Long-Term Outcomes of Carbon Dioxide Insufflation in Thoracoscopic Esophagectomy After Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma: A Retrospective Cohort Study

Background: Thoracoscopic esophagectomy (TE) with carbon dioxide (CO₂) insufflation is increasingly performed for esophageal cancer; however, there is limited evidence of the long-term outcomes of CO₂ insufflation on postoperative survival.

Objectives: We investigated the long-term outcomes of TE with or without CO₂ insufflation.

Methods: We enrolled 182 patients who underwent TE for esophageal cancer between January 2003 and October 2013 and categorized them into two groups: with and without CO₂ insufflation. The primary endpoint was five-year overall survival (5y-OS). Secondary endpoints included long-term outcomes, such as five-year relapse-free survival (5y-RFS) and five-year cancer-specific survival (5y-CSS), and short-term outcomes, such as surgical and non-surgical complications and reoperation within 30 days.

Results: Follow-up until death or the five-year postoperative period was 98.9% (median follow-up duration was six years in survivors). After adjusting for age, sex, and yield pathologic tumor, node, and metastasis (TNM) stage, we found no significant differences in 5y-OS (HR 1.12, 95% CI 0.66-1.91), 5y-RFS (HR 1.12, 95% CI 0.67-1.83), or 5y-CSS rates (HR 1.00, 95% CI 0.57-1.75). For short-term outcomes, significant intergroup differences in operation time (p=0.02), blood loss (p<0.001), postoperative length of stay (p<0.001), and incidence of atelectasis (p=0.004) were observed. The results of the sensitivity analysis were similar to the main results.

Conclusions: In thoracoscopic procedures, CO₂ insufflation significantly improved short-term outcomes, and it appears that the recurrence risk of esophageal cancer may not impact the long-term prognosis. While the influence of CO₂ insufflation in thoracoscopic esophageal surgery remains unclear, our study suggests that the long-term prognosis is not compromised in other thoracic surgeries.