Respiratory Outcomes After Robotic, Thoracoscopic, and Open Esophagectomy

Objective: Postoperative pulmonary complications are a major determinant of morbidity after esophagectomy. This study evaluated the association between surgical approach and respiratory outcomes following robot-assisted minimally invasive esophagectomy (RAMIE), thoracoscopic minimally invasive esophagectomy (VATS-MIE), and open esophagectomy (OE). Methods: A retrospective cohort analysis was conducted on consecutive patients who underwent thoracic-phase esophagectomy for esophageal cancer at a single tertiary center between October 2020 and December 2024. Pulmonary outcomes, including pneumonia, respiratory failure or acute respiratory distress syndrome, re-intubation, prolonged mechanical ventilation, and intensive care unit (ICU) admission, were evaluated. Intensive care unit admission was also analyzed separately, and sensitivity analyses excluding ICU admission from the composite endpoints were performed. Multivariate logistic regression was used to evaluate adjusted associations with pulmonary morbidity. Results: Among 146 patients, 48 underwent RAMIE, 73 VATS-MIE, and 25 OE. The incidence of any pulmonary complication was significantly higher after OE than after minimally invasive approaches (60.0% vs. 22.3%, P < .001). Severe pulmonary events occurred in 32.0% of the OE procedures and 16.5% of the minimally invasive esophagectomy (MIE) procedures (P = .13). Pneumonia was more frequent after OE than after MIE (36.0% vs. 14.0%, P = .020). In sensitivity analyses excluding ICU admission, the difference in any pulmonary complication persisted between OE and MIE (60.0% vs. 19.0%, P < .001). In the adjusted analyses, OE remained associated with higher odds of pulmonary morbidity compared with RAMIE (OR 3.84, 95% CI = 1.34-10.98). No significant differences were observed between RAMIE and VATS-MIE for any or severe complications. Conclusion: In this single-center retrospective cohort, MIE was associated with lower overall postoperative pulmonary morbidity than OE. Pneumonia appeared to be the principal individual respiratory event contributing to this difference. Although RAMIE showed favorable overall pulmonary outcomes compared with OE, the absence of a statistically significant difference in severe pulmonary complications between RAMIE and VATS-MIE should not be interpreted as evidence of equivalence. Future multicenter studies with standardized perioperative protocols are needed to better define patient selection and comparative respiratory outcomes. Cite this article as: Deryol R, Tekin O, Uca Y, Abdukaya A, Yüksel S, Arikan S. Respiratory outcomes after robotic, thoracoscopic, and open esophagectomy. Cerrahpaşa Med J 2026, 50, 0078, doi: 10.5152/cjm.2026.26078.