Artificial Intelligence in Esophagectomy: A Systematic Review

<b>Background</b>: Esophagectomy remains a technically demanding oncologic procedure with substantial morbidity, despite ongoing advances in minimally invasive and robotic techniques. Limitations in intraoperative visualization and anatomical recognition contribute to complications such as nerve injury and bleeding. Artificial intelligence (AI)-based intraoperative video analysis has emerged as a potential adjunct to enhance surgical perception and safety, but its application in esophagectomy has not been comprehensively reviewed. <b>Methods</b>: A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Scopus, and Web of Science were searched without a lower date limit to identify eligible studies published up to January 2026, capturing early and contemporary applications of intraoperative AI in esophagectomy. Human studies involving any surgical approach were included. Data on the AI task, methodology, validation strategy, performance metrics, and reported clinical outcomes was extracted. Risk of bias was assessed using the ROBINS-I tool. <b>Results</b>: Six studies met the inclusion criteria, predominantly evaluating AI-driven analysis of intraoperative video during minimally invasive or robotic esophagectomy. Reported applications included real-time anatomical structure recognition, recurrent laryngeal nerve segmentation, detection of excessive nerve traction, instrument and event recognition, and surgical phase identification. Across studies, AI systems demonstrated performance comparable to expert surgeons for selected tasks and achieved real-time or near-real-time inference. One study reported earlier detection of excessive recurrent laryngeal nerve traction compared to conventional nerve integrity monitoring. However, most studies were retrospective, single-center, and feasibility-focused, with limited external validation and minimal assessment of patient-centered clinical outcomes. <b>Conclusions</b>: Artificial intelligence-based intraoperative analysis in esophagectomy is increasingly achievable and may enhance anatomical recognition, intraoperative risk detection, and procedural awareness. Nevertheless, current evidence remains preliminary, heterogeneous, and largely exploratory. Prospective, multicenter studies with standardized reporting and clinically meaningful outcome evaluation are required before routine implementation. Until such data is available, AI should be regarded as a complementary intraoperative tool rather than a standalone clinical decision-making system.