# Postoperative outcomes after minimally invasive esophagectomy: an international cohort study from the Oesophagogastric Anastomosis Audit (OGAA)

## TL;DR

This study compares postoperative outcomes of different esophagectomy approaches and finds that totally minimally invasive surgery is linked to fewer pulmonary complications.

## Contribution

The study provides real-world evidence on the benefits of totally minimally invasive esophagectomy compared to open and hybrid approaches.

## Key findings

- Totally minimally invasive esophagectomy (TMIE) was associated with lower postoperative pulmonary complications compared to open and hybrid approaches.
- TMIE also showed lower overall complications compared to open esophagectomy.
- Findings were consistent even in patients with respiratory disease or receiving neoadjuvant chemoradiotherapy.

## Abstract

To compare the postoperative pulmonary complications (PPC) after minimally invasive or open transthoracic esophagectomy for esophageal cancer in an international, multicenter cohort.

Ongoing debate exists around the optimal surgical approach for esophageal cancer, with limited data assessing the external validity of randomised trials on outcomes of MIE

Patients undergoing open (OE, n = 744), hybrid (HE, n = 500), and totally minimally invasive esophagectomy (TMIE, n = 540) for esophageal cancer were identified from the international, prospective Oesophagogastric Anastomosis Audit (OGAA). Multivariable models were used to investigate PPC (primary outcome) as well as overall complications, major complications, anastomotic leak and 90-day mortality (secondary outcomes).

PPC rates were lower after TMIE compared to OE and HE (28% vs 37% vs 39%, p = 0.002), even on adjusted analyses compared to OE (odds ratio (OR): 0.60, CI95%: 0.45—0.78). TMIE was also associated with significantly lower overall complications (OR: 0.68, CI95%: 0.52—0.88) compared to OE, but not for major complications (OR: 0.90, CI95%: 0.67—1.21), anastomotic leak (OR: 1.39, CI95%: 0.96—2.01) and 90-day mortality (OR: 0.49, CI95%: 0.22—1.04). Sensitivity analyses by underlying respiratory disease, neoadjuvant chemoradiotherapy or high-volume centers confirmed above findings.

This study provides real-world data that TMIE was associated with lower 90-day PPC than OE and HE approaches, especially in patients with underlying respiratory disease or receiving neoadjuvant chemoradiotherapy. These warrant a further review into causes and mechanisms in selected patients, and that quality assurance in delivery of TMIE is probably of major importance. The ideal surgical approach remains unclear, and ongoing trials will provide more evidence within a few years that may clarify the optimum approach to locally advanced esophageal cancers.

The online version contains supplementary material available at 10.1186/s12893-025-02941-6.