Robotic-assisted versus conventional minimally invasive esophagectomy after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

Background Robotic-assisted minimally invasive esophagectomy (RAMIE) is increasingly used as an alternative to conventional minimally invasive esophagectomy (CMIE). However, many prior comparisons include mixed patient populations and variable neoadjuvant treatment strategies. Because neoadjuvant chemoradiotherapy (nCRT) can make esophagectomy technically more difficult, the relative performance of RAMIE in this specific setting remains uncertain. Methods We performed a systematic review and meta-analysis using Nested Knowledge AutoLit to compare RAMIE and CMIE among patients undergoing esophagectomy after predominantly nCRT-based treatment. Eligible studies directly compared the two operative approaches and reported perioperative, surgical, or oncologic outcomes. Effect estimates were pooled with random-effects models. Odds ratios (ORs) were used for dichotomous outcomes, and mean differences (MDs) were used for continuous outcomes. Analyses were performed in R version 4.5.2 using the meta package. Risk of bias was assessed with ROBINS-I. Results Seven studies including 2,395 patients were analyzed; 609 patients underwent RAMIE and 1,786 underwent CMIE. Compared with CMIE, RAMIE was associated with lower estimated blood loss (MD −26.44 mL, 95% CI −34.36 to −18.51; p < 0.001), shorter hospital length of stay (MD −1.78 days, 95% CI −3.41 to −0.15; p = 0.032), and higher lymph node yield (MD 2.60 nodes, 95% CI 1.81–3.38; p < 0.001). No significant differences were identified for pathologic complete response, R0 resection, overall postoperative complications, anastomotic leak, 30-day mortality, or 90-day mortality. Conclusions Among patients undergoing esophagectomy after predominantly nCRT-based treatment, RAMIE was associated with lower blood loss, shorter hospital stay, and higher lymph node yield compared with CMIE, without significant differences in oncologic outcomes, postoperative morbidity, or short-term mortality. These findings suggest that RAMIE is a safe and effective minimally invasive approach in this population, although interpretation is limited by the observational design of the included studies.