Minimally invasive versus open esophagectomy for resectable esophageal cancer: Systematic review and meta-analysis of randomized controlled trials.

e16117 Background: Minimally invasive esophagectomy (MIE; thoracoscopic/robotic/hybrid) is on the rise for resectable esophageal cancer, but the impact on long-term survival and key postoperative outcomes between MIE and open transthoracic esophagectomy remains clinically important. We aim to compare MIE versus open transthoracic esophagectomy in terms of efficacy and safety. Methods: PubMed, Embase, Cochrane Library and ClinicalTrials.gov were searched for randomized controlled trials comparing MIE (including hybrid and robotic-assisted approaches) with open transthoracic esophagectomy. The primary endpoint was overall survival (OS). Secondary endpoints were pulmonary complications and major morbidity; anastomotic leak and short-term mortality were further included in the analysis. Outcomes were pooled as hazard ratios (HRs), and binary outcomes as risk ratios (RRs), using a DerSimonian and Laird random-effects model; heterogeneity was assessed with I². Results: Six RCTs were included for perioperative endpoints (data summarized in Table.1). MIE was associated with improved OS HR 0.75 (95% CI 0.57-0.99; I² = 0%). Pulmonary complications were significantly reduced with MIE RR 0.65 (95% CI 0.47-0.90; I² = 51.0%). There was a non-significant reduction in major morbidity RR 0.81 (95% CI 0.64-1.02; I² = 62.6%). Anastomotic leak was non-significantly higher with MIE RR 1.36 (95% CI 0.97-1.91; I² = 0%). Short-term mortality did not differ between approaches RR 0.97 (95% CI 0.43-2.22; I² = 0%). Conclusions: MIE is associated with improved OS and fewer pulmonary complications versus open transthoracic esophagectomy, with no clear difference in short-term mortality. Anastomotic leak was non-significantly higher with MIE, which signals the importance of continued optimization of anastomotic technique as MIE becomes more widely adopted. Data summery table with event counts for each outcome. Trial Pulmonary Events Major Morbidity Anastomotic Leak Short-term Mortality Biere et al, 2012 7/59 vs 19/56 - 7/59 vs 4/56 1/59 vs 0/56 Paireder et al, 2018 3/14 vs 3/12 6/14 vs 4/12 3/14 vs 2/12 0/14 vs 1/12 Mariette et al, 2019 18/102 vs 31/103 37/103 vs 67/104 11/102 vs 7/103 1/103 vs 2/104 Van der Sluis et al, 2019 17/54 vs 32/55 32/54 vs 44/55 13/54 vs 11/55 1/54 vs 0/55 ROMIO Study Group 2024 85/258 vs 91/261 82/258 vs 88/261 21/258 vs 21/261 4/259 vs 6/261 Takeuchi et al, 2025 12/150 vs 18/150 63/150 vs 65/150 17/150 vs 7/150 4/150 vs 2/150 Total 142/637 vs 194/637 220/579 vs 268/582 72/637 vs 52/637 11/639 vs 11/638