Short- and Long-term Outcomes of Mediastinoscopic Radical Esophagectomy Compared with Open Esophagectomy for Esophageal Cancer: A Consecutive Single-Institution Cohort Study.

BACKGROUND: Mediastinoscopic esophagectomy has emerged as a non-transthoracic minimally invasive approach, but concerns remain regarding its oncologic adequacy and long-term outcomes. We evaluated short-term morbidity and long-term survival after mediastinoscopic versus open esophagectomy for esophageal cancer. METHODS: From an institutional esophagectomy database comprising 330 patients, 116 consecutive patients with pathological stage I-III esophageal cancer who underwent curative esophagectomy between 2007 and 2025 in the modern neoadjuvant era were analyzed. Data were collected retrospectively until 2017 and prospectively thereafter. Fifty-six patients underwent open esophagectomy and 60 underwent mediastinoscopic esophagectomy. RESULTS: Baseline pathological stage and neoadjuvant chemotherapy use were comparable between groups. Despite comparable tumor-related characteristics, patients undergoing mediastinoscopic esophagectomy were significantly older and more frequently classified as ASA physical status ≥ III. Mediastinoscopic esophagectomy was associated with lower blood loss (median 147 vs 500mL, P < 0.001), a shorter postoperative hospital stay (median 14 vs 29 days, P < 0.001), and fewer severe postoperative complications (Clavien-Dindo grade ≥ III; 11.7% vs 41.1%, P < 0.001), without reducing lymph node yield or increasing recurrent laryngeal nerve palsy. On multivariable analysis, mediastinoscopic esophagectomy independently reduced the risk of severe complications (odds ratio 0.11, 95% confidence interval 0.03-0.35, P < 0.001). Overall survival and cancer-specific survival were comparable to those of open esophagectomy. Three- and five-year cancer-specific survival rates were 82.7% and 82.7% after mediastinoscopic esophagectomy and 75.4% and 71.0% after open esophagectomy. CONCLUSION: Mediastinoscopic esophagectomy provides a substantial reduction in severe postoperative morbidity while maintaining long-term oncologic outcomes comparable to those of open esophagectomy.