Minimally Invasive or Open Esophagectomy for Esophageal Squamous Cell Carcinoma: A Comprehensive Systematic Review of Surgical and Survival Outcomes

Anas Bassam Barnawi¹Waseem M Hajjar²Adel D. Almaymuni^3*Ammar Alzahim⁴Osama Thamer Al-Ahmari¹Basim Alshahrani¹Abdulaziz Aljanoubi¹Layan Rafat Bukhari¹Muhanad Sultan Alsharari¹Meshari Abdulrahman AL-SAHLI¹Abdulmalik Abdulelah Bin Kassim¹Aldana Alodayani¹

• ¹College of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
• ²Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
• ³Department of Surgery, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
• ⁴King Saud University Medical City, Riyadh, Saudi Arabia

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 versus OE in ESCC. Methods: We conducted a PRISMA-compliant systematic review registered on PROSPERO (CRD420251158559). PubMed/MEDLINE, Web of Science, and the Cochrane Library were searched for studies published between January 2010 and May 2024. Nine comparative studies (n = 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.