Postoperative complications after Minimally Invasive transCervical oEsophagectomy (MICE) versus Transthoracic Minimally Invasive oEsophagectomy (TMIE): an inverse probability of treatment weighted analysis.

Minimally Invasive transCervical oEsophagectomy (MICE) is a novel technique with radical lymphadenectomy that avoids a transthoracic access, potentially preserving pleural integrity and obviating one lung ventilation, thereby reducing postoperative pulmonary complications. However, its advantages over conventional Transthoracic Minimally Invasive oEsophagectomy (TMIE) remain unclear. The objective of this study was to assess postoperative outcomes after TMIE and MICE. A retrospective cohort study was conducted including patients with resectable esophageal cancer (cT1-4aN0-3M0) who underwent esophagectomy at the Radboudumc, the Netherlands between 2020 and 2024. The primary outcome was the incidence of postoperative complications within 30 days. Inverse probability of treatment weighting (IPTW) was used to account for confounding between the groups. A total of 115 MICE and 172 TMIE patients were included. After IPTW, overall postoperative complications were more frequent after MICE (60.3% vs. 43.9%, RD: 16.4%, 95% CI: 3.3-29.4). This difference was predominantly driven by a higher incidence of recurrent laryngeal nerve palsy (RLNP) (MICE: 30.4% vs. TMIE: 0.0%). No statistical significant difference was observed in pulmonary complications (18.9% vs. 21.8%, RD: -2.9, 95% CI: -17.1 to 12.5) or anastomotic leakage (5.6% vs. 8.1%, RD: -2.4%, 95% CI: -11.5 to 7.3). Although overall postoperative complication rates were higher after MICE, this difference was mainly attributable to an increased incidence of mostly transient recurrent laryngeal nerve palsy, which is inevitably associated with the transcervical approach. Rates of pneumonia and anastomotic leakage were similar between MICE and TMIE. As these data include cases performed during the early experience with MICE, complication rates may improve as experience accumulates across surgical teams. These findings highlight the need for further evaluation and optimization of the MICE procedure prior to broader implementation.