Revisiting Thoracic Duct Resection in Esophageal Squamous Cell Carcinoma: A Propensity‐Matched Analysis and Immunologic Insight Into Recurrence Risk

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is an aggressive malignancy with a poor prognosis. In an effort to reduce recurrence, the thoracic duct (TD), a key conduit for immune and nutritional homeostasis, is sometimes resected during esophagectomy. The clinical and immunological impact of this procedure remains controversial. This study therefore aimed to evaluate the prognostic significance of intraoperative thoracic duct resection (TDR) in ESCC patients. METHODS: We retrospectively analyzed 722 patients with ESCC who underwent McKeown esophagectomy at Sun Yat-sen University Cancer Center between January 2020 and December 2022. Patients were classified into TDR and TD-preserved groups. Propensity score matching (PSM) was used to balance baseline characteristics. Overall survival (OS) and recurrence-free survival (RFS) were compared using Kaplan-Meier analysis and Cox regression models. RESULTS: After PSM, there were no significant differences between the TDR and TD-preserved groups in median OS (both 33.96 months) or in 1-, 3-, and 5-year OS rates (p = 0.66). RFS was also similar (p = 0.31). Subgroup analyses showed that TDR had no significant impact on OS or RFS, regardless of adjuvant therapy or immunotherapy at recurrence. However, among patients without lymph node metastasis (pN0), TDR was associated with a higher recurrence risk (HR, 2.09; 95% CI, 1.16-3.73; p = 0.013). CONCLUSIONS: Intraoperative TDR did not improve long-term survival in ESCC and may increase recurrence risk in early-stage node-negative patients. Routine TDR should be avoided, and its indication individualized.