Comparable outcomes after McKeown and Ivor-Lewis minimally invasive esophagectomy with standardized two-field lymphadenectomy: a propensity score-matched study.

BACKGROUND: Minimally invasive esophagectomy (MIE) is widely used for esophageal cancer, but the optimal choice between McKeown and Ivor-Lewis MIE remains controversial. This study compared perioperative outcomes and 5-year overall survival (OS) between the two approaches under a standardized two-field lymphadenectomy framework. METHODS: We retrospectively reviewed a cohort of 1,011 patients who underwent MIE for esophageal cancer between May 2017 and May 2020. To minimize selection bias, 1:1 propensity score matching (PSM) was performed using the following covariates: age, gender, body mass index(BMI), FEV1%, weight loss, albumin, smoking and drinking history, hypertension, diabetes, coronary heart disease, ASA score, histologic type, tumor location, TNM stage, and neoadjuvant therapy. The primary endpoint was 5-year OS, and the secondary endpoints were perioperative outcomes and postoperative complications. RESULTS: After matching, 542 patients were included, with 271 patients in each group. In the matched cohort, overall postoperative complications were comparable between the McKeown and Ivor-Lewis groups (28.4% vs. 30.6%, P = 0.572), as were Clavien-Dindo grade III or higher complications (18.5% vs. 22.1%, P = 0.286), 30-day mortality (1.5% vs. 1.1%, P = 1.000), and 90-day mortality (2.6% vs. 3.3%, P = 0.612). Five-year OS was 43.5% and 36.2%, respectively, with no significant difference between groups after matching (log-rank P = 0.58). Multivariable Cox analysis showed that surgical approach was not independently associated with OS (Ivor-Lewis vs. McKeown: HR 0.93, 95% CI 0.74-1.16, P = 0.522), whereas prolonged postoperative hospital stay, tumor location, advanced TNM stage, and Clavien-Dindo grade III or higher complications were independently associated with OS. CONCLUSIONS: In this real-world propensity score-matched cohort, McKeown and Ivor-Lewis MIE achieved comparable perioperative safety and long-term OS under a standardized two-field lymphadenectomy framework. Long-term prognosis appeared to be more closely associated with tumor stage, tumor location, postoperative hospital stay, and severe postoperative complications than with the surgical approach itself.