Comparison of mediastinoscopic and thoracoscopic esophagectomy for esophageal cancer using matched cohorts of 152 cases

Video-assisted thoracoscopic surgery (VATS) is currently the most widely used approach for esophageal cancer resection. It performs thoracic esophagectomy and mediastinal lymph node dissection via a small incision, right thoracic approach. However, thoracoscopic access to the thoracic esophagus is often technically challenging in patients who have previously undergone lung surgery or pleurodesis. Inflatable video-assisted mediastinoscopic esophagectomy (VAMS) offers an option for these patients. The posterior mediastinum is inflated with carbon dioxide via the cervical incision to create an artificial space for radical esophagectomy. The operation avoids access to the pleural cavity, unlike VATS. Nevertheless, concerns have been raised about inadequate lymph node retrieval and a high risk of recurrent laryngeal nerve palsy. Our study aimed to address these concerns by reviewing our recent operations, which incorporated significant technical improvements over our initial practice. We retrospectively analyzed a cohort of patients who underwent VAMS for esophageal cancer resection at Nanjing Drum Tower Hospital from January 2023 to December 2024. The comparison cohort was selected from those who received VATS at Cancer Hospital Chinese Academy of Medical Sciences during the same period. Exclusion criteria included non-squamous cell carcinoma, reconstruction not using the stomach, multiple primary malignant neoplasms, and loss to follow-up. After propensity score matching to balance demographics and clinical features, the two cohorts were compared on operative time, blood loss, lymph node retrieval, postoperative complications, length of hospital stay, and 2-year survival. As a result, we reviewed 398 eligible patients, of whom 183 underwent VAMS. Propensity score matching generated two study cohorts, each with 76 patients, for comparative analysis. The two cohorts had similar blood loss, the number of dissected lymph nodes, and postoperative hospital stay. R0 resection without conversion to thoracotomy was achieved in all patients. There was no death in 30 days postoperatively. Postoperative complications were infrequent and did not differ significantly between the cohorts. The rate of vocal hoarseness appeared higher in the VAMS cohort than in the VATS cohort, although the difference was not statistically significant. Nevertheless, the VAMS cohort had a shorter operative time than the VATS cohort, with a median reduction of approximately 16 min. The 2-year disease-free and overall survival did not differ significantly between the cohorts. Tumor recurrence occurred in 13 patients in each cohort, with distant metastasis the most frequent cause. Only three patients had locoregional recurrence, including one case of anastomotic recurrence and two cases of regional lymph node metastasis. In conclusion, our study has revealed that VAMS has a shorter operative time and is not significantly different from VATS in lymph node retrieval, postoperative complications, and 2-year survival. These encouraging findings warrant prospective studies that include more high-volume hospitals with consensus on surgical procedures.