Survival of Open Versus Thoracoscopic Esophagectomy for Esophageal Squamous Cell Cancer by Tumor Location: An Energy Balancing Weights Analysis.

Background: The survival impact of open esophagectomy (OE) versus thoracoscopic esophagectomy (TE) in patients with esophageal squamous cell carcinoma (ESCC) based on tumor location remains debated. This study employs energy balancing weights (EBW) to compare long-term survival between OE and TE across tumor locations.

Patients and methods: This ambispective cohort study analyzed 1778 patients with ESCC undergoing OE or TE at a tertiary hospital between January 2015 and December 2016. Primary endpoints were 5-year overall survival (OS) and disease-free survival (DFS); secondary endpoints included operative safety. EBW-adjusted Cox regression was used to compare long-term survival, with sensitivity analyses via inverse probability of treatment weighting and matching weight methods.

Results: The median survival times for upper, middle, and lower tumor locations were 60.06, 60.48, and 64.35 months, respectively. Compared with OE, the Cox regression analysis of TE showed that in the upper group, the HR was 0.45 (95% CI 0.27-0.75) for OS and the HR was 0.55 (0.34-0.89) for DFS. In the middle group, theHR was 0.64 (0.48-0.85) for OS and the HR was 0.70 (0.53-0.91) for DFS. And in the lower group, the HR was 0.70 (0.44-1.11) for OS and the HR was 0.67 (0.43-1.04) for DFS. Additionally, TE was associated with reduced blood loss and increased lymph node yield but had longer operative times and higher costs (P < 0.05).

Conclusions: TE improved survival and safety in upper/middle ESCC, while lower tumor locations require individualized approaches. EBW enhanced confounder control, supporting reliable clinical decisions.