Perioperative outcomes of robotic versus conventional minimally invasive McKeown esophagectomy for esophageal cancer: An updated systematic review and meta-analysis.

This meta-analysis aims to provide an up-to-date comparison of robotic-assisted versus conventional minimally invasive McKeown esophagectomy (RAMIE vs. CMIE), along with a formal assessment of certainty of evidence using the GRADE approach. The database search included PubMed, Scopus, and the Cochrane Library. Odds ratios were used for dichotomous outcomes, along with random effects and the mean difference with inverse variance for continuous outcomes. Publication bias was assessed for the primary analysis. Certainty of evidence was assessed using GRADE. Subgroup analyses were performed for prospective studies and squamous cell carcinoma cohorts. Sensitivity analysis was performed for key outcomes. In total, twenty-five observational studies and three randomized controlled trials were included. In the primary analysis RAMIE was associated with a higher total lymph node yield (MD + 1.46, 95% CI 0.33–2.58,p = 0.01), higher mediastinal lymph node yield (MD + 1.13, 0.07–2.20, p = 0.04), higher left recurrent laryngeal lymph node yield (MD + 0.59, 0.20–0.98, p = 0.006), fewer pulmonary complications (OR 0.69, 0.59–0.82, p < 0.0001) and lower rates of recurrent laryngeal nerve palsy (OR 0.73, 0.55–0.96, p = 0.03). The operative duration estimated blood loss, right recurrent laryngeal lymph node yield, abdominal lymph node yield, anastomotic leakage, conversion to open surgery, 30- and 90-day mortality, chyle leak, length of stay, cardiac and infectious complications did not differ significantly. In prospective studies, RAMIE was associated with a significant increase in the total lymph node yield (MD + 2.71, 0.23–5.19, p = 0.04). Non-significant differences were observed in the remaining outcomes. In squamous cell carcinoma cohort, RAMIE was associated with reduced estimated blood loss (MD − 12.59 mL, − 25.05 to − 0.12, p = 0.05), and pulmonary complications (OR 0.67, 0.55–0.83, p = 0.001) along with a higher total lymph node yield (MD + 1.86, 1.05–2.68, p = 0.0006) and a higher left recurrent laryngeal nerve lymph node yield (MD + 0.69, 0.21–1.17, p = 0.01). In the RCT subgroup, RAMIE was associated with significantly reduced blood loss, with the other outcomes remaining non-significant certainty evidence was moderate for lymph node-related outcomes and pulmonary complications and low to very low for most peri-operative outcomes due to heterogeneity and imprecision. RAMIE was associated with higher lymph node yield and lower pulmonary complications and recurrent laryngeal nerve palsies compared with CMIE in the McKeown approach. However, the overall certainty of the evidence ranged from very low to moderate, with substantial heterogeneity, and findings should be interpreted with caution. Well-designed randomized controlled trials are necessary to verify the benefits of RAMIE and determine the impact on long-term outcomes.PROSPERO registration: CRD420261290901.