Comparing long-term survival for minimally invasive vs. open esophagectomy
Editorial Commentary

Comparing long-term survival for minimally invasive vs. open esophagectomy

Adrian Valderrama1 ORCID logo, Lily Niehaus2 ORCID logo, Andrea Gochi1 ORCID logo, Jeffrey Velotta3,4,5 ORCID logo

1Department of Surgery, UCSF East Bay, Oakland, CA, USA; 2Department of Exercise Physiology, University of North Carolina, Chapel Hill, NC, USA; 3Department of Surgery, UCSF, San Francisco, CA, USA; 4Department of Clinical Sciences, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA; 5Department of Surgery, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA

Correspondence to: Adrian Valderrama, MD. Department of Surgery, UCSF East Bay, 1411 East 31st Street, Oakland, CA 94602, USA. Email: avalderrama@alamedahealthsystem.org.

Comment on: Igaue S, Fujita T, Oguma J, et al. Long-term Survival in Esophageal Cancer: Comparison of Minimally Invasive and Open Esophagectomy. Ann Thorac Surg 2025;119:805-14.

Keywords: Overall survival (OS); esophageal cancer; minimally invasive surgery

Received: 13 January 2026; Accepted: 10 March 2026; Published online: 10 June 2026.

doi: 10.21037/vats-2026-1-0002

Esophageal cancer is the sixth leading cause of cancer mortality worldwide (1,2). Despite advancements in screening, staging, and treatment modalities, prognosis remains poor with a 5-year survival of 20% in the United States (3-5). For patients with both squamous cell carcinoma (SCC) and adenocarcinoma with early-stage to locally advanced disease, surgical resection is the most effective treatment for improving survival (6,7).

Historically, open esophagectomy has represented the cornerstone of surgical management, but is associated with significant perioperative morbidity (6,8,9). In the last two decades, advancements in surgical techniques have led to the development and widespread adoption of minimally invasive esophagectomy (MIE) (8,10-12). The perioperative benefits of MIE—including hybrid, totally minimally invasive, and robot-assisted thoracoscopic approaches—compared to open thoracotomy are well established. These include lower rates of surgical site infection, perioperative mortality and decreased postoperative length of stay (9-11,13). Despite these benefits, evidence regarding the impact of MIE on long-term survival remains limited.

Several randomized trials have compared long-term survival—defined here as survival at 3 years or beyond—after minimally invasive vs. open esophagectomy. The TIME trial, which randomized 115 patients across five European centers, found no differences in disease-free (DFS) or overall survival (OS) at 3 years (13,14). The MIRO trial (n=207) reported higher 3- and 5-year DFS and OS with hybrid MIE, though these differences were not statistically significant (15,16). The single-center ROBOT trial (n=112) similarly demonstrated no difference in OS at 5-year follow-up (17,18). More recently, the MONET trial—a multicenter Japanese noninferiority study—randomized 300 patients to thoracoscopic or open esophagectomy and demonstrated noninferiority for thoracoscopic surgery at 3 years (19) (Table 1).

Table 1

Long-term follow-up of RCTs comparing minimally invasive and open esophagectomy

Study Number of patients Key findings Survival outcomes
Straatman et al. 2017 (TIME trial) (14) 115 total (59 MIE, 56 open) Significantly lower pulmonary infection with minimally invasive esophagectomy vs. open (9% vs. 29% at 2 weeks; 12% vs. 34% in-hospital). No difference in early mortality 3-year OS: MIE 50% vs. open 40% (P=0.21)
van der Sluis et al. 2019 (ROBOT trial) (17) 112 total (56 RAMIE, 56 open) Fewer overall postoperative complications with RAMIE vs. open (59% vs. 80%, P=0.02), fewer pulmonary (RR 0.54) and cardiac (RR 0.47) complications 5-year OS: robotic 41% vs. open 40% (P=0.83)
Nuytens et al. 2021 (MIRO trial) (16) 207 total (103 hybrid, 104 open) Major intraoperative and postoperative complications (HR 1.94, 95% CI: 1.1–3.10, P=0.005) were associated with decreased OS 5-year OS: hybrid MIE 59% vs. open 47% (HR 0.71, 95% CI: 0.48–1.06)
Takeuchi et al. 2025 (MONET trial) (19) 300 total (150 thoracoscopic, 150 open) Thoracoscopic surgery was associated with decreased rates of grade 3 or higher pneumonia (8% vs. 12%) and grade 3 anastomotic leakage (11% vs. 5%) 3-year OS: thoracoscopic 82% vs. open 71% (one-sided P<0.001)

CI, confidence interval; HR, hazard ratio; MIE, minimally invasive esophagectomy; OE, open esophagectomy; OS, overall survival; RAMIE, robot-assisted minimally invasive esophagectomy; RCT, randomized controlled trial; RR, relative risk.

Collectively, randomized data comparing minimally invasive and open esophagectomy remain limited, though emerging data suggest comparable long-term survival between the two approaches.

Despite these randomized studies, comparisons between minimally invasive and open esophagectomy continue to rely heavily on retrospective evidence. A 2019 meta-analysis by Gottlieb-Vedi et al. encompassing 55 predominantly small, single-center studies (n=14,592) reported improved 3- and 5-year OS with minimally invasive techniques (20). More recent, large retrospective cohort studies have yielded mixed findings, with several demonstrating improved OS following MIE and others showing no difference compared to open approaches (21-28). Consistent with this heterogeneity, a 2025 analysis of the National Cancer Database found no difference in OS between minimally invasive and open approaches (29). Together, these findings highlight the persistent ambiguity surrounding long-term survival outcomes and the need for more methodologically rigorous investigations (Table 2).

Table 2

Non-randomized comparative studies of minimally invasive vs. open esophagectomy

Study Year N Design Survival outcome Long-term oncologic signal
Gottlieb-Vedi et al. (20) 2019 14,592 Meta-analysis (55 studies) MIE associated with lower 5-year all-cause mortality (HR 0.82, 95% CI: 0.76–0.88) MIE superior
Kalff et al. (24) 2022 ~1,600 National audit, PSM 5-year OS was similar between MIE and open surgery (49.2% vs. 51.1%; P=0.70) Oncologic equivalence
Hayami et al. (21) 2022 1,404 Population registry MIE improved OS (HR 0.72, 95% CI: 0.55–0.94) MIE superior
Rong et al. (27) 2022 270 Single-center PSM cohort After PSM, no significant difference in 3-year OS or DFS between MIE and OE Oncologic equivalence
Mao et al. (22) 2023 1,722 Multicenter PSM cohort 3-year OS higher with MIE (77.0% vs. 69.3%, P=0.03); DFS trended favorably (68.1% vs. 60.9%, P=0.09) MIE superior
Wang et al. (28) 2023 2,053 National registry, 1:2 PSM After PSM, 3-year OS was higher with MIE (58.6% vs. 47.6%, P<0.001); MIE was independently associated with improved OS MIE superior
Jia et al. (25) 2024 1,104 Ambispective PSM 5-year OS (83.7% vs. 70.1%, P<0.001) and DFS (77.8% vs. 67.2%, P<0.001) were higher with MIE MIE superior
Terayama et al. (26) 2024 1,117 Multicenter cohort After IPTW, 3-year OS and cancer-specific survival were higher with MIE (P<0.001), with lower locoregional recurrence; benefit driven by cT3–4 tumors MIE superior
Li et al. (23) 2025 469 Elderly PSM cohort Median OS longer with MIE (60.2 vs. 29.2 months; HR 1.45 after PSM, P=0.04) MIE superior
Jia et al. (25) 2025 1,715 Overlap-weighted cohort MIE improved OS and DFS in early-stage (OS HR 0.43; DFS HR 0.44) and advanced-stage disease (OS HR 0.70; DFS HR 0.73) MIE superior
Battan-Wraith et al. (29) 2025 2,702 NCDB multivariable After multivariable adjustment, no independent OS difference between MIE and open surgery (HR 1.07, P=0.77) Oncologic equivalence

CI, confidence interval; DFS, disease-free survival; HR, hazard ratio; IPTW, inverse probability of treatment weighting; MIE, minimally invasive esophagectomy; NCDB, National Cancer Database; OE, open esophagectomy; OS, overall survival; PSM, propensity score matching.

Given the limitations of the current evidence base, the work of Igaue et al. makes a valuable contribution to the existing literature (30). Although retrospective, this multi-center study based in Japan evaluates long-term overall, cancer-specific, and DFS using propensity score matching (PSM) and further stratifies by cancer stage. Among the study sample, approximately two-thirds received neoadjuvant chemotherapy, reflecting current trends that increasingly favor surgical resection for more advanced disease, making the sample more representative of contemporary treatment practices. The analysis also evaluates how post-operative complications, particularly pneumonia, may affect long-term survival, thereby reducing bias in the impact of perioperative outcomes on survival.

After PSM of 313 patient pairs from a cohort of 1,559 patients, Igaue et al. reported a 5-year OS of 52% following open esophagectomy compared with 62% after MIE. OS differences were evident at 1, 3, and 5 years, with increasing separation over time, suggesting a durable association between MIE and improved long-term survival. In stage-stratified analyses, this survival advantage was not observed among patients with stage I/II disease but was significant for those with stage III/IV disease. Notably, prior large cohort studies have not demonstrated a stage-specific survival advantage for MIE among patients with advanced esophageal carcinoma.

OS was further stratified by the occurrence of pneumonia or any postoperative complication classified as Clavien-Dindo III or higher. Across both open and minimally invasive groups, the development of pneumonia or major postoperative complications was associated with worse long-term survival. Although rates of pneumonia and other major complications were similar between groups, this stratified analysis enables partial disentanglement of operative approach from perioperative morbidity, which is particularly relevant given the well-established association between open esophagectomy and higher postoperative complication rates. Importantly, open esophagectomy remained associated with worse OS even among patients who did not experience major postoperative complications, suggesting that factors beyond perioperative morbidity may contribute to observed survival differences.

Perioperative outcomes were additionally assessed, revealing that MIE was associated with lower estimated blood loss and shorter operative time. While reduced blood loss is an expected benefit of minimally invasive techniques, reduced operative time is less intuitive and may reflect the maturation of thoracoscopic platforms and increasing surgeon experience in high-volume centers. Lymph node yield was similar between approaches. Unexpectedly, overall perioperative complication rates did not differ between groups, a finding that contrasts with prior studies reporting perioperative advantages for MIE.

Despite the strengths of this study, several important limitations warrant consideration. First, the retrospective, nonrandomized design introduces the possibility of selection bias. This is reflected in the substantial baseline differences between groups prior to matching, with patients undergoing open esophagectomy being more likely to have advanced disease and to have undergone surgery earlier in the study period. Although PSM was used to mitigate these imbalances, residual confounding from unmeasured variables cannot be excluded. In addition, the authors incorporated pathologic stage variables (pT, pN, and pM) into the propensity model. Pathologic stage is determined after surgery and may be influenced by operative approach, extent of lymphadenectomy, and staging intensity; conditioning on such post-treatment variables introduces the potential for over-adjustment and collider bias. This limits causal inference regarding any observed survival advantage associated with thoracoscopic esophagectomy.

In addition to limitations in study design, several aspects of the results are inconsistent with a true oncologic survival advantage for thoracoscopic esophagectomy. A greater proportion of deaths in the open esophagectomy group were attributable to non-cancer-related causes, raising the possibility that baseline differences in patient health, rather than cancer control, may underlie the OS advantage. Although the American Society of Anesthesiologists (ASA) class was balanced between groups, this measure does not fully capture differences in frailty or comorbidity burden. Furthermore, neither cancer-specific nor relapse-free survival differed significantly between groups. Together, these features suggest that the observed OS advantage may reflect residual confounding rather than a true oncologic effect of thoracoscopic resection.

It is necessary to contextualize the findings of Iguae et al. before extrapolating their results to other populations. This study was conducted at two ultra-high-volume cancer centers in Japan, where thoracoscopic McKeown esophagectomy was performed by highly specialized surgeons. The predominance of SCC (approximately 95%), the routine use of cervical anastomosis, and underlying population and treatment differences further distinguish this cohort from Western esophageal cancer populations, which are largely adenocarcinoma-predominant and commonly managed with Ivor Lewis-type resections. Consequently, caution is warranted when generalizing these results to broader practice settings or non-Japanese populations.

The work of Iguae et al. provides an important contribution to the literature by demonstrating an association between thoracoscopic esophagectomy and improved OS in a large, well-characterized cohort. The use of rigorous PSM and long-term follow-up strengthens the internal validity of their findings and offers a model for how high-quality retrospective comparative effectiveness research can be conducted in complex surgical populations. However, the observed survival advantage should be interpreted as an association rather than definitive evidence of a causal oncologic benefit, given the potential for residual confounding and the absence of corresponding differences in cancer-specific or DFS.

Esophagectomy remains central to improving survival in patients with esophageal cancer, and minimally invasive techniques are now widely adopted because of their well-established perioperative benefits. However, high-quality evidence comparing minimally invasive and open esophagectomy remains relatively limited, with available randomized trials demonstrating comparable long-term survival and observational studies yielding heterogeneous results. In this context, the study by Igaue et al. provides valuable contemporary data from expert centers, supporting the oncologic equivalence of minimally invasive and open approaches while raising the possibility of a survival advantage with MIE in select patients with advanced disease. Given the inherent limitations of observational data, further prospective randomized studies remain necessary to define any true long-term oncologic difference between surgical approaches.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0002/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0002/coif). J.V. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from September 2025 to August 2027. The other 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.

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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doi: 10.21037/vats-2026-1-0002
Cite this article as: Valderrama A, Niehaus L, Gochi A, Velotta J. Comparing long-term survival for minimally invasive vs. open esophagectomy. Video-assist Thorac Surg 2026;11:23.

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