Prognosis of Robot-Assisted Esophagectomy with Thoracic Duct Resection in Esophageal Squamous Cell Carcinoma.

Background: The authors' previous study found no significant difference in short-term clinical outcomes between patients undergoing robot-assisted esophagectomy (RAE) with or without thoracic duct resection (TDR). However, the impact of RAE-TDR on long-term prognosis remains unclear.

Methods: From January 2019 to July 2020, the study prospectively and consecutively enrolled 127 thoracic duct (TD)-preserved and 73 TD-resected patients who underwent standard McKeown RAE surgery. The overall survival (OS) and recurrence-free survival (RFS) were compared between these two groups.

Results: During a median follow-up period of 48.6 months, the 3-year OS rates were 70.6% and 70.9% in the TD-preserved and TD-resected group, and the 3-year RFS rates were 61.9% and 55.5%, respectively. The TD-preserved and TD-resected groups did not differ significantly in local-regional (12.6% vs. 15.1%; p = 0.623), distant (23.6% vs. 28.8%; p = 0.422), or mixed (2.4% vs. 4.1%; p = 0.670) recurrence. However, among the eight (11%) patients with TD lymph node (LN) metastasis in the TD-resected group, six patients experienced recurrences (1 local-regional and 5 distant). The patients who had thoracic duct lymph node (TDLN) metastasis experienced significantly worse RFS than those who did not (p = 0.04). Additionally, TDLN metastasis was significantly associated with advanced nodal stage (cN2-3, 6/8; p = 0.001) and bulky tumors (pT3, 7/8; p = 0.028).

Conclusion: In ESCC, RAE-TDR does not improve recurrence or survival outcomes. However, identification of TDLN metastasis through TDR carries significant prognostic implications considering its strong association with aggressive tumor biology and inferior oncologic outcomes. Therefore, TDR should not be routinely performed, but its selective application for patients with advanced tumors may provide critical staging information to guide tailored postoperative strategies.