Robot-assisted Ivor-Lewis esophagectomy with intrathoracic anastomosis for adenocarcinoma of the esophagogastric junction: a cohort study of 156 cases.

BACKGROUND: To compare the efficacy and safety of neoadjuvant therapy (NT) followed by robot-assisted Ivor-Lewis esophagectomy vs. upfront surgery (S) in patients with locally advanced adenocarcinoma of the esophagogastric junction (AEG). METHODS: We retrospectively analyzed 156 patients with locally advanced AEG (cT2-4a/N0-2) who underwent robot-assisted Ivor-Lewis surgery with intrathoracic anastomosis between 2017 and 2024. Baseline characteristics, pathological responses, and surgical outcomes were compared between the NT and S groups. Survival data were evaluated using Kaplan-Meier analysis. RESULTS: Of the 156 patients, 41 (26.3%) received NT. The NT group achieved a pathological complete response (pCR) rate of 24.4% (vs. 0% in the S group) and higher node-negative rates (pN0: 56.1% vs. 32.2%, P = 0.009), with significant downstaging in pT stage (T0-2: 41.5% vs. 17.4%, P < 0.001), TNM stage (I-II: 53.7% vs. 23.5%, P < 0.001), and lymphovascular invasion (7.3% vs. 27.0%, P = 0.008). Surgical outcomes were comparable between groups, including conversion rates (9.8% vs. 10.4%, P = 1.000), anastomotic leaks (2.4% vs. 4.3%, P = 1.000), and pneumonia (7.3% vs. 10.4%, P = 0.761), despite more frequent use of overlap anastomosis in the NT group (68.3% vs. 34.8%, P = 0.001). After a median follow-up of 21 months (n = 129), the NT group showed superior 2-year overall survival (OS) (87.5% vs. 71.0%, P = 0.042), with pCR patients achieving 100% 2-year OS. CONCLUSION: NT significantly improves pathological responses and survival in advanced AEG without increasing surgical risks. The robotic-assisted approach enables the safe implementation of this multimodal treatment strategy. VISUAL ABSTRACT: http://links.lww.com/MS9/B274.