Survival Comparison Between Open and Thoracoscopic Esophagectomy for Esophageal Squamous Cell Carcinoma Stratified by Pathological Tumor-Node-Metastasis Stage: An Overlap Weighting Analysis.

Background: The survival differences between open esophagectomy (OE) and thoracoscopic esophagectomy (TE) for patients with esophageal squamous cell carcinoma (ESCC) across different pathological tumor-node-metastasis stage (pStage) remain controversial. Therefore, this study aims to compare long-term survival between OE and TE in patients with ESCC across different pStage groups using overlap weighting.

Methods: This ambispective cohort study analyzed patients with ESCC who underwent OE or TE between January 2015 and December 2016 at a tertiary hospital in Henan Province. The primary endpoints were 5-year overall survival (OS), while disease-free survival (DFS) was a secondary endpoint. Operation safety was also assessed. Cox regression was used after overlap weighting, with sensitivity analysis by propensity score matching.

Results: The study cohort included 1715 eligible patients. Median survival was 66.07 months for pStage 0/I/II and 38.47 months for pStage III/IV. Overlap-weighted Cox regression showed significant survival benefits of TE. In the pStage 0/I/II group, the hazard ration (HR) for OS was 0.43 (95% confidence intervals, CI: 0.33-0.57) and for DFS was 0.44 (95% CI: 0.33-0.58). In the pStage III/IV group, the HR for OS was 0.70 (95% CI: 0.57-0.87) and for DFS was 0.73 (95% CI: 0.58-0.90). TE reduced blood loss, increased lymph node dissection, and lowered anastomotic leaks, though it required longer operative time and higher costs (P < 0.05).

Conclusions: TE improved OS and DFS and operation safety compared with OE in patients with early and advanced-stage ESCC after adjusting for confounding factors.