Abstract
Introduction
Despite being highly invasive, esophagectomy remains the mainstay of treatment for early- and intermediate-stage esophageal cancer. With the advancement of minimally invasive techniques, single-port thoraco-laparoscopic esophagectomy has been increasingly applied in clinical practice, offering advantages in terms of improved cosmetic outcomes, reduced postoperative pain, and enhanced recovery. However, the procedure is technically demanding. In addition, the traditional posterior mediastinal route for reconstruction is associated with a relatively high risk of complications, whereas reconstruction via the substernal route may significantly reduce cardiopulmonary morbidity.
Objective
To evaluate the short-term outcomes of uniportal thoracoscopic and single-incision plus one port laparoscopic minimally invasive esophagectomy combined with direct retrosternal approach for radical esophagectomy.
Methods and analysis
The clinical data of 60 patients who underwent uniportal thoracoscopic and single-incision plus one port laparoscopic minimally invasive esophagectomy combined with direct retrosternal approach for radical esophagectomy between January 2024 and February 2025 were retrospectively analyzed. Perioperative indicators and postoperative follow-up data were recorded in detail.
Results
All surgeries were successfully completed with no conversion to open thoracotomy or laparotomy, and no perioperative deaths occurred. The mean operative time was 209.35 ± 28.57 min, the mean intraoperative blood loss was 64.17 ± 20.53 mL, and the mean number of lymph nodes dissected was 32.35 ± 11.51. The visual analog scale (VAS) scores for pain at postoperative were 2.20 ± 0.99. The average length of hospital stay was 7.92 ± 2.11 days. Ten patients developed postoperative complications, with a complication rate of 16.67%.
Conclusion
Uniportal thoracoscopic and single-incision plus one port laparoscopic minimally invasive esophagectomy combined with direct retrosternal approach is a safe and feasible technique for esophageal cancer, with potential advantages in terms of cosmetic outcomes and reduced postoperative incisional pain.
Keywords: Esophageal cancer, Radical esophagectomy, Thoracoabdominal laparoscopy, Single-incision, Retrosternal approach
Introduction
Although esophagectomy with lymphadenectomy is considered one of the most invasive procedures in thoracic surgery [1], subtotal esophagectomy combined with two-field or three-field lymph node dissection remains the mainstay treatment for early- and intermediate-stage esophageal cancer [2]. In 2010, Diego González successfully performed the first single-port thoracoscopic lobectomy for lung cancer [3], marking a new era in minimally invasive thoracic surgery. With the advancement of endoscopic techniques and the refinement of surgical instruments, novel minimally invasive approaches such as single-port and reduced-port procedures have emerged. In 2015, scholars from Taiwan were the first to apply single-port thoracoscopic techniques to esophagectomy, which was subsequently adopted and promoted both domestically and internationally. Later, Lee et al. reported the first case of uniportal thoracoscopic and single-incision plus one port laparoscopic minimally invasive esophagectomy (SIMIE), ushering in a new chapter in the application of single-port endoscopic surgery for esophageal cancer. Compared to conventional multi-port procedures, single-port surgery offers certain advantages in terms of cosmetic outcomes, reduced postoperative pain, and accelerated recovery [4]. However, technical challenges such as limited exposure and instrument interference have hindered its widespread adoption.
Traditionally, the posterior mediastinal route has been the preferred pathway for esophageal reconstruction. However, when anastomotic leakage or other complications occur, this route may lead to severe consequences, including life-threatening pulmonary infections or catastrophic hemorrhage due to erosion of major mediastinal vessels [5]. In contrast, the retrosternal route, although technically more demanding, offers a more favorable anatomical position that may reduce the risk of such complications. In our center, we have achieved promising short-term outcomes in esophageal cancer treatment by employing uniportal thoracoscopic and single-incision plus one port laparoscopic surgery combined with retrosternal reconstruction under direct vision.
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Methods and analysis
Clinical data
Clinical data of 60 patients with esophageal cancer treated at Fujian Cancer Hospital between January 2024 and February 2025 were retrospectively collected. The inclusion criteria were as follows: [1] Age between 18 and 80 years; [2] Histologically or cytologically confirmed esophageal squamous cell carcinoma, staged as cT1b-3NanyM0 according to the 8th edition of the AJCC staging system; [3] Eastern Cooperative Oncology Group (ECOG) performance status score of 0–1; [4] Normal function of major organs with an American Society of Anesthesiologists (ASA) score ≤ III; [5] Underwent uniportal thoracoscopic and single-incision plus one port laparoscopic three-field radical esophagectomy with retrosternal reconstruction under direct vision; [6] Preoperative cardiopulmonary function assessment indicating surgical tolerance.
Exclusion criteria included: [1] Age >80 years; [2] Clinical evidence of distant metastasis or tumor invasion into adjacent vital organs precluding R0 resection; [3] Severe cardiopulmonary comorbidities contraindicating thoracoscopic surgery; [4] History of thoracoabdominal surgery or prior median sternotomy and severe pleural adhesions from previous thoracic surgery or inflammation; [5] History of other malignancies; [6] Significant mediasinal fibrosis from prior radiation therapy; [7] Severe kyphoscoliosis limiting thoracoscopic acces; [8] Incomplete clinical data or inability to complete follow-up.
Surgical procedure
All procedures were performed by the same senior chief surgeon, who has extensive experience in uniportal thoracoscopic and single-incision plus one port laparoscopic three-field radical esophagectomy and retrosternal reconstruction for esophageal cancer. The surgical team was highly experienced in both single-port minimally invasive esophagectomy and reconstruction via the retrosternal route under direct vision.
Thoracic phase
The patient was placed in the left semi-prone position. Following general anesthesia, a double-lumen endotracheal tube was inserted to enable single-lung ventilation on the left side. The surgeon and the endoscope assistant stood on the ventral side of the patient, with the endoscope assistant positioned at the surgeon’s head side and the first assistant on the dorsal side.A 3–5 cm incision was made in the right fourth intercostal space along the mid-axillary line, through which a wound protector was inserted (Fig. 1). A 10-mm thoracoscope was introduced via the posterior part of the incision, and standard single-port thoracoscopic instruments were used to complete the thoracic portion of the procedure.The mediastinal pleura was incised along the upper edge of the azygos arch, anterior to the spine and in the direction of the vagus nerve, extending to the apex of the pleural dome (Fig. 2). The vagus nerve was dissected retrogradely to the level of the subclavian artery, where the origin of the right recurrent laryngeal nerve was identified and preserved. Further dissection upward exposed the nerve, and surrounding lymphatic and adipose tissues were removed (Fig. 3). The posterior wall of the upper esophagus was mobilized, exposing and preserving the thoracic duct, followed by mobilization of the anterior wall up to the thoracic inlet (Fig. 4). The azygos arch and bronchial arteries were preserved, while the lymph nodes inferior to the arch were dissected (Fig. 5). The lower esophagus beneath the azygos arch was mobilized, stapled, and transected using a linear stapler (Fig. 6). To avoiding affecting the cervical anastomosis, we divide the esophagus in the thoracic cavity at a site more than 5 cm above or below the tumorm margin, while ensuring an adequate proximal resection margin. The assistant elevated the upper esophagus, while the surgeon used a suction device to gently press the membranous portion of the trachea, facilitating dissection of the left tracheoesophageal groove with an ultrasonic scalpel. The left recurrent laryngeal nerve was carefully exposed and preserved, and lymph nodes from its origin to the thoracic inlet were cleared (Fig. 7). The distal esophageal stump was lifted, with careful preservation of the vagal branches to the esophagus, hilum, and heart, and subcarinal lymph nodes were dissected. The middle and lower thoracic esophagus was then sequentially mobilized from the posterior, left lateral, and anterior walls down to the esophageal hiatus. The lymphatic and fatty tissues within the contralateral mediastinal pleura were thoroughly removed (Fig. 8). The operative field was carefully inspected for bleeding. A fine drainage tube was placed through the eighth intercostal space at the mid-axillary line. After suctioning secretions and reinflating the lungs, a standard chest tube was inserted through the incision. The incision was then closed in layers.
Fig. 1.
Thoracic incision
Fig. 2.
The mediastinal pleura was incised at the pleural apex
Fig. 3.
Dissection of the lymph nodes adjacent to the right recurrent laryngeal nerve
Fig. 4.
The posterior wall of the esophagus was mobilized with preservation of the thoracic duct
Fig. 5.
Dissection of the lymph nodes located beneath the azygos arch
Fig. 6.
The esophagus was transected
Fig. 7.
The left recurrent laryngeal nerve was identified and carefully preserved
Fig. 8.
The middle and lower esophagus was mobilized down to the esophageal hiatus
Abdominal phase
The patient was placed in the supine position with legs abducted and both arms resting naturally at the sides. The surgeon stood between the patient’s legs, while the endoscope assistant and first assistant stood on the patient’s right side. A 3 cm incision was made above the umbilicus, through which a multi-channel single-port sealed wound protector was inserted. Pneumoperitoneum was established, and intra-abdominal pressure was maintained at 10–13 mmHg. Additionally, a 1 cm auxiliary port was created 2 cm below the costal margin along the left midclavicular line for insertion of atraumatic graspers and standard laparoscopic instruments (Fig. 9). To optimize exposure, a liver retraction technique was employed intraoperatively. We used prolene suture line, inserting the needle 2 cm below the xiphoid process on the left side of the falciform ligament and again 2 cm below the costal margin on the right side of the falciform ligament. Both ends of the suture were brought outside the abdominal cavity and tied externally. By tightening and securing the suture outside the abdomen, the left lobe of the liver was effectively suspended (Figs. 10, 11 and 12). The patient was positioned in a 15° reverse Trendelenburg and 30° right tilt to allow gravitational retraction of abdominal viscera, thereby avoiding obstruction of the surgical field and achieving optimal exposure. An ultrasonic scalpel was used to dissect the greater omentum approximately 2.0 cm lateral to the vascular arcade along the greater curvature of the stomach. Avascular zones were marked with gauze, with care taken to preserve the right gastroepiploic vascular arcade (Fig. 13). The left gastroepiploic artery, short gastric vessels, and peritoneal attachments surrounding the abdominal esophagus were ligated and divided. The patient was then tilted 30° to the left to facilitate dissection of the lesser curvature, during which lymph nodes adjacent to the left gastric artery, splenic artery, and common hepatic artery were meticulously dissected. The left gastric vessels were clipped with Hem-o-Lok clips and divided (Fig. 14). Gastric mobilization was continued, and regional perigastric and abdominal lymph nodes were thoroughly dissected. After incising the esophageal hiatus, the abdominal esophagus was mobilized by dissecting the surrounding tissues and clearing lymph nodes along the left and right sides of the cardia, until the lower thoracic esophagus was completely freed and continuity with the mediastinum was established. The distal esophageal stump was then gently pulled into the abdominal cavity (Fig. 15). The esophageal stump was further retracted ventrally, and the lower pole of the spleen was carefully dissected and separated (Fig. 16), ensuring complete mobilization of the stomach.
Fig. 9.
Abdominal incision
Fig. 10.
Liver retraction technique (1)
Fig. 11.
Liver retraction technique (2)
Fig. 12.
Liver retraction technique (3)
Fig. 13.
The right gastroepiploic vascular arch was preserved
Fig. 14.
Lymphadenectomy was performed along the left gastric artery, splenic artery, and common hepatic artery
Fig. 15.
The esophageal stump was exteriorized
Fig. 16.
The inferior pole of the spleen was mobilized
Retrosternal tunnel
With the patient in the supine position, the surgeon stood on the right side and the endoscope assistant on the left. Under direct laparoscopic visualization, an ultrasonic scalpel was used to create the retrosternal tunnel starting from the area below the xiphoid process. During dissection, the parietal pleura was carefully preserved, and the tunnel was maintained strictly along the midline to avoid inadvertent entry into the pericardium or mediastinal pleura. The tunnel was extended superiorly toward the root of the left neck (Fig. 17). The retrosternal fascia at the upper margin of the substernal space was fully dissected to enlarge the entry site beneath the xiphoid process. The abdominal esophagus and stomach were exteriorized through the abdominal incision, and a gastric conduit was fashioned extracorporeally using a linear stapler.
Fig. 17.
The retrosternal tunnel was created under direct vision
Cervical phase
The patient remained in the supine position. A 3–4 cm incision was made along the medial border of the left sternocleidomastoid muscle to expose the cervical esophagus. The cervical esophagus was mobilized, a purse-string suture was placed, and the proximal esophagus was transected. The anvil of a circular stapler was inserted into the esophageal stump. A strip of Vaseline gauze was passed through the retrosternal tunnel to further dilate the tract. Under direct laparoscopic vision, the gastric conduit was then carefully pulled through the retrosternal tunnel into the neck. Esophagogastric anastomosis was completed using a circular stapler at the cervical level (Fig. 18).
Fig. 18.
The tubularized stomach was elevated under direct vision
Outcome measures
Baseline characteristics and perioperative outcomes were retrospectively collected. The perioperative parameters included operative time, intraoperative blood loss, number of lymph nodes dissected, postoperative pain score on postoperative day 1 using the visual analogue scale (VAS), length of postoperative hospital stay, and complications occurring within 30 days after surgery.
Statistical analysis
All statistical analyses were performed using SPSS version 22.0. Continuous variables were presented as mean ± standard deviation or median with interquartile range, depending on the distribution. Categorical variables were expressed as frequencies and percentages. Descriptive statistics were used to assess the safety and efficacy of the surgical procedure, including demographic and clinical characteristics, perioperative outcomes, and the incidence of postoperative complications.
Result
Demographic and clinical characteristics
A total of 60 patients with esophageal cancer were included in this study. The mean age was 62.70 ± 8.64 years, with a predominance of male patients 80.00% (n = 48) over male patients 20.00% (n = 12). The mean body mass index was 21.78 ± 2.92 kg/m². Eleven patients (18.33%) were former smokers, while only three patient (5.00%) was a former drinker. Regarding performance status, 68.33% (n = 41) of patients had an Eastern Cooperative Oncology Group (ECOG) score of 0, and 31.67% (n = 19) had a score of 1.
The most common comorbidity was cardiovascular disease/hypertension 23.33% (n = 14), followed by diabetes mellitus 13.33% (n = 8), chronic bronchitis 10.00% (n = 6), and tuberculosis 5.00% (n = 3). Clinical staging revealed that the majority of patients presented with T3 disease 73.33% (n = 44), while T2, T1, and T4 disease accounted for 16.67% (n = 10), 8.33% (n = 5), and 1.67% (n = 1), respectively. Regarding nodal status, 50.00% (n = 30) of patients were clinically N0, 38.33% (n = 23) were N1, and 11.67% (n = 7) were N2.
The mean distance from the tumor to the incisor was 29.92 ± 4.98 cm. Tumors were predominantly located in the lower 40.00% (n = 24) and middle 45.00% (n = 27) esophagus, with fewer cases in the upper esophagus 15.00% (n = 9). Approximately half of the patients 51.67% (n = 31) received neoadjuvant treatment prior to surgery (Table 1).
Table 1.
Clinical characteristics of patients
| Variables | Total (n = 60) |
|---|---|
| Age, years (Mean ± SD) | 62.70 ± 8.64 |
| Gender, n(%) | |
| Females | 12 (20.00) |
| Males | 48 (80.00) |
| Body Mass Index, (Mean ± SD) | 21.78 ± 2.92 |
| Former smoker, n(%) | 11 (18.33) |
| Former drinker, n(%) | 3 (5.00) |
| ECOG, n(%) | |
| 0 | 41 (68.33) |
| 1 | 19 (31.67) |
| Comorbidities, n(%) | |
| Cardiovascular/Hypertension | 14 (23.33) |
| Diabetes mellitus | 8 (13.33) |
| Tuberculosis | 3 (5.00) |
| Chronic bronchitis | 6 (10.00) |
| Clinical T stage, n(%) | |
| 1 | 5 (8.33) |
| 2 | 10 (16.67) |
| 3 | 44 (73.33) |
| 4 | 1 (1.67) |
| Clinical N stage, n(%) | |
| 0 | 30 (50.00) |
| 1 | 23 (38.33) |
| 2 | 7 (11.67) |
| Distance from tumor to incisor, cm (Mean ± SD) | 29.92 ± 4.98 |
| Tumor location, n(%) | |
| Upper | 9 (15.00) |
| Middle | 27 (45.00) |
| Low | 24(40.00) |
| Neoadjuvant treatment, n(%) | 31 (51.67) |
Surgical and pathological outcomes
The mean operation time was 209.35 ± 28.57 min, with an average intraoperative blood loss of 64.17 ± 20.53 ml. The mean number of harvested lymph nodes was 32.35 ± 11.51 per patient. The azygos arch was preserved in all cases (100%), and an R0 resection was achieved in all patients (100%). Histopathological examination revealed moderately differentiated tumors (G2) in 45.00% (n = 27) of cases, followed by well-differentiated tumors (G1) in 38.33% (n = 23), and poorly differentiated tumors (G3) in 5.00% (n = 3). The differentiation status could not be determined (Gx) in 11.67% (n = 7) of cases. Pathological staging demonstrated downstaging in some patients compared to clinical staging, with 6.67% (n = 4) achieving a complete pathological response (pT0). The distribution of pathological T stages was as follows: pT1 in 21.67% (n = 13), pT2 in 23.33% (n = 14), and pT3 in 48.33% (n = 29). Regarding pathological N stage, 51.67% (n = 31) of patients were pN0, 18.33% (n = 11) were pN1, 28.33% (n = 17) were pN2, and 1.67% (n = 1) was pN3 (Table 2).
Table 2.
Surgical and pathological outcomes
| Variables | Total (n = 60) |
|---|---|
| Operation time (minutes), Mean ± SD | 209.35 ± 28.57 |
| Intraoperative blood loss (ml), Mean ± SD | 64.17 ± 20.53 |
| Lymph node harvest, Mean ± SD | 32.35 ± 11.51 |
| Preserve the azygos arch | 60(100.00) |
| R0 resection rate, n(%) | 60(100.00) |
| Tumor grade, n(%) | |
| G1 | 23(38.33) |
| G2 | 27(45.00) |
| G3 | 3(5.00) |
| Gx | 7(11.67) |
| Pathological T stage, n(%) | |
| 0 | 4 (6.67) |
| 1 | 13 (21.67) |
| 2 | 14 (23.33) |
| 3 | 29 (48.33) |
| Pathologcal N stage, n(%) | |
| 0 | 31 (51.67) |
| 1 | 11 (18.33) |
| 2 | 17 (28.33) |
| 3 | 1 (1.67) |
Perioperative outcomes and complications
The mean time to gastric tube removal was 4.50 ± 0.65 days, while the jejunal feeding tube was removed after 21.00 ± 13.86 days on average. All patients had their neck drainage tubes removed on the first day after surgery. Patients reported a mean visual analog scale (VAS) pain score of 2.20 ± 0.99 postoperatively. The mean length of hospital stay was 7.92 ± 2.11 days. Postoperative complications occurred in 16.67% (n = 10) of patients. These included arrhythmia 5.00% (n = 3), pneumonia 6.67% (n = 4), hoarseness 3.33% (n = 2), and anastomotic leakage 5.00% (n = 3). No cases of chylothorax, bleeding, incision infection, pulmonary embolism, or stroke were observed. According to the Clavien-Dindo classification, 83.33% (n = 50) of patients had no complications (grade 0), 15.00% (n = 9) had grade 2 complications, and 1.67% (n = 1) had a grade 3b complication. Postoperative adjuvant therapy was administered to 63.33% (n = 38) of patients. Notably, there were no 30-day readmissions or 90-day mortality cases in this cohort (Table 3).
Table 3.
Perioperative outcomes and complications
| Variables | Total (n = 60) |
|---|---|
| Time of gastric tube removal (d), Mean ± SD | 4.50 ± 0.65 |
| Jejunal feeding tube removal time (d), Mean ± SD | 21.00 ± 13.86 |
| Time for neck drainage tube removal (d), Mean ± SD | 1.00 ± 0.00 |
| VAS score on postoperative, Mean ± SD | 2.20 ± 0.99 |
| Length of hospital stay (d), Mean ± SD | 7.92 ± 2.11 |
| Complication, n(%) | 10 (16.67) |
| Pneumonia, n(%) | 4 (6.67) |
| Anastomotic leak, n(%) | 3 (5.00) |
| Chylothorax, n(%) | 0 (0.00) |
| Hoarseness, n(%) | 2 (3.33) |
| Arrhythmia, n(%) | 3 (5.00) |
| Bleeding, n(%) | 0 (0.00) |
| Infection of incision, n(%) | 0 (0.00) |
| Pulmonary embolism, n(%) | 0 (0.00) |
| Stroke, n(%) | 0 (0.00) |
| Clavien-Dindo, n(%) | |
| 0 | 50 (83.33) |
| 2 | 9 (15.00) |
| 3b | 1 (1.67) |
| Postoperative adjuvant therapy, n(%) | 38 (63.33) |
| 30-day readmission, n(%) | 0 (0.00) |
| 90-day mortality, n(%) | 0 (0.00) |
Discussion
Since Muhe performed the world’s first laparoscopic cholecystectomy in 1986, minimally invasive surgery has advanced rapidly. Minimally invasive techniques for esophageal cancer have also garnered increasing attention from thoracic surgeons. Thoracoscopic and laparoscopic minimally invasive esophagectomy (MIE) has gradually become a widely accepted treatment option, with multiple studies demonstrating its advantages in reducing pulmonary complications and promoting postoperative recovery [6]. However, conventional thoraco-laparoscopic esophagectomy typically requires multiple incisions in both the thoracic and abdominal regions, and the creation of the gastric conduit often necessitates extension of the upper abdominal incision, which limits the extent of minimal invasiveness. Multiple intercostal incisions increase the risk of intercostal nerve injury, thereby exacerbating postoperative pain. Similarly, repeated manipulation through multiple abdominal ports can also adversely affect postoperative recovery. With the introduction of uniportal thoracoscopic and single-incision plus one port laparoscopic echniques in esophageal cancer surgery, the field has gradually entered the single-port era. Compared with conventional multi-port approaches, single-port procedures offer significant advantages in reducing postoperative pain and enhancing recovery. The findings of the present study demonstrate that uniportal thoracoscopic and single-incision plus one port laparoscopic esophagectomy combined with retrosternal reconstruction under direct vision yields satisfactory perioperative outcomes and complication rates in the treatment of esophageal cancer.
Currently, reports on the application of single-incision endoscopic techniques in esophagectomy are primarily retrospective in nature, and large-scale randomized controlled trials are lacking. This may be attributed to the overall technical difficulty associated with the procedure. Nachira and Wang et al. ([7]– [8]) reported on 12 and 44 cases of single-incision minimally invasive esophagectomy (MIE), respectively, and demonstrated that operative time and the number of lymph nodes dissected were comparable to those in conventional multi-port MIE. Similarly, Fang et al. conducted a retrospective analysis of 202 patients who underwent single-port thoracoscopic esophagectomy at our center, showing that the incidence of postoperative complications was lower and short-term outcomes were more favorable compared with conventional multi-port MIE [9]. Intraoperative blood loss and thoracic drainage volumes were found to be similar between the two approaches [10], while hospital stay, postoperative pain, pulmonary complications, and anastomotic leakage were all significantly reduced in the single-port group [11], confirming the advantages of single-port thoracoscopic esophagectomy in improving postoperative recovery and reducing morbidity. In addition, Lee et al. [12] were the first to report a retrospective study comparing uniportal thoracoscopic and single-incision plus one port laparoscopic minimally invasive esophagectomy (SIMIE) with conventional multi-port MIE. Their analysis included 16 patients undergoing SIMIE and 315 patients undergoing traditional MIE. The results showed that SIMIE yielded comparable outcomes in terms of ventilator use, ICU stay, and number of lymph nodes dissected. In the present study, we successfully performed uniportal thoracoscopic and single-incision plus one port laparoscopic three-field radical esophagectomy with retrosternal reconstruction under direct vision in 60 patients with esophageal cancer. The mean operative time was 209.35 ± 28.57 min, which was not significantly different from previously reported durations for conventional multi-port MIE. These findings suggest that this single-incision approach is technically feasible and clinically acceptable. Our experience also indicates that, with well-coordinated surgical teamwork and optimized procedural workflow, the uniportal thoracoscopic and single-incision plus one port laparoscopic approach combined with retrosternal reconstruction can effectively overcome challenges such as instrument interference and suboptimal exposure, while maintaining surgical safety and efficacy.
In the treatment of esophageal cancer, complete lymphadenectomy and recurrent laryngeal nerve preservation are prioritized over cosmetic incision and postoperative pain control. In an earlier report by Lee et al. [12], single-port thoraco-laparoscopic esophagectomy achieved an average lymph node yield of 28.6 ± 14.6. In the present study, all patients underwent R0 resection with an average of 32.35 ± 11.51 lymph nodes harvested, which exceeds previous reports and indicates that this technique fully meets the oncological standards for radical esophagectomy. No local recurrence was observed during postoperative follow-up, suggesting that this approach yields satisfactory oncological outcomes. Moreover, no intraoperative complications or conversions to thoracotomy or laparotomy occurred. Compared with traditional multi-port minimally invasive esophagectomy (MIE), the single-port approach offers superior cosmetic results and reduced surgical trauma. In a propensity-matched analysis, Lee et al. [4]reported significantly lower pain scores one week postoperatively in the single-port group compared to the multi-port group. In our study, the mean postoperative pain score was 2.20 ± 0.99, further supporting the notion that this approach is associated with milder postoperative pain, which facilitates early recovery and may effectively reduce the incidence of complications such as pneumonia [13].
Currently, gastric conduit reconstruction for esophageal cancer primarily involves three routes: retrosternal, posterior mediastinal, and subcutaneous pathways. Each reconstruction route has its own advantages and disadvantages, and the optimal pathway following esophagectomy remains controversial. Some studies suggest that the retrosternal route is shorter than the posterior mediastinal route, indicating potentially better blood supply to the gastric conduit, which may benefit anastomotic healing [14]. Pulmonary complications, occurring in approximately 15% of cases, are among the most common postoperative adverse events [15] and have a significant negative impact on overall survival after esophagectomy. Data from the Japanese National Clinical Database (NCD) show that the incidence of pneumonia is significantly lower in the retrosternal group compared to the posterior mediastinal group (12.2% vs. 13.7%). Moreover, a case-control study reported pneumonia rates of 7.1% and 29.0% in minimally invasive esophagectomy (MIE) performed via the retrosternal and posterior mediastinal routes, respectively [16]. In our study, all 60 patients underwent retrosternal reconstruction under direct vision, with only four cases (6.67%) developing postoperative pneumonia, a rate substantially lower than those reported in the literature. The posterior mediastinal route may result in compression of the trachea and bronchi by the gastric conduit and omentum, leading to atelectasis and pneumonia, whereas such issues are absent in the retrosternal route, which may explain the difference. Our findings demonstrate a significant advantage of the retrosternal route in reducing postoperative pulmonary infections. Collectively, these results suggest that uniportal thoracoscopic and single-incision plus one port laparoscopic esophagectomy combined with direct-vision retrosternal reconstruction is a safe and effective approach, offering benefits of improved cosmesis, reduced surgical trauma, and decreased postoperative complications.
In recent years, functional surgery for esophageal cancer has attracted increasing attention from thoracic surgeons. Naturally, such functional procedures must not compromise the principles of radical oncologic resection. Early reports by J. Boone et al. demonstrated that preservation of the azygos vein during esophagectomy did not adversely affect mediastinal lymphadenectomy [17]. Subsequently, multiple domestic studies further explored functional esophageal cancer surgery involving preservation of the azygos vein, bronchial arteries, and vagal pulmonary branches. These studies showed no significant differences between the functional surgery group and conventional esophagectomy in terms of lymph node yield, short-term recurrence or metastasis rates, and survival outcomes [18]. In the present study, all 60 patients underwent retrosternal reconstruction under direct vision, which avoided disruption of the posterior mediastinal tissues by the gastric conduit and inherently facilitated protection of the azygos vein, bronchial arteries, and vagal pulmonary branches. In addition, our practice involves maintaining the jejunostomy tube for a relatively prolonged period (mean 21.00 ± 13.86 days) to optimize postoperative management. This strategy ensure adequate nutritional support during the early recovery phase, provides protection against potential late anastomotic complications, and allows a gradual transition to oral intake under careful monitoring for anastomotic stricture or swallowing difficulties.
This study also has several limitations. Firstly, it was a retrospective, single-center study based on the experience of a single surgeon, which may introduce selection bias. As patients were not randomly assigned to receive this surgical apporach. This may have resulted in the selection of patients with more favorable characteristics for this technically demanding procedure. Secondly, the learning curve for this complex procedure is steep, and outcome may vary significantly during the initial implementation phase at other centers. Our team had substantial prior experience with conventional minimally invasive esophagectomy before transitioning to this single-port apporach, which likely contributed to our favorable outcomes. Thirdly, our focus on perioperative limits our long-term oncological efficacy of this approcah. We are currently collecting long-term survival data, which will be essential for a comprehensive evaluation of this surgical technique. Finally, future studies should incorporate standardized assessment tools such as the EORTC QLQ-C30 and FACT-E, to better evaluate the functional outcomes and patient-reported experience.
In summary, for centers with extensive experience in endoscopic techniques, uniportal thoracoscopic and single-incision plus one port laparoscopic esophagectomy combined with direct-vision retrosternal reconstruction apperas to be a safe and feasible option for selected patients with esophageal cancer when performed by well-trained surgeons experienced in minimally invasive esophageal surgery.
Acknowledgements
We appreciate all the team members from Fujian Cancer Hospital, the Department of Thoracic Oncology for their help.
Authors’ contributions
(I) Conception and design: RuiRong Lin(II) Administrative support: Weiming Fang(III) Provision of study materials or patients: Jiarong Zhang, Weiming Fang(IV) Collection and assembly of data: RuiRong Lin, Jiarong Zhang, Yijing Lin(V) Data analysis and interpretation: RuiRong Lin, Jiarong Zhang, Yijing Lin(VI) Manuscript writing: Ruirong Lin, Yijin Lin, Weikun Su, Guibin Weng, Lin Chen, Weimin Fang1, Jiarong Zhang(VII) Final approval of manuscript: Ruirong Lin, Yijin Lin, Weikun Su, Guibin Weng, Lin Chen, Weimin Fang1, Jiarong Zhang.
Funding
This work was supported by Medical Innovation Project of Fujian Province (2024Y9633, 2024Y9632).
Data availability
Due to privacy concerns, the data is not publicly available, but can be obtained from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of the Fujian Cancer Hospital (SQ2024-018) and study was conducted under the guidance of the Declaration of Helsinki. All participants signed a written informed consent form.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Ruirong Lin and Yijin Lin contributed equally to this work.
Contributor Information
Weimin Fang, Email: fwm3660063@163.com.
Jiarong Zhang, Email: 985691470@qq.com.
References
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Associated Data
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Data Availability Statement
Due to privacy concerns, the data is not publicly available, but can be obtained from the corresponding author upon reasonable request.