy. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-196/rc).
Methods
Study design
It was a single-center retrospective study including all consecutive patients who underwent MIE with single-port or multi-port thoracoscopy at Fujian Cancer Hospital from January 2018 to December 2022. The clinical data of the following patients were included in the analysis: (I) patients with pathological diagnosis of squamous cell carcinoma; (II) patients underwent single-port or multi-port thoracoscopic MIE; and (III) patients with complete resection (R0). We excluded the clinical data of the following patients: (I) patients underwent administration of neoadjuvant immunotherapy, radiotherapy, or chemotherapy; (II) patients with a history of chest or abdominal surgery; and (III) patients with incomplete data.
Patients were divided into two groups based whether single-port (single-port group) or multi-port thoracoscopic esophagectomy (multi-port group) was performed. The two groups were statistically compared regarding perioperative, postoperative outcomes, pain control, and aesthetic results to assess whether the single-port group presents significant advantages compared to the multi-port group.
This study was approved by the Ethical Committee of Fujian Cancer Hospital (No. SQ2024-018) and was performed in accordance with the Declaration of Helsinki (as revised in 2013). All patients provided written informed consent to participate in this study.
Surgical methods
Both groups of patients underwent surgery, first of the chest and then of the abdomen and neck. Surgery included intravenous combined general anesthesia; the single-port group used double-lumen tracheal intubation and left lung ventilation during thoracoscopic surgery. The multi-port procedure included single-lumen tracheal intubation and artificial pneumothorax. Bilateral lung ventilation was used during abdominal surgery in both groups, and intravenous pump analgesia was used after surgery in both groups.
Single-port and multi-port thoracoscopy and McKeown radical esophagectomy
The surgical procedures of thoracic surgery and abdominal surgery were conducted according to a previous study (9) and were reported here with some modifications. Briefly, the patient was placed in left lateral decubitus position, with both upper limbs lifted, and ventilated in one lung on the left side (Figure 1A). A 3- to 4-cm incision was made in the fourth intercostal space between right axillary midline and posterior axillary line. A 10-mm thoracoscope was placed on the dorsal side of the incision, and a single-port lung surgical instrument was used for thoracic surgery (Figure 1B). The azygos vein was cut off with Endo GIA Staplers (model No. GST45W; Ethicon Endo-Surgery, Chihuahua, Mexico). The esophagus was pulled forward, and infracarinal lymph nodes and the left paralaryngeal recurrent nerve lymph nodes were cleaned (Figure 1C). A thoracic drainage tube was placed on the dorsal side of the incision, and a fine drainage tube was placed in the 7th intercostal space of the axillary midline, and the incision was sutured (Figure 1D).
The surgical procedures of thoracic surgery and abdominal surgery were also performed as described in a previous study (9).
Neck surgery
The neck surgery was performed in the same manner for both groups. A 3- to 4-cm incision was made at the inner edge of the sternocleidomastoid muscle of the left neck, the cervical esophagus was freed, the esophagus was cut off after purse-string suture, staplers were placed against the base at the proximal end. The stomach and thoracoabdominal esophagus were pulled out of the body along the abdominal incision, and a tubular stomach (2–3 cm wide) was made along the greater curvature of stomach with a linear cutting closure device to remove the tumor. The tubular stomach was pulled to the neck through the abdominal esophageal bed. The proximal stump of the esophagus was anastomosed with a tubular stapler, and then the neck incision was sutured.
Clinical variables
Baseline characteristics of patients were evaluated, including gender, age, body mass index (BMI), tumor location, and tumor stage. Surgery-related indices were also determined, including total operation time, thoracoscopic operation time, bleeding volume, postoperative drainage volume, postoperative drainage time, postoperative hospitalization time, postoperative visual analogue scale (VAS) of pain 1 day after operation, postoperative VAS score 7 days after operation, incision aesthetic score, number of thoracic lymph node dissections, number of lymph node sorting groups, and postoperative complications.
Statistical analysis
Data were expressed as mean ± standard deviation (SD) for continuous variables or absolute number and percentage for categorical variables. Fisher’s exact test or Chi-squared and Student t-test were used to compare categorical variables and continuous variables, respectively.
To reduce the inter-group difference due to the retrospective nature of the study, gender, age, BMI, Eastern Cooperative Oncology Group (ECOG) score, tumor location, pathological T stage, and pathological N stage were propensity score-matched, and confounding factors other than surgical methods were removed.
A P value <0.05 indicated a statistically significant difference. SPSS 26.0 software (IBM Corp., Armonk, NY, USA) was used for the analysis.
Results
Basic characteristics of patients
Our study population included 443 patients: with 224 in the single-port group and 219 in the multi-port group. There were no significant differences in gender, age, BMI, ECOG score, tumor location, pathological T stage, and tumor-node-metastasis (TNM) stage between the two study groups, except for pathological N stage (Table 1).
Table 1
| Variables | Single-port (n=224) | Multi-port (n=219) | t | P |
|---|---|---|---|---|
| Gender | 0.217 | 0.64 | ||
| Male | 162 | 154 | ||
| Female | 62 | 65 | ||
| Age (years) | 62.3±8.0 | 61.2±7.1 | 1.529 | 0.13 |
| BMI (kg/m2) | 21.8±2.4 | 22.1±2.5 | −1.492 | 0.14 |
| ASA score (anesthesia grade) | 0.09±0.29 | 0.11±0.31 | −3.960 | 0.69 |
| ECOG score | 0.70±0.70 | 0.64±0.64 | 0.964 | 0.34 |
| Tumor location | 4.447 | >0.99 | ||
| Upper | 20 | 30 | ||
| Middle | 130 | 133 | ||
| Lower | 74 | 56 | ||
| Pathological T stage | 4.671 | 0.19 | ||
| 0 | 2 | 2 | ||
| 1 | 46 | 57 | ||
| 2 | 39 | 48 | ||
| 3 | 137 | 112 | ||
| Pathological N stage | 7.960 | 0.047 | ||
| 0 | 118 | 136 | ||
| 1 | 50 | 50 | ||
| 2 | 41 | 27 | ||
| 3 | 15 | 6 | ||
| TNM staging | 8.256 | 0.07 | ||
| 0 | 2 | 1 | ||
| I | 41 | 52 | ||
| II | 91 | 102 | ||
| III | 75 | 58 | ||
| IVA | 15 | 6 |
Data are presented as number or mean ± SD. ASA, American Society of Anesthesiologists; BMI, body mass index; ECOG, Eastern Cooperative Oncology Group; SD, standard deviation; TNM, tumor-node-metastasis.
After propensity score matching, a total of 181 patients with single-port thoracoscopy and 181 patients with multi-port thoracoscopy were included. There were no significant differences in the baseline characteristics between patients in the two groups (Table 2).
Table 2
| Variables | Single-port (n=181) | Multi-port (n=181) | t | P |
|---|---|---|---|---|
| Gender | 0.013 | >0.99 | ||
| Male | 127 | 128 | ||
| Female | 54 | 53 | ||
| Age (years) | 62.1±8.1 | 61.7±7.1 | 0.418 | 0.68 |
| BMI (kg/m2) | 21.92±2.35 | 22.10±2.50 | −0.706 | 0.48 |
| ASA score (anesthesia grade) | 0.10±0.30 | 0.09±0.29 | 0.177 | 0.86 |
| ECOG score | 0.63±0.65 | 0.68±0.65 | −0.647 | 0.52 |
| Tumor location | 0.724 | 0.71 | ||
| Upper | 18 | 23 | ||
| Middle | 111 | 106 | ||
| Lower | 52 | 52 | ||
| Pathological T stage | 0.893 | 0.83 | ||
| 0 | 2 | 1 | ||
| 1 | 43 | 38 | ||
| 2 | 36 | 39 | ||
| 3 | 100 | 103 | ||
| Pathological N stage | 0.622 | 0.89 | ||
| 0 | 109 | 104 | ||
| 1 | 41 | 44 | ||
| 2 | 27 | 27 | ||
| 3 | 4 | 6 | ||
| TNM staging | 2.683 | 0.64 | ||
| 0 | 2 | 0 | ||
| I | 39 | 33 | ||
| II | 83 | 86 | ||
| III | 53 | 56 | ||
| IVA | 4 | 6 |
Data are presented as number or mean ± SD. ASA, American Society of Anesthesiologists; BMI, body mass index; ECOG, Eastern Cooperative Oncology Group; SD, standard deviation; TNM, tumor-node-metastasis.
Perioperative and postoperative outcomes
The data are summarized in Tables 3,4. Before propensity score matching (Table 3), the single-port group compared to the multi-port group presented a significant reduction of hospitalization (8.1±1.9 vs. 10.1±2.0 days, P<0.001), while no significant differences were found regarding operative time bleeding volume, and thoracic lymph node dissection.
Table 3
| Variables | Single-port (n=224) | Multi-port (n=219) | t | P |
|---|---|---|---|---|
| Thoracoscopic operation time (min) | 63.2±10.9 | 65.5±15.0 | −1.821 | 0.07 |
| Surgical time (min) | 209.8±27.5 | 240.0±46.8 | −8.242 | <0.001 |
| Bleeding volume (mL) | 71.3±15.3 | 73.2±14.8 | −1.313 | 0.19 |
| Thoracic lymph node dissections (number) | 17.4±6.0 | 16.7±3.9 | 1.538 | 0.13 |
| Lymph node sorting groups (station) | 1.77±2.49 | 1.15±1.96 | 2.898 | 0.004 |
| Postoperative drainage volume (mL) | 346.2±140.0 | 439.1±81.7 | −8.564 | <0.001 |
| Postoperative drainage time (days) | 3.7±1.7 | 4.2±1.5 | −3.817 | <0.001 |
| Postoperative hospitalization time (days) | 8.1±1.9 | 10.1±2.0 | −11.148 | <0.001 |
| VAS score 1 day after surgery | 4.19±1.29 | 7.59±1.09 | −29.969 | <0.001 |
| VAS score 7 days after surgery | 2.08±1.03 | 3.25±1.14 | −11.366 | <0.001 |
| Incision aesthetic score | 7.9±0.8 | 6.0±1.4 | 17.569 | <0.001 |
Data are presented as mean ± SD. SD, standard deviation; VAS, visual analogue scale.
Table 4
| Variables | Single-port (n=181) | Multi-port (n=181) | t | P |
|---|---|---|---|---|
| Thoracoscopic operation time (min) | 62.69±11.07 | 64.59±14.98 | −1.369 | 0.17 |
| Surgical time (min) | 208.72±28.56 | 233.90±46.74 | −6.183 | <0.001 |
| Bleeding volume (mL) | 71.13±15.38 | 73.04±14.52 | −1.212 | 0.23 |
| Thoracic lymph node dissections (number) | 17.53±6.037 | 16.65±3.97 | 1.646 | 0.10 |
| Lymph node sorting groups (station) | 1.19±2.00 | 1.33±2.10 | −0.668 | 0.51 |
| Postoperative drainage volume (mL) | 341.00±135.89 | 438.96±81.41 | −8.32 | <0.001 |
| Postoperative drainage time (days) | 3.65±1.78 | 4.15±1.23 | −3.089 | 0.002 |
| Postoperative hospitalization time (days) | 8.09±2.02 | 10.01±1.74 | −9.674 | <0.001 |
| VAS score 1 day after surgery | 4.18±1.24 | 7.66±1.08 | −28.344 | <0.001 |
| VAS score 7 days after surgery | 2.03±1.00 | 3.31±1.15 | −11.322 | <0.001 |
| Incision aesthetic score | 7.90±0.83 | 5.99±1.41 | 15.651 | <0.001 |
Data are presented as mean ± SD. SD, standard deviation; VAS, visual analogue scale.
After propensity score matching (Table 4), operation time was similar between the two groups (P=0.17), while the single-port group presented a significant shorter surgical time than the multi-port group (208.72±28.56 vs. 233.90±46.74 min, P<0.001). No significant differences were found regarding the number of thoracic lymph node dissections (P=0.10; Table 4) nor sorting groups (P=0.51). The intraoperative bleeding volume in the single-port group (71.13±15.38 mL) was lower than that in the multi-port group (73.04 ±14.52 mL) but it did not reach significant difference (P=0.23). Compared to the multi-port group, the single-port group was associated with a significant reduction of postoperative drainage volume (341.00±135.89 vs. 438.96±81.41 mL, P<0.001), length of drainage stay (3.65±1.78 vs. 4.15±1.23 days, P=0.002), and length of hospital stay (8.09±2.02 vs. 10.01±1.74 days, P=0.001).
Postoperative pain and aesthetics outcomes
Before and after matching analysis, the single-port group compared to the multi-port group was associated with better pain control on the 1st postoperative day (P<0.001) and on the 7th postoperative day (P<0.001) and with better aesthetic results (P<0.001).
Postoperative morbidity and mortality
The data are summarized in Table 5. The incidence of postoperative complications reached no statistical difference between the two study groups before (P=0.84) and after propensity score matching analysis (P=0.93), Pneumonia was the main complication observed in nine cases of the single-port group and in 11 cases of the multi-port group while anastomotic leakage was observed in two cases in both the single-port and the multi-port groups.
Table 5
| Variables | Before propensity score matching | After propensity score matching | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Single-port (n=224) | Multi-port (n=219) | t | P | Single-port (n=181) | Multi-port (n=181) | t | P | ||
| Postoperative complications | 0.396 | 0.84 | 0.351 | 0.93 | |||||
| Pneumonia | 10 | 11 | 9 | 11 | |||||
| Anastomotic fistula | 2 | 3 | 2 | 2 | |||||
| None | 212 | 205 | 170 | 168 | |||||
Data are presented as number.
Discussion
Esophagectomy is a complex procedure associated with significant morbidity and mortality. MIE is preferred to open approach as it is associated with a lower rate of pulmonary complications, a significant reduction of bleeding and of hospital stay yet with similar oncological outcomes as shown in randomized studies and meta-analyses. However, surgical techniques are evolving with the goal of being less invasiveness, having smaller and fewer incisions. Single-port thoracoscopy is widely used for surgical treatment of lung and mediastinal lesions, but only a few centers adopt this strategy for performing esophagectomy probably due to the complexity of the procedure and the deep learning curve (10,11). Yet, the real advantages of single-port esophagectomy over multi-port esophagectomy are still under debate. Two previous studies (9,12) compared the clinical outcomes of single-port and multi-port thoracoscopy esophagectomy and there was no clear evidence of the significant benefits of single-port thoracoscopy esophagectomy. Guo et al. (12), compared the clinical data of patients undergoing Ivor-Lewis esophagectomy (MIE) with single-port thoracoscopy and with multi-port thoracoscopy. They found no significant differences regarding perioperative, postoperative, and oncological outcomes between the two study groups. Similarly, Lee et al. (9) did not find differences in total surgery time, hospitalization and total number of lymph nodes dissected when they compared multi-port and single-port minimally esophagectomy techniques. Therefore, we retrospectively examined the application of single-port thoracoscopy in the context of McKeown esophagectomy in a large study population to assess whether this strategy is associated with significant clinical benefits compared to multi-port thoracoscopy esophagectomy.
In agreement with previous studies (9,12), we found no significant differences between the two study groups regarding postoperative morbidity and mortality, R0 rate resection, duration of surgery, intra-operative bleeding, and lymph node counts resected. In contrast, we found that single-port esophagectomy was associated with a significant reduction of length of hospital stay probably due to the reduction of postoperative pain and length of drainage stay. The different surgical techniques adopted [Ivor-Lewis esophagectomy in previous series (9,12) and McKeown esophagectomy in our study] could likely explain the different results between our study and those of the other studies (9,12).
Furthermore, single-port esophagectomy was associated with a significant reduction of postoperative pain in all measurement time slots. The less surgical trauma of single surgical incision compared to that of multi-incision likely explained these results. Similarly, Lee et al. (9) found a significant reduction of pain scores in the single-port group compared to the multi-port group on the 7th day after surgery while no significant differences were found on the 1st postoperative day. In theory, the long effects of general anesthesia could still control the pain in the 1st postoperative hours and limit the effect of a reduced incision wound on the pain that could be more evident later, when patients recover from the drastic trauma of surgery, and are no longer experiencing discomfort from the drainage tubes.
Single-port esophagectomy remains a safe procedure and feasible procedure as no significant differences were found regarding complication rate and oncological results compared to multi-port esophagectomy. Hu et al. (13) indicated that the placement of single-port esophageal surgical instruments was more difficult than that of single-port lung surgery. Our experience suggests that the lens should be kept distant from the surgical field before the surgeon’s instruments reaching the surgical field for the operation. When the surgeon’s instrument reaches the position to be operated upon, the lens should be pulled closer to reduce interference of the lens on the instrument. We realize that for surgeons with rich experience in single-port lung surgery, the learning curve of single-port esophageal cancer surgery is not steep. The use of single-port video-assisted thoracoscopic surgery (VATS) no longer limits the number of instruments that can be applied, but to a certain extent, it does increase the skill requirements of surgeons in their ability to place these instruments. Single-port VATS only causes injury to one intercostal nerve, which reduces postoperative pain considerably (14). Single-port VATS differs from traditional multi-port radical esophagectomy. Because the visual field is always the same as that of the surgeon, the visual field seen by the surgeon is similar to the direct vision offered by traditional open chest surgery, as well as that with device’s operation. We found that the duration of the thoracic portion of surgery in the single-port group was the same as that in the multi-port group, but the total operation time of the single-port group was shorter than that of the multi-port group (63.2±10.9 vs. 65.5±15.0 min, P=0.07). This is mainly attributable to the optimization of the operation process in the abdominal cavity and neck portion of the single-port group. Furthermore, the level of coordination between the surgeon and assistants also affects the operation time to a certain extent. Moreover, compared with that in the multi-port group, the amount of thoracic drainage fluid in the single-port group was significantly reduced, while the drainage time was significantly shortened and the average length of hospital stay reduced by 2 days. These findings may be related to fact that under the same scope of lymph node dissection, the chest wall wound in the single-port approach is less extensive compared to that of the multi-port approach, thus reducing blood and fluid leakage.
Our study presented several limitations that should be considered before drawing definitive conclusions. The main limitation was the retrospective nature of the study, despite our data were compared before and after propensity score matching analysis to reduce the inter-group differences due to the lack of randomization. Additionally, no data regarding disease-free survival and overall survival were evaluated, limiting the evaluation on the oncological outcomes.
Conclusions
Our study confirmed that single-port video-assisted thoracoscopic esophagectomy is a feasible and safe procedure. Compared with multi-port esophagectomy, it is associated with a less surgical trauma and thus a significant reduction of postoperative morbidity and mortality, a better aesthetic results, yet with similar oncological outcomes in terms of radical resection of tumor and of lymph nodes. However, our results, despite encouraging, should be corroborated with prospective randomized studies.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-196/rc
Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-196/dss
Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-196/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-196/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 Ethical Committee of Fujian Cancer Hospital (No. SQ2024-018) and was performed in accordance with the Declaration of Helsinki (as revised in 2013). All patients provided written informed consent to participate in this study.
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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(English Language Editor: J. Gray)
