Robot-assisted esophagectomy noninferior to thoracoscopic surgery for squamous cell carcinoma

medwireNews: Patients undergoing minimally invasive esophagectomy for resectable esophageal squamous cell carcinoma have similar long-term survival, regardless of whether the procedure is robot-assisted or performed thoracoscopically, indicates the RAMIE trial.

“Robot-assisted oesophagectomy is a viable alternative surgical treatment to thoracoscopic oesophagectomy for patients with resectable thoracic oesophageal squamous cell cancer,” say Zhigand Li (Shanghai Jiao Tong University School of Medicine, China) and colleagues.

Initial findings from the phase 3, noninferiority trial showed short-term benefits, such as “shorter operative time and improved thoracic lymph node dissection” with robot-assisted minimally invasive, compared with thoracoscopic, esophagectomy, observe the researchers. The researchers then considered whether these early benefits extended to “meaningful long-term advantages over the established standard.”

As reported in The Lancet Gastroenterology and Hepatology, 362 patients aged 18–75 years with biopsy-proven disease with a clinical stage of cT1–4a, N0–2, and M0 or supraclavicular lymph node M1 were enrolled from six esophageal cancer centers in China. The mean age of the participants was 63.5 years and 85% were men.

The patients were randomly assigned to undergo robot-assisted or thoracoscopic esophagectomy by experienced surgeons who had completed over 300 procedures including at least 40 robot-assisted cases.

“[T]he procedure consisted of transthoracic oesophagectomy, stomach mobilisation, two-field lymphadenectomy and bilateral recurrent laryngeal nerves lymph node dissection, creation of gastric conduit with linear stapler, and stapled cervical oesophagogastric anastomosis,” the researchers explain.

A similar proportion of patients in the robot-assisted and thoracoscopic groups were receiving neoadjuvant therapy (22 vs 21%).

After a median follow-up of 71.5 months, the 5-year overall survival (OS) rate was a comparable 69.4% in the robot-assisted esophagectomy arm and 56.2% in the thoracoscopic esophagectomy arm. This yielded a hazard ratio for death of 0.71, which was significant for robot-assisted esophagectomy being noninferior to thoracoscopic esophagectomy.

There was also exploratory evidence suggesting a superior 5-year OS with robot-assisted esophagectomy in patients who received neoadjuvant therapy, at a rate of 69.8% versus 37.8% with thoracoscopic esophagectomy, but the team warns that this “underpowered finding warrants careful consideration.”

They continue, however: “It is plausible that the technical advantages of the robot—enhanced dexterity and visualisation—are most impactful in the post-treatment setting, where tissue planes are altered and dissection is more challenging.”

The investigators believe that a “more precise resection in this context could translate into a survival benefit, a possibility that merits focused investigation in future studies.”

Additional subgroup analysis showed no difference in survival outcomes between the two surgical techniques according to surgeon expertise, based on a cutoff of 100 cases.

“A key advantage of the robot-assisted technique is that it simplifies the external requirements for minimally invasive surgery to a greater extent and reduces the learning curve for fine surgical skills, which makes it particularly beneficial for lower-volume centres and less experienced surgeons, provided there is a good training system in place,” the study authors comment.

At data cutoff, 42% of study participants had died; 38% due to esophageal cancer. Deaths from esophageal cancer occurred in 33% of patients undergoing robot-assisted esophagectomy and in 42% of patients receiving thoracoscopic esophagectomy. The 5-year disease-free survival rates were a comparable 60.7% and 51.2%, respectively.

Li et al conclude that “[w]ith the increasing application of robot-assisted surgery, our findings will be more widely applicable, especially in centres that have not previously done robot-assisted oesophagectomy,”

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Lancet Gastroenterol Hepatol 2026; doi:10.1016/S2468-1253(25)00402-9