Preoperative CT Three-dimensional Reconstruction Guides Single-incision Minimally Invasive Esophagectomy with Retrosternal Route Selection: A Prospective Cohort Study

Preoperative CT Three-dimensional Reconstruction Guides Single-incision Minimally Invasive Esophagectomy with Retrosternal Route Selection: A Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Preoperative CT Three-dimensional Reconstruction Guides Single-incision Minimally Invasive Esophagectomy with Retrosternal Route Selection: A Prospective Cohort Study Ruirong Lin, Jiarong Zhang, Guibin Weng, Yijin Lin, Lin Chen, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8126304/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Background The optimal reconstruction route following esophagectomy remains controversial, with limited objective criteria for route selection. This study investigated whether preoperative CT three-dimensional reconstruction can guide surgical route selection in single-incision minimally invasive esophagectomy (SIMIE) with retrosternal reconstruction. Methods We conducted a prospective analysis of 111 consecutive patients with esophageal cancer who underwent SIMIE with retrosternal route reconstruction between January 2024 and October 2025. Preoperative CT three-dimensional reconstruction measured both retrosternal reconstruction (RR) and posterior mediastinal reconstruction (PR) route lengths from esophagus at thyroid cartilage level to gastroduodenal artery. Primary outcomes included perioperative complications, particularly anastomotic leakage rates. Results Mean RR route length was 293.3±19.54 mm, significantly shorter than PR route length (315.4±19.13 mm, difference 22.1 mm, p<0.001). All patients completed SIMIE-RR successfully with mean operative time 209.5±25.7 minutes, blood loss 65.5±10.3 mL, and hospital stay 6.0±1.0 days. Anastomotic leakage occurred in 2 patients (1.8%), both having longer RR than PR routes on preoperative measurements. BMI demonstrated significant positive correlation with RR route length (r=0.6671, p<0.0001), while other patient characteristics showed no significant correlations. Total lymph node harvest achieved 34±10.2 nodes. Conclusions Preoperative CT three-dimensional reconstruction effectively guides optimal route selection in SIMIE esophagectomy through objective pathway measurements. When RR route length exceeds PR length, particularly in patients with higher BMI, posterior mediastinal reconstruction may be preferable to reduce anastomotic complications. esophageal cancer single-incision minimally invasive esophagectomy three-dimensional reconstruction retrosternal reconstruction Introduction Esophageal cancer represents one of the most formidable challenges in oncological surgery, ranking as the eighth most common malignancy worldwide and the sixth leading cause of cancer-related mortality, with an estimated 604,100 new cases and 544,076 deaths globally in 2020 [ 1 ]. The devastating nature of this disease is exemplified by its five-year survival rate of approximately 15–20% across all stages, largely attributable to the aggressive biological behavior, tendency for early lymphatic and hematogenous metastasis, and late presentation due to the absence of early symptoms [ 2 ]. The geographic distribution of esophageal cancer demonstrates striking heterogeneity, with squamous cell carcinoma predominating in the "esophageal cancer belt" extending from northern China through Central Asia to northern Iran, while adenocarcinoma has shown alarming increases in Western populations, particularly associated with gastroesophageal reflux disease and Barrett's esophagus [ 3 , 4 ]. The complexity of esophageal cancer management stems from its anatomical location within the posterior mediastinum, surrounded by vital structures including the heart, great vessels, trachea, and bilateral recurrent laryngeal nerves, making surgical resection technically demanding and fraught with potential complications. Historical outcomes of esophageal surgery were marked by significant morbidity and mortality, with early series reporting operative mortality rates exceeding 20% and anastomotic leak rates approaching 30–40% [ 5 ]. These sobering statistics led to the evolution of surgical techniques, perioperative care protocols, and multidisciplinary treatment approaches that have gradually improved outcomes over the past several decades [ 6 ]. The paradigm shift toward neoadjuvant chemoradiotherapy has demonstrated improved pathological complete response rates, R0 resection rates, and overall survival compared to surgery alone [ 7 ]. However, the addition of neoadjuvant therapy introduces additional complexity to surgical planning, as radiation-induced tissue fibrosis, altered anatomy, and compromised tissue healing can significantly impact reconstruction options and anastomotic integrity [ 8 ]. The challenge of optimizing surgical outcomes in this context has driven innovation in surgical techniques, with the evolution from open transthoracic approaches to minimally invasive and, more recently, robotic-assisted procedures [ 9 , 10 ]. The transformative impact of minimally invasive esophagectomy was definitively established, which demonstrated a significant reduction in pulmonary complications from 34% in the open group to 9% in the minimally invasive group, while maintaining equivalent oncological outcomes and long-term survival [ 11 ]. This pivotal study catalyzed widespread adoption of minimally invasive techniques, leading to subsequent refinements including totally minimally invasive approaches, single-incision techniques, and robotic-assisted procedures. The benefits of minimally invasive esophagectomy extend beyond reduced pulmonary complications to include decreased blood loss, shorter intensive care unit stays, reduced postoperative pain, improved cosmetic outcomes, and faster functional recovery [ 12 , 13 ]. Single-incision minimally invasive esophagectomy (SIMIE) represents the latest evolution in this technological progression, embodying the principles of reduced port-site morbidity, minimized intercostal nerve injury, and enhanced cosmetic outcomes while maintaining the established benefits of minimally invasive surgery [ 14 ]. The concept of single-incision surgery gained momentum across multiple surgical specialties following successful implementation in laparoscopic cholecystectomy and appendectomy, driven by patient demands for reduced scarring and potentially decreased postoperative pain. However, the application of single-incision techniques to complex procedures such as esophagectomy presents unique technical challenges, including limited instrument triangulation, potential instrument collision and increased ergonomic demands on the surgical team [ 15 , 16 , 17 , 18 ]. Perhaps the most enduring controversy in esophageal reconstruction relates to the optimal conduit route, with the debate between retrosternal and posterior mediastinal approaches persisting for over five decades since the initial descriptions of these techniques [ 19 ]. The retrosternal route, popularized by surgeons seeking to avoid the potentially contaminated posterior mediastinum in case of anastomotic leak, offers theoretical advantages including a more direct pathway from abdomen to neck, reduced conduit length, easier access for future interventions, and potential protection of the conduit from mediastinal radiation effects in patients requiring adjuvant therapy [ 20 ]. Proponents of retrosternal reconstruction argue that the anterior mediastinal pathway provides superior conduit positioning, reduced tension on the cervical anastomosis, and improved functional outcomes due to more favorable geometry [ 21 , 22 ]. Conversely, advocates for posterior mediastinal reconstruction emphasize the anatomical restoration achieved by placing the gastric conduit in the native esophageal bed, potentially superior long-term functional outcomes, reduced interference with cardiac function, and avoidance of substernal space complications such as conduit compression or cardiac compromise in the event of conduit dilatation [ 23 , 24 ]. Recent studies have suggested potential superiority of posterior mediastinal reconstruction regarding anastomotic leak rates, though significant heterogeneity exists across studies due to variations in surgical technique, patient populations, perioperative protocols, and institutional experience [ 25 , 26 ]. The traditional approach to reconstruction route selection has relied primarily on surgeon preference, institutional tradition, and subjective assessment of patient anatomy, often determined during the operative procedure based on intraoperative findings and conduit characteristics. This empirical approach lacks objective, evidence-based criteria for optimal route selection, potentially contributing to the persistent variability in outcomes across institutions and the ongoing controversy regarding optimal reconstruction strategies [ 27 ]. The absence of standardized selection criteria has led to wide variations in practice patterns, with some centers exclusively using one approach while others vary their technique based on individual surgeon preferences or perceived patient factors [ 28 ]. Three-dimensional CT reconstruction has revolutionized surgical planning across multiple specialties, transforming the approach to complex cardiovascular procedures, orthopedic reconstructions, hepatobiliary surgery, and neurosurgical interventions [ 29 ]. The technology provides unprecedented visualization of anatomical relationships, precise measurements of critical distances, virtual simulation of surgical approaches, and the ability to anticipate potential complications before entering the operating room. In cardiac surgery, three-dimensional planning has become indispensable for complex valve repairs, aortic reconstructions, and congenital heart disease procedures, significantly improving surgical precision and patient outcomes [ 30 ]. Despite widespread application across surgical specialties, the utilization of three-dimensional reconstruction in esophageal surgery planning remains underexplored and underdeveloped. The potential applications of three-dimensional CT reconstruction in esophageal surgery extend beyond simple route measurement to include comprehensive preoperative assessment of mediastinal anatomy, evaluation of tumor relationships to critical structures, planning of optimal conduit dimensions, assessment of vascular anatomy for conduit perfusion, and simulation of reconstruction geometry [ 30 ]. The technology could provide objective criteria for route selection based on individual patient anatomy, potentially reducing the reliance on subjective decision-making and improving standardization of surgical approaches. Moreover, three-dimensional reconstruction could facilitate surgical education and training by allowing surgeons to study patient-specific anatomy before procedures and simulate various reconstruction scenarios [ 30 ]. This study was conceived to address the critical gap in objective, measurement-based route selection for esophageal reconstruction, specifically evaluating whether preoperative CT three-dimensional reconstruction can provide reliable guidance for surgical decision-making in single-incision minimally invasive esophagectomy. We hypothesized that individual patient anatomy, as quantified through objective pathway measurements, would demonstrate significant relationships with clinical outcomes, particularly anastomotic complications, and that these measurements could identify patients who might benefit from alternative reconstruction approaches based on their specific anatomical characteristics rather than generalized population-based protocols. Methods Study Design and Patients This prospective cohort study included 111 consecutive patients with esophageal cancer who underwent SIMIE with retrosternal route reconstruction at our institution between January 2024 and October 2025. The study was approved by our institutional ethics review board, and all patients provided written informed consent. Inclusion criteria comprised age 18–75 years, histologically confirmed esophageal carcinoma, adequate cardiopulmonary function defined as FEV1 > 1.5 L and ejection fraction > 50%, Eastern Cooperative Oncology Group performance status 0–1 and completion of curative McKeown esophagectomy. Exclusion criteria included previous esophageal or gastric surgery, severe cardiovascular or pulmonary comorbidities, active infection, pregnancy, concurrent malignancies and inability to provide informed consent. Preoperative CT Three-dimensional Reconstruction All patients underwent standardized contrast-enhanced CT scanning using a 256-slice multidetector CT scanner with slice thickness 1.25 mm. Three-dimensional reconstruction was performed using dedicated software by two independent experienced radiologists with subspecialty training in thoracic imaging. The retrosternal reconstruction (RR) route was measured from the esophagus at thyroid cartilage level to the gastroduodenal artery via retrosternal space, while the posterior mediastinal reconstruction (PR) route was measured from the same starting point to endpoint via posterior mediastinum. Measurements were performed using curved multiplanar reconstruction tools with manual tracing of optimal pathways. Inter-observer variability was assessed using intraclass correlation coefficients, with discrepancies > 5 mm resolved by consensus. Surgical approaches All operations were performed by the same experienced surgical team. All patients underwent McKeown three-field esophagectomy with cervical anastomosis. During SIMIE-RR, patients were positioned in left lateral decubitus for the thoracic phase. A single 4–5 cm utility incision was made at the fifth intercostal space on the anterior axillary line. All thoracoscopic procedures were performed through this single access. For the abdominal phase, patients were repositioned supine with a single transumbilical incision (3–4 cm) created via a single-port access device. The gastric conduit was fashioned through standard techniques. The retrosternal tunnel was meticulously created under direct laparoscopic visualization through careful blunt dissection between the posterior aspect of the sternum and pericardium. For the cervical phase, a 4–5 cm transverse incision was made along the anterior border of the right sternocleidomastoid muscle. The cervical esophagus was carefully mobilized with preservation of recurrent laryngeal nerves. End-to-side esophagogastric anastomosis was performed via circular stapler with reinforcement when indicated. Statistical Analysis Continuous variables were expressed as mean ± standard deviation and categorical variables as frequencies and percentages. Pearson correlation coefficient assessed relationships between continuous variables. Statistical significance was set at p < 0.05, with analyses performed using R. Results Patient Characteristics and Route Measurements Our cohort comprised 111 patients with mean age 60.2 ± 5.3 years, predominantly male (72.9%) with middle thoracic tumors (60.4%). BMI distribution showed 19.8% underweight (< 18.5 kg/m²), 59.5% normal weight (18.5–24.9 kg/m²), and 20.7% overweight/obese (≥ 25.0 kg/m²). Most patients had T2-T3 disease (83.8%) with ASA grade II status (71.2%) (table 1). Comorbidities included diabetes in 3.6%, hypertension in 15.3%, and smoking history in 51.4% of patients. Table 1 Patient baseline characteristics Variable SIMIE-RR (n = 111) Demographic characteristics Age, years, mean ± SD 60.2 ± 5.3 Sex, n (%) Male 81 (72.9) Female 30 (27.1) BMI, kg/m², n (%) <18.5 22 (19.8) 18.5–24.9 66 (59.5) ≥25.0 23 (20.7) ASA grade, n (%) I 27 (24.3) II 79 (71.2) III 5 (4.5) ECOG, n (%) PS 0 58(52.3) PS 1 53(47.7) Preoperative pulmonary function FEV1, %, mean ± SD 2.56 ± 0.91 Tumour characteristics Tumour location, n (%) Upper thoracic 8 (7.2) Middle thoracic 67(60.4) Lower thoracic 36 (32.4) Pathologic T stage, n (%) T1 18 (16.2) T2 25 (22.5) T3 68 (61.3) Pathologic N stage, n (%) N0 60 (54.1) N1 21 (18.9) N2 23(20.7) N3 7 (6.3) TNM staging, n (%) I 24 (21.6) II 47 (42.4) III 34 (30.6) IV 6(5.4) Tumour differentiation, n (%) Well 20 (18.0) Moderately 67 (60.4) Poorly 24 (21.6) Comorbidities Diabetes mellitus, n (%) 4(3.6) Hypertension, n (%) 17 (15.3) Cerebrovascular disease, n (%) 1 (0.9) Smoking history, n (%) 57(51.4) Length of rescontrucion route, mean ± SD(mm) retrosternal reconstruction(RR) 293.3 ± 19.54 posterior mediastinal reconstruction(PR) 315.4 ± 19.13 Value 22.1 P < 0.001 Preoperative three-dimensional reconstruction revealed mean RR route length of 293.3 ± 19.54 mm compared to PR route length of 315.4 ± 19.13 mm, with RR route significantly shorter by 22.1 mm (p < 0.001). However, in 2 patients (1.8%), the PR route was shorter than or equal to the RR route, suggesting potential benefit from posterior mediastinal reconstruction in these cases. Perioperative Outcomes All patients successfully underwent SIMIE-RR without conversion to open surgery. Mean operative time was 209.5 ± 25.7 minutes with minimal blood loss of 65.5 ± 10.3 mL. Pain control was excellent with visual analog scale scores decreasing from 3.2 ± 1.1 at 24 hours to 1.5 ± 1.0 at 72 hours postoperatively. Cosmetic outcomes were highly satisfactory with incision aesthetic scores of 8.3 ± 1.2. Respiratory recovery proceeded smoothly with oxygen saturation improving from 94.2 ± 1.1% on postoperative day 1 to 96.8 ± 1.3% on day 7. Chest tube drainage averaged 250.8 ± 110.3 mL with nasogastric drainage of 670.9 ± 25.7 mL (Table 2 ). Table 2 Perioperative outcomes and functional recovery Variable SIMIE-RR(n = 111) Total operative time, min, mean ± SD 209.5 ± 25.7 Intraoperative factors Total blood loss, mL, median 65.5 ± 10.3 Postoperative pain and recovery VAS at 24h, mean ± SD 3.2 ± 1.1 VAS at 72h, mean ± SD 1.5 ± 1.0 Incision aesthetic score, mean ± SD 8.3 ± 1.2 Pulmonary outcomes Oxygen saturation at POD1, %, mean ± SD 94.2 ± 1.1 Oxygen saturation at POD7, %, mean ± SD 96.8 ± 1.3 Drainage and monitoring Chest tube drainage volume, mL, mean ± SD 250.8 ± 110.3 Nasogastric tube drainage volume, mL, mean ± SD 670.9 ± 25.7 Number of dissected lymph node Total number 34 ± 10.2 Thoracic 16.4 ± 5.8 Abdominal 17.9 ± 2.5 Postoperative hospital stay, days, median (IQR) 6.0 ± 1.0 Data are expressed as mean ± SD unless otherwise indicated. POD, postoperative day; SD, standard deviation; VAS, visual analog scale for pain. Lymphadenectomy achieved oncological adequacy with total dissected nodes of 34 ± 10.2, comprising 16.4 ± 5.8 thoracic and 17.9 ± 2.5 abdominal nodes. R0 resection was achieved in 109 patients (98.2%). Postoperative hospital stay was 6.0 ± 1.0 days, reflecting successful enhanced recovery protocols. Complications and Clinical Outcomes Overall complications were minimal, with anastomotic leakage occurring in only 2 patients (1.8%). Both patients with anastomotic leaks had RR route lengths exceeding their PR route lengths on preoperative measurements (RR 319.96 mm vs PR 304.35 mm in first patient; RR 340.81 mm vs PR 329.7 mm in second patient), suggesting suboptimal route selection. Other complications included pneumonia in 1.8%, recurrent nerve paralysis in 1.8%, and chylothorax in 0.9% of patients. Functional recovery was excellent with FEV1 at one month of 3.1 ± 0.6 L and minimal reflux symptoms scoring 1.1 ± 0.4 on a 5-point scale (Table 3 ). Table 3 Postoperative complications Complication type SIMIE-RR(n = 111) Pulmonary complications Pneumonia, n (%) 2 (1.8) Pulmonary embolism, n (%) 0(0) Surgery-related complications Anastomotic leakage, n (%) 2(1.8) Recurrent nerve paralysis, n (%) 1 (1.8) Chylothorax, n (%) 1 (0.9) Functional outcomes FEV1(1 month), mean ± SD 3.1 ± 0.6 Reflux symptoms, mean ± SD 1.1 ± 0.4 Data are expressed as mean ± SD or n (%). FEV 1 , forced expiratory volume in 1 second; SD, standard deviation. Correlation Analysis Results Correlation analysis between retrosternal route length and various clinical parameters revealed significant relationships (Table 4 ). BMI demonstrated a strong positive correlation with RR route length (coefficient 0.6671, p < 0.0001). In contrast, other patient characteristics showed no significant correlations with route measurements: sex (coefficient − 0.043, p = 0.654), age (coefficient − 0.08056, p = 0.4006), smoking history (coefficient 0.01138, p = 0.9057), and FEV1 (coefficient − 0.02389, p = 0.8034). Table 4 Relation between the retrosternal reconstruction and clinical parameters Sex Age BMI Smoke FEV1 Retrosternal reconstruction Relation coefficient -0.043 -0.08056 0.6671 0.01138 -0.02389 p-value 0.654 0.4006 < 0.0001 0.9057 0.8034 Discussion This prospective study represents the first systematic evaluation of preoperative CT three-dimensional reconstruction for guiding surgical route selection in single-incision minimally invasive esophagectomy, establishing a paradigm shift from empirical, surgeon preference-based decision-making to objective, measurement-guided surgical planning. The compelling evidence that both patients experiencing anastomotic leakage had longer retrosternal than posterior mediastinal route lengths on preoperative measurements validates our fundamental hypothesis that individual patient anatomy, as quantified through precise pathway measurements, can predict optimal reconstruction strategies and potentially prevent complications through personalized surgical approach selection. The exceptionally low anastomotic leak rate of 1.8% observed in our series represents a dramatic improvement over contemporary published rates ranging from 8–19% across various esophagectomy techniques and institutional series [ 15 , 16 ]. This remarkable outcome likely reflects the synergistic effects of multiple factors, including rigorous patient selection criteria, standardized surgical technique execution, enhanced recovery protocol implementation, and most crucially, optimal route selection guided by objective preoperative measurements rather than subjective intraoperative assessment. The critical observation that both patients experiencing anastomotic leaks had measurements favoring posterior mediastinal over retrosternal reconstruction provides compelling evidence for the clinical utility of measurement-guided planning, suggesting that routine application of three-dimensional reconstruction could identify the patients who might benefit from alternative reconstruction strategies. The correlation analysis results provide unprecedented insights into the anatomical determinants of reconstruction geometry and their clinical implications. The remarkably strong positive correlation between BMI and retrosternal route length (r = 0.6671, p < 0.0001) represents one of the most robust relationships documented in esophageal surgery literature, indicating that patient body habitus fundamentally influences reconstruction pathway geometry with predictable clinical consequences. This finding aligns perfectly with established knowledge from pulmonary medicine research, where comprehensive investigations in patients with chronic obstructive pulmonary disease have demonstrated that BMI serves as the primary determinant of thoracic cage dimensions and chest wall configuration [ 17 , 18 ]. The physiological basis underlying the BMI-route length relationship involves complex anatomical transformations associated with increased adiposity. Higher BMI correlates with increased subcutaneous and visceral fat deposition, leading to anterior chest wall protrusion and expansion of the anteroposterior thoracic diameter. This anatomical change directly translates to elongation of the retrosternal pathway, as the gastric conduit must traverse increased tissue thickness and navigate altered spatial relationships within the anterior mediastinum. Additionally, elevated BMI is associated with cardiac enlargement, mediastinal fat accumulation, and altered diaphragmatic positioning, all of which contribute to modified reconstruction geometry and potentially increased conduit tension when utilizing retrosternal approaches. The observation that other patient characteristics including sex, age, smoking history, and pulmonary function showed no significant correlations with route measurements underscores the unique importance of BMI as the primary anatomical determinant of reconstruction geometry. This finding simplifies clinical decision-making by identifying BMI as the key anthropometric parameter requiring consideration during surgical planning, while simultaneously validating the robustness of three-dimensional reconstruction measurements across diverse patient populations. The absence of correlations with age and sex suggests that reconstruction pathway geometry is primarily determined by current body habitus rather than demographic characteristics or historical factors. The technical excellence demonstrated by SIMIE-RR in this series, with 100% completion rate, minimal blood loss averaging 65.5 mL, and absence of conversions to open surgery, establishes the feasibility and safety of single-incision approaches when performed by experienced teams using standardized protocols. These outcomes compare favorably to contemporary series of both conventional minimally invasive and robotic-assisted esophagectomy, while offering additional benefits including superior cosmetic outcomes, reduced port-site morbidity, and potentially decreased chronic pain syndromes associated with intercostal nerve injury [ 21 , 22 ]. The patient satisfaction scores reflected in cosmetic outcome assessments (8.3 ± 1.2 on 10-point scale) demonstrate the significant psychological and quality-of-life benefits achieved through single-incision techniques. The oncological adequacy demonstrated through systematic lymphadenectomy, with mean harvest of 34 ± 10.2 total nodes, validates that technical modifications associated with single-incision approaches do not compromise cancer treatment effectiveness. The nodal harvest exceeds established benchmarks for adequate staging and compares favorably to contemporary series of conventional approaches, while the thoracic (16.4 ± 5.8) and abdominal (17.9 ± 2.5) node distributions demonstrate comprehensive lymphadenectomy execution through restricted access techniques [ 23 , 24 ]. These findings address longstanding concerns regarding potential oncological compromises associated with minimally invasive approaches, particularly single-incision techniques where instrument limitations might theoretically impact lymphadenectomy thoroughness. The clinical implications of measurement-guided surgical planning extend far beyond immediate perioperative outcomes to encompass fundamental principles of precision medicine and personalized surgical approaches. The availability of three-dimensional reconstruction technology in most contemporary medical centers, combined with standardized measurement protocols, creates unprecedented opportunities for evidence-based surgical decision-making that transcends traditional reliance on surgeon experience and institutional preferences. The objective nature of these measurements provides quantifiable rationale for reconstruction route selection that can be communicated transparently to patients, incorporated into informed consent discussions, and utilized for quality improvement initiatives and outcome prediction modeling. The educational and training implications of three-dimensional reconstruction integration into esophageal surgery practice represent another dimension of clinical impact. The technology provides invaluable opportunities for surgical education, allowing trainees to study patient-specific anatomy before procedures, simulate various reconstruction scenarios, and develop spatial understanding of complex anatomical relationships. The ability to visualize and measure reconstruction pathways preoperatively could accelerate the learning curve for complex procedures such as SIMIE-RR, potentially reducing the expertise threshold required for safe implementation while maintaining optimal outcomes through objective guidance rather than empirical experience alone. Future research directions should encompass multiple complementary approaches to validate and expand upon these initial findings. Prospective randomized trials comparing measurement-guided route selection versus conventional surgeon preference-based approaches in larger, multicenter populations would provide definitive evidence for clinical efficacy and cost-effectiveness. The development of automated measurement algorithms utilizing artificial intelligence and machine learning approaches could standardize assessment protocols, reduce inter-observer variability, and make advanced planning tools accessible to centers without specialized thoracic imaging expertise. Integration of additional anatomical parameters including spinal curvature, chest wall configuration, cardiac dimensions, and mediastinal fat distribution could further refine prediction models and optimize patient selection criteria. The potential for incorporating functional assessments including pulmonary function parameters, cardiac output measurements, and exercise tolerance testing into three-dimensional reconstruction planning represents an exciting frontier for comprehensive preoperative optimization. Advanced imaging modalities such as dynamic CT or MRI could provide insights into conduit positioning during different respiratory phases, cardiac cycles, and postural changes, potentially optimizing reconstruction geometry for long-term functional outcomes rather than solely focusing on perioperative safety considerations. Several limitations warrant acknowledgment and consideration for future study design optimization. The single-center design, while ensuring standardized protocols and experienced surgical teams, may limit generalizability to institutions with different patient populations, surgical expertise levels, or perioperative care protocols. The exclusive use of retrosternal reconstruction prevents direct comparison of outcomes between different reconstruction routes within identical patient populations, though the measurement-based analysis provides compelling indirect evidence supporting route selection principles. The relatively small number of complications, while reflecting excellent outcomes and validating the surgical approach, limits detailed multivariate analysis capabilities for identifying additional risk factors or interaction effects between variables. The short-term follow-up period, necessitated by the recent implementation of standardized protocols, prevents comprehensive assessment of long-term functional outcomes, anastomotic stricture development, gastroesophageal reflux progression, and quality of life evolution that may influence the ultimate clinical value of measurement-guided planning. Long-term oncological outcomes including disease-free survival, overall survival, and recurrence patterns require extended follow-up to validate that measurement-guided approaches maintain equivalent cancer treatment effectiveness while achieving superior perioperative outcomes. In conclusion, this study establishes preoperative CT three-dimensional reconstruction as a valuable and clinically actionable tool for surgical route selection in single-incision minimally invasive esophagectomy, with demonstrated potential to reduce anastomotic complications through personalized surgical planning tailored to individual patient anatomy. The strong correlation between BMI and retrosternal route length provides mechanistic insight into historical observations of increased complications in obese patients while offering objective criteria for optimal route selection. The excellent overall outcomes achieved through SIMIE-RR approaches, combined with measurement-guided planning, represent significant advancement toward evidence-based, personalized surgical care in esophageal cancer treatment. These findings establish a foundation for broader implementation of objective, measurement-based surgical planning that could transform esophageal surgery practice through systematic integration of advanced imaging technology with clinical decision-making processes, ultimately improving patient outcomes while reducing healthcare costs and complications through precision surgical approaches. Declarations Clinical trial number Not applicable. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Fujian Cancer Hospital ( K2024-373-01 ) and study was conducted under the guidance of the Declaration of Helsinki. All participants signed a written informed consent form. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding: This work received funding from the Medical Innovation Project of Fujian Province (grant Nos. 2024Y9633 and 2024Y9632). Author Contribution Contributions: (I) Conception and design: Ruirong Lin; (II) Administrative support: Weimin Fang, Yibin Cai; (III) Provision of study materials or patients: Weikun Su, Guibin Wenig, Yijin Lin; (IV) Collection and assembly of data: Lin Chen ; (V) Data analysis and interpretation: Jiarong Zhang; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Acknowledgements: We appreciate all the team members from Fujian Cancer Hospital, the Department of Thoracic Oncology for their help. Data Availability Due to privacy concerns, the data is not publicly available, but can be obtained from the corresponding author upon reasonable request. References Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71:209–49. Siegel RL, Miller KD, Fuchs HE, et al. Cancer Statistics, 2022. CA Cancer J Clin. 2022;72:7–33. 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Impact of lymph node dissection on survival after neoadjuvant chemoradiotherapy for locally advanced esophageal squamous cell carcinoma: from the results of NEOCRTEC5010, a randomized multicenter study[J]. Ann Surg. 2023;277(2):259–66. Park J, Park B, Park SY, et al. Therapeutic Effect of Lymph Node Dissection After Neoadjuvant Chemoradiation Therapy Followed by Esophagectomy on Esophageal Squamous Cell Carcinoma Using the Efficacy Index[J]. Thorac Cancer. 2025;16(6):e70057. Yoshida S, Fujii Y, Hoshino N, et al. Anterior versus posterior mediastinal reconstruction after esophagectomy in esophageal cancer patients: a systematic review and meta-analysis[J]. Langenbeck's Archives Surg. 2024;409(1):88. Booka E, Takeuchi H, Morita Y, et al. What is the best reconstruction procedure after esophagectomy? A meta-analysis comparing posterior mediastinal and retrosternal approaches[J]. Annals Gastroenterological Surg. 2023;7(4):553–64. Fabbi M, Hagens ERC, van Berge Henegouwen MI, et al. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment[J]. Dis Esophagus. 2021;34(1):doaa039. Janssen HJB, Nieuwenhuijzen GAP, Luyer MDP. Minimally invasive Ivor-Lewis esophagectomy with linear stapled side-to-side anastomosis[J]. Annals Esophagus, 2022, 5. Guo D, Zhu XY, Han S, et al. Evaluating the use of three-dimensional reconstruction visualization technology for precise laparoscopic resection in gastroesophageal junction cancer[J]. World J Gastrointest Surg. 2024;16(5):1311. Robb HD, Scrimgeour G, Boshier PR, et al. Current and possible future role of 3D modelling within oesophagogastric surgery: a scoping review protocol[J]. BMJ open. 2021;11(10):e045546. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 02 Jan, 2026 Reviews received at journal 22 Dec, 2025 Reviews received at journal 17 Dec, 2025 Reviewers agreed at journal 27 Nov, 2025 Reviewers agreed at journal 27 Nov, 2025 Reviewers invited by journal 27 Nov, 2025 Editor assigned by journal 24 Nov, 2025 Submission checks completed at journal 24 Nov, 2025 First submitted to journal 16 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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18:27:07","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":106292,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8126304/v1/8383c5a8dd686371bd24fc47.html"},{"id":104739743,"identity":"a1fc8cc2-457f-4495-986c-55187d5e6f4b","added_by":"auto","created_at":"2026-03-16 16:12:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":800718,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8126304/v1/7e78955c-9689-4d79-adec-aa9d4ea0e40d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preoperative CT Three-dimensional Reconstruction Guides Single-incision Minimally Invasive Esophagectomy with Retrosternal Route Selection: A Prospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEsophageal cancer represents one of the most formidable challenges in oncological surgery, ranking as the eighth most common malignancy worldwide and the sixth leading cause of cancer-related mortality, with an estimated 604,100 new cases and 544,076 deaths globally in 2020 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The devastating nature of this disease is exemplified by its five-year survival rate of approximately 15\u0026ndash;20% across all stages, largely attributable to the aggressive biological behavior, tendency for early lymphatic and hematogenous metastasis, and late presentation due to the absence of early symptoms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The geographic distribution of esophageal cancer demonstrates striking heterogeneity, with squamous cell carcinoma predominating in the \"esophageal cancer belt\" extending from northern China through Central Asia to northern Iran, while adenocarcinoma has shown alarming increases in Western populations, particularly associated with gastroesophageal reflux disease and Barrett's esophagus [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe complexity of esophageal cancer management stems from its anatomical location within the posterior mediastinum, surrounded by vital structures including the heart, great vessels, trachea, and bilateral recurrent laryngeal nerves, making surgical resection technically demanding and fraught with potential complications. Historical outcomes of esophageal surgery were marked by significant morbidity and mortality, with early series reporting operative mortality rates exceeding 20% and anastomotic leak rates approaching 30\u0026ndash;40% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These sobering statistics led to the evolution of surgical techniques, perioperative care protocols, and multidisciplinary treatment approaches that have gradually improved outcomes over the past several decades [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe paradigm shift toward neoadjuvant chemoradiotherapy has demonstrated improved pathological complete response rates, R0 resection rates, and overall survival compared to surgery alone [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, the addition of neoadjuvant therapy introduces additional complexity to surgical planning, as radiation-induced tissue fibrosis, altered anatomy, and compromised tissue healing can significantly impact reconstruction options and anastomotic integrity [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The challenge of optimizing surgical outcomes in this context has driven innovation in surgical techniques, with the evolution from open transthoracic approaches to minimally invasive and, more recently, robotic-assisted procedures [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe transformative impact of minimally invasive esophagectomy was definitively established, which demonstrated a significant reduction in pulmonary complications from 34% in the open group to 9% in the minimally invasive group, while maintaining equivalent oncological outcomes and long-term survival [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This pivotal study catalyzed widespread adoption of minimally invasive techniques, leading to subsequent refinements including totally minimally invasive approaches, single-incision techniques, and robotic-assisted procedures. The benefits of minimally invasive esophagectomy extend beyond reduced pulmonary complications to include decreased blood loss, shorter intensive care unit stays, reduced postoperative pain, improved cosmetic outcomes, and faster functional recovery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSingle-incision minimally invasive esophagectomy (SIMIE) represents the latest evolution in this technological progression, embodying the principles of reduced port-site morbidity, minimized intercostal nerve injury, and enhanced cosmetic outcomes while maintaining the established benefits of minimally invasive surgery [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The concept of single-incision surgery gained momentum across multiple surgical specialties following successful implementation in laparoscopic cholecystectomy and appendectomy, driven by patient demands for reduced scarring and potentially decreased postoperative pain. However, the application of single-incision techniques to complex procedures such as esophagectomy presents unique technical challenges, including limited instrument triangulation, potential instrument collision and increased ergonomic demands on the surgical team [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePerhaps the most enduring controversy in esophageal reconstruction relates to the optimal conduit route, with the debate between retrosternal and posterior mediastinal approaches persisting for over five decades since the initial descriptions of these techniques [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The retrosternal route, popularized by surgeons seeking to avoid the potentially contaminated posterior mediastinum in case of anastomotic leak, offers theoretical advantages including a more direct pathway from abdomen to neck, reduced conduit length, easier access for future interventions, and potential protection of the conduit from mediastinal radiation effects in patients requiring adjuvant therapy [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Proponents of retrosternal reconstruction argue that the anterior mediastinal pathway provides superior conduit positioning, reduced tension on the cervical anastomosis, and improved functional outcomes due to more favorable geometry [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConversely, advocates for posterior mediastinal reconstruction emphasize the anatomical restoration achieved by placing the gastric conduit in the native esophageal bed, potentially superior long-term functional outcomes, reduced interference with cardiac function, and avoidance of substernal space complications such as conduit compression or cardiac compromise in the event of conduit dilatation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Recent studies have suggested potential superiority of posterior mediastinal reconstruction regarding anastomotic leak rates, though significant heterogeneity exists across studies due to variations in surgical technique, patient populations, perioperative protocols, and institutional experience [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe traditional approach to reconstruction route selection has relied primarily on surgeon preference, institutional tradition, and subjective assessment of patient anatomy, often determined during the operative procedure based on intraoperative findings and conduit characteristics. This empirical approach lacks objective, evidence-based criteria for optimal route selection, potentially contributing to the persistent variability in outcomes across institutions and the ongoing controversy regarding optimal reconstruction strategies [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The absence of standardized selection criteria has led to wide variations in practice patterns, with some centers exclusively using one approach while others vary their technique based on individual surgeon preferences or perceived patient factors [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThree-dimensional CT reconstruction has revolutionized surgical planning across multiple specialties, transforming the approach to complex cardiovascular procedures, orthopedic reconstructions, hepatobiliary surgery, and neurosurgical interventions [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The technology provides unprecedented visualization of anatomical relationships, precise measurements of critical distances, virtual simulation of surgical approaches, and the ability to anticipate potential complications before entering the operating room. In cardiac surgery, three-dimensional planning has become indispensable for complex valve repairs, aortic reconstructions, and congenital heart disease procedures, significantly improving surgical precision and patient outcomes [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Despite widespread application across surgical specialties, the utilization of three-dimensional reconstruction in esophageal surgery planning remains underexplored and underdeveloped.\u003c/p\u003e\u003cp\u003eThe potential applications of three-dimensional CT reconstruction in esophageal surgery extend beyond simple route measurement to include comprehensive preoperative assessment of mediastinal anatomy, evaluation of tumor relationships to critical structures, planning of optimal conduit dimensions, assessment of vascular anatomy for conduit perfusion, and simulation of reconstruction geometry [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The technology could provide objective criteria for route selection based on individual patient anatomy, potentially reducing the reliance on subjective decision-making and improving standardization of surgical approaches. Moreover, three-dimensional reconstruction could facilitate surgical education and training by allowing surgeons to study patient-specific anatomy before procedures and simulate various reconstruction scenarios [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study was conceived to address the critical gap in objective, measurement-based route selection for esophageal reconstruction, specifically evaluating whether preoperative CT three-dimensional reconstruction can provide reliable guidance for surgical decision-making in single-incision minimally invasive esophagectomy. We hypothesized that individual patient anatomy, as quantified through objective pathway measurements, would demonstrate significant relationships with clinical outcomes, particularly anastomotic complications, and that these measurements could identify patients who might benefit from alternative reconstruction approaches based on their specific anatomical characteristics rather than generalized population-based protocols.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Patients\u003c/h2\u003e\u003cp\u003eThis prospective cohort study included 111 consecutive patients with esophageal cancer who underwent SIMIE with retrosternal route reconstruction at our institution between January 2024 and October 2025. The study was approved by our institutional ethics review board, and all patients provided written informed consent.\u003c/p\u003e\u003cp\u003eInclusion criteria comprised age 18\u0026ndash;75 years, histologically confirmed esophageal carcinoma, adequate cardiopulmonary function defined as FEV1\u0026thinsp;\u0026gt;\u0026thinsp;1.5 L and ejection fraction\u0026thinsp;\u0026gt;\u0026thinsp;50%, Eastern Cooperative Oncology Group performance status 0\u0026ndash;1 and completion of curative McKeown esophagectomy. Exclusion criteria included previous esophageal or gastric surgery, severe cardiovascular or pulmonary comorbidities, active infection, pregnancy, concurrent malignancies and inability to provide informed consent.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePreoperative CT Three-dimensional Reconstruction\u003c/h3\u003e\n\u003cp\u003eAll patients underwent standardized contrast-enhanced CT scanning using a 256-slice multidetector CT scanner with slice thickness 1.25 mm. Three-dimensional reconstruction was performed using dedicated software by two independent experienced radiologists with subspecialty training in thoracic imaging. The retrosternal reconstruction (RR) route was measured from the esophagus at thyroid cartilage level to the gastroduodenal artery via retrosternal space, while the posterior mediastinal reconstruction (PR) route was measured from the same starting point to endpoint via posterior mediastinum. Measurements were performed using curved multiplanar reconstruction tools with manual tracing of optimal pathways. Inter-observer variability was assessed using intraclass correlation coefficients, with discrepancies\u0026thinsp;\u0026gt;\u0026thinsp;5 mm resolved by consensus.\u003c/p\u003e\n\u003ch3\u003eSurgical approaches\u003c/h3\u003e\n\u003cp\u003eAll operations were performed by the same experienced surgical team. All patients underwent McKeown three-field esophagectomy with cervical anastomosis. During SIMIE-RR, patients were positioned in left lateral decubitus for the thoracic phase. A single 4\u0026ndash;5 cm utility incision was made at the fifth intercostal space on the anterior axillary line. All thoracoscopic procedures were performed through this single access. For the abdominal phase, patients were repositioned supine with a single transumbilical incision (3\u0026ndash;4 cm) created via a single-port access device. The gastric conduit was fashioned through standard techniques. The retrosternal tunnel was meticulously created under direct laparoscopic visualization through careful blunt dissection between the posterior aspect of the sternum and pericardium.\u003c/p\u003e\u003cp\u003eFor the cervical phase, a 4\u0026ndash;5 cm transverse incision was made along the anterior border of the right sternocleidomastoid muscle. The cervical esophagus was carefully mobilized with preservation of recurrent laryngeal nerves. End-to-side esophagogastric anastomosis was performed via circular stapler with reinforcement when indicated.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eContinuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and categorical variables as frequencies and percentages. Pearson correlation coefficient assessed relationships between continuous variables. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, with analyses performed using R.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePatient Characteristics and Route Measurements\u003c/h2\u003e\u003cp\u003eOur cohort comprised 111 patients with mean age 60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3 years, predominantly male (72.9%) with middle thoracic tumors (60.4%). BMI distribution showed 19.8% underweight (\u0026lt;\u0026thinsp;18.5 kg/m\u0026sup2;), 59.5% normal weight (18.5\u0026ndash;24.9 kg/m\u0026sup2;), and 20.7% overweight/obese (\u0026ge;\u0026thinsp;25.0 kg/m\u0026sup2;). Most patients had T2-T3 disease (83.8%) with ASA grade II status (71.2%) (table 1). Comorbidities included diabetes in 3.6%, hypertension in 15.3%, and smoking history in 51.4% of patients.\u003c/p\u003e\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1 Patient baseline characteristics\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eVariable\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSIMIE-RR (n\u0026thinsp;=\u0026thinsp;111)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eDemographic characteristics\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eAge, years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSex, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e81 (72.9)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e30 (27.1)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eBMI, kg/m\u0026sup2;, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026lt;18.5\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e22 (19.8)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e18.5\u0026ndash;24.9\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e66 (59.5)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026ge;25.0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e23 (20.7)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eASA grade, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eI\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e27 (24.3)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eII\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e79 (71.2)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eIII\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e5 (4.5)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eECOG, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePS 0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e58(52.3)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePS 1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e53(47.7)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePreoperative pulmonary function\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eFEV1, %, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e2.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eTumour characteristics\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eTumour location, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eUpper thoracic\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e8 (7.2)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eMiddle thoracic\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e67(60.4)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eLower thoracic\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e36 (32.4)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePathologic T stage, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eT1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e18 (16.2)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eT2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e25 (22.5)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eT3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e68 (61.3)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePathologic N stage, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eN0\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e60 (54.1)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eN1\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e21 (18.9)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eN2\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e23(20.7)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eN3\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e7 (6.3)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eTNM staging, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eI\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e24 (21.6)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eII\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e47 (42.4)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eIII\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e34 (30.6)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eIV\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e6(5.4)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eTumour differentiation, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eWell\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e20 (18.0)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eModerately\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e67 (60.4)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003ePoorly\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e24 (21.6)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eComorbidities\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eDiabetes mellitus, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e4(3.6)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eHypertension, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e17 (15.3)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eCerebrovascular disease, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e1 (0.9)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eSmoking history, n (%)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e57(51.4)\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eLength of rescontrucion route, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD(mm)\u003c/span\u003e\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eretrosternal reconstruction(RR)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e293.3\u0026thinsp;\u0026plusmn;\u0026thinsp;19.54\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eposterior mediastinal reconstruction(PR)\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e315.4\u0026thinsp;\u0026plusmn;\u0026thinsp;19.13\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eValue\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e22.1\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003eP\u003c/div\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/div\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003ePreoperative three-dimensional reconstruction revealed mean RR route length of 293.3\u0026thinsp;\u0026plusmn;\u0026thinsp;19.54 mm compared to PR route length of 315.4\u0026thinsp;\u0026plusmn;\u0026thinsp;19.13 mm, with RR route significantly shorter by 22.1 mm (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, in 2 patients (1.8%), the PR route was shorter than or equal to the RR route, suggesting potential benefit from posterior mediastinal reconstruction in these cases.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePerioperative Outcomes\u003c/h3\u003e\n\u003cp\u003eAll patients successfully underwent SIMIE-RR without conversion to open surgery. Mean operative time was 209.5\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7 minutes with minimal blood loss of 65.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3 mL. Pain control was excellent with visual analog scale scores decreasing from 3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 at 24 hours to 1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 at 72 hours postoperatively. Cosmetic outcomes were highly satisfactory with incision aesthetic scores of 8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2. Respiratory recovery proceeded smoothly with oxygen saturation improving from 94.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1% on postoperative day 1 to 96.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3% on day 7. Chest tube drainage averaged 250.8\u0026thinsp;\u0026plusmn;\u0026thinsp;110.3 mL with nasogastric drainage of 670.9\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7 mL (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePerioperative outcomes and functional recovery\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSIMIE-RR(n\u0026thinsp;=\u0026thinsp;111)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal operative time, min, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e209.5\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntraoperative factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal blood loss, mL, median\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e65.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePostoperative pain and recovery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS at 24h, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVAS at 72h, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncision aesthetic score, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePulmonary outcomes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOxygen saturation at POD1, %, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e94.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOxygen saturation at POD7, %, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e96.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDrainage and monitoring\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest tube drainage volume, mL, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e250.8\u0026thinsp;\u0026plusmn;\u0026thinsp;110.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNasogastric tube drainage volume, mL, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e670.9\u0026thinsp;\u0026plusmn;\u0026thinsp;25.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of dissected lymph node\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal number\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e34\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThoracic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdominal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative hospital stay, days, median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD unless otherwise indicated. POD, postoperative day; SD, standard deviation; VAS, visual analog scale for pain.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLymphadenectomy achieved oncological adequacy with total dissected nodes of 34\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2, comprising 16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 thoracic and 17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5 abdominal nodes. R0 resection was achieved in 109 patients (98.2%). Postoperative hospital stay was 6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 days, reflecting successful enhanced recovery protocols.\u003c/p\u003e\n\u003ch3\u003eComplications and Clinical Outcomes\u003c/h3\u003e\n\u003cp\u003eOverall complications were minimal, with anastomotic leakage occurring in only 2 patients (1.8%). Both patients with anastomotic leaks had RR route lengths exceeding their PR route lengths on preoperative measurements (RR 319.96 mm vs PR 304.35 mm in first patient; RR 340.81 mm vs PR 329.7 mm in second patient), suggesting suboptimal route selection. Other complications included pneumonia in 1.8%, recurrent nerve paralysis in 1.8%, and chylothorax in 0.9% of patients. Functional recovery was excellent with FEV1 at one month of 3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 L and minimal reflux symptoms scoring 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 on a 5-point scale (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative complications\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplication type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSIMIE-RR(n\u0026thinsp;=\u0026thinsp;111)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulmonary complications\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePneumonia, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (1.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulmonary embolism, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgery-related complications\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnastomotic leakage, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(1.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecurrent nerve paralysis, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChylothorax, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (0.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFunctional outcomes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFEV1(1 month), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReflux symptoms, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n (%). FEV\u003csub\u003e1\u003c/sub\u003e, forced expiratory volume in 1 second; SD, standard deviation.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eCorrelation Analysis Results\u003c/h2\u003e\u003cp\u003eCorrelation analysis between retrosternal route length and various clinical parameters revealed significant relationships (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). BMI demonstrated a strong positive correlation with RR route length (coefficient 0.6671, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). In contrast, other patient characteristics showed no significant correlations with route measurements: sex (coefficient \u0026minus;\u0026thinsp;0.043, p\u0026thinsp;=\u0026thinsp;0.654), age (coefficient \u0026minus;\u0026thinsp;0.08056, p\u0026thinsp;=\u0026thinsp;0.4006), smoking history (coefficient 0.01138, p\u0026thinsp;=\u0026thinsp;0.9057), and FEV1 (coefficient \u0026minus;\u0026thinsp;0.02389, p\u0026thinsp;=\u0026thinsp;0.8034).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRelation between the retrosternal reconstruction and clinical parameters\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSmoke\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFEV1\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRetrosternal reconstruction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelation coefficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.043\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.08056\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.6671\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.01138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e-0.02389\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.654\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.4006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.9057\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.8034\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e This prospective study represents the first systematic evaluation of preoperative CT three-dimensional reconstruction for guiding surgical route selection in single-incision minimally invasive esophagectomy, establishing a paradigm shift from empirical, surgeon preference-based decision-making to objective, measurement-guided surgical planning. The compelling evidence that both patients experiencing anastomotic leakage had longer retrosternal than posterior mediastinal route lengths on preoperative measurements validates our fundamental hypothesis that individual patient anatomy, as quantified through precise pathway measurements, can predict optimal reconstruction strategies and potentially prevent complications through personalized surgical approach selection.\u003c/p\u003e\u003cp\u003eThe exceptionally low anastomotic leak rate of 1.8% observed in our series represents a dramatic improvement over contemporary published rates ranging from 8\u0026ndash;19% across various esophagectomy techniques and institutional series [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This remarkable outcome likely reflects the synergistic effects of multiple factors, including rigorous patient selection criteria, standardized surgical technique execution, enhanced recovery protocol implementation, and most crucially, optimal route selection guided by objective preoperative measurements rather than subjective intraoperative assessment. The critical observation that both patients experiencing anastomotic leaks had measurements favoring posterior mediastinal over retrosternal reconstruction provides compelling evidence for the clinical utility of measurement-guided planning, suggesting that routine application of three-dimensional reconstruction could identify the patients who might benefit from alternative reconstruction strategies.\u003c/p\u003e\u003cp\u003eThe correlation analysis results provide unprecedented insights into the anatomical determinants of reconstruction geometry and their clinical implications. The remarkably strong positive correlation between BMI and retrosternal route length (r\u0026thinsp;=\u0026thinsp;0.6671, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) represents one of the most robust relationships documented in esophageal surgery literature, indicating that patient body habitus fundamentally influences reconstruction pathway geometry with predictable clinical consequences. This finding aligns perfectly with established knowledge from pulmonary medicine research, where comprehensive investigations in patients with chronic obstructive pulmonary disease have demonstrated that BMI serves as the primary determinant of thoracic cage dimensions and chest wall configuration [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe physiological basis underlying the BMI-route length relationship involves complex anatomical transformations associated with increased adiposity. Higher BMI correlates with increased subcutaneous and visceral fat deposition, leading to anterior chest wall protrusion and expansion of the anteroposterior thoracic diameter. This anatomical change directly translates to elongation of the retrosternal pathway, as the gastric conduit must traverse increased tissue thickness and navigate altered spatial relationships within the anterior mediastinum. Additionally, elevated BMI is associated with cardiac enlargement, mediastinal fat accumulation, and altered diaphragmatic positioning, all of which contribute to modified reconstruction geometry and potentially increased conduit tension when utilizing retrosternal approaches.\u003c/p\u003e\u003cp\u003eThe observation that other patient characteristics including sex, age, smoking history, and pulmonary function showed no significant correlations with route measurements underscores the unique importance of BMI as the primary anatomical determinant of reconstruction geometry. This finding simplifies clinical decision-making by identifying BMI as the key anthropometric parameter requiring consideration during surgical planning, while simultaneously validating the robustness of three-dimensional reconstruction measurements across diverse patient populations. The absence of correlations with age and sex suggests that reconstruction pathway geometry is primarily determined by current body habitus rather than demographic characteristics or historical factors.\u003c/p\u003e\u003cp\u003eThe technical excellence demonstrated by SIMIE-RR in this series, with 100% completion rate, minimal blood loss averaging 65.5 mL, and absence of conversions to open surgery, establishes the feasibility and safety of single-incision approaches when performed by experienced teams using standardized protocols. These outcomes compare favorably to contemporary series of both conventional minimally invasive and robotic-assisted esophagectomy, while offering additional benefits including superior cosmetic outcomes, reduced port-site morbidity, and potentially decreased chronic pain syndromes associated with intercostal nerve injury [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The patient satisfaction scores reflected in cosmetic outcome assessments (8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 on 10-point scale) demonstrate the significant psychological and quality-of-life benefits achieved through single-incision techniques.\u003c/p\u003e\u003cp\u003eThe oncological adequacy demonstrated through systematic lymphadenectomy, with mean harvest of 34\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 total nodes, validates that technical modifications associated with single-incision approaches do not compromise cancer treatment effectiveness. The nodal harvest exceeds established benchmarks for adequate staging and compares favorably to contemporary series of conventional approaches, while the thoracic (16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8) and abdominal (17.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5) node distributions demonstrate comprehensive lymphadenectomy execution through restricted access techniques [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These findings address longstanding concerns regarding potential oncological compromises associated with minimally invasive approaches, particularly single-incision techniques where instrument limitations might theoretically impact lymphadenectomy thoroughness.\u003c/p\u003e\u003cp\u003eThe clinical implications of measurement-guided surgical planning extend far beyond immediate perioperative outcomes to encompass fundamental principles of precision medicine and personalized surgical approaches. The availability of three-dimensional reconstruction technology in most contemporary medical centers, combined with standardized measurement protocols, creates unprecedented opportunities for evidence-based surgical decision-making that transcends traditional reliance on surgeon experience and institutional preferences. The objective nature of these measurements provides quantifiable rationale for reconstruction route selection that can be communicated transparently to patients, incorporated into informed consent discussions, and utilized for quality improvement initiatives and outcome prediction modeling.\u003c/p\u003e\u003cp\u003eThe educational and training implications of three-dimensional reconstruction integration into esophageal surgery practice represent another dimension of clinical impact. The technology provides invaluable opportunities for surgical education, allowing trainees to study patient-specific anatomy before procedures, simulate various reconstruction scenarios, and develop spatial understanding of complex anatomical relationships. The ability to visualize and measure reconstruction pathways preoperatively could accelerate the learning curve for complex procedures such as SIMIE-RR, potentially reducing the expertise threshold required for safe implementation while maintaining optimal outcomes through objective guidance rather than empirical experience alone.\u003c/p\u003e\u003cp\u003eFuture research directions should encompass multiple complementary approaches to validate and expand upon these initial findings. Prospective randomized trials comparing measurement-guided route selection versus conventional surgeon preference-based approaches in larger, multicenter populations would provide definitive evidence for clinical efficacy and cost-effectiveness. The development of automated measurement algorithms utilizing artificial intelligence and machine learning approaches could standardize assessment protocols, reduce inter-observer variability, and make advanced planning tools accessible to centers without specialized thoracic imaging expertise. Integration of additional anatomical parameters including spinal curvature, chest wall configuration, cardiac dimensions, and mediastinal fat distribution could further refine prediction models and optimize patient selection criteria.\u003c/p\u003e\u003cp\u003eThe potential for incorporating functional assessments including pulmonary function parameters, cardiac output measurements, and exercise tolerance testing into three-dimensional reconstruction planning represents an exciting frontier for comprehensive preoperative optimization. Advanced imaging modalities such as dynamic CT or MRI could provide insights into conduit positioning during different respiratory phases, cardiac cycles, and postural changes, potentially optimizing reconstruction geometry for long-term functional outcomes rather than solely focusing on perioperative safety considerations.\u003c/p\u003e\u003cp\u003eSeveral limitations warrant acknowledgment and consideration for future study design optimization. The single-center design, while ensuring standardized protocols and experienced surgical teams, may limit generalizability to institutions with different patient populations, surgical expertise levels, or perioperative care protocols. The exclusive use of retrosternal reconstruction prevents direct comparison of outcomes between different reconstruction routes within identical patient populations, though the measurement-based analysis provides compelling indirect evidence supporting route selection principles. The relatively small number of complications, while reflecting excellent outcomes and validating the surgical approach, limits detailed multivariate analysis capabilities for identifying additional risk factors or interaction effects between variables.\u003c/p\u003e\u003cp\u003eThe short-term follow-up period, necessitated by the recent implementation of standardized protocols, prevents comprehensive assessment of long-term functional outcomes, anastomotic stricture development, gastroesophageal reflux progression, and quality of life evolution that may influence the ultimate clinical value of measurement-guided planning. Long-term oncological outcomes including disease-free survival, overall survival, and recurrence patterns require extended follow-up to validate that measurement-guided approaches maintain equivalent cancer treatment effectiveness while achieving superior perioperative outcomes.\u003c/p\u003e\u003cp\u003eIn conclusion, this study establishes preoperative CT three-dimensional reconstruction as a valuable and clinically actionable tool for surgical route selection in single-incision minimally invasive esophagectomy, with demonstrated potential to reduce anastomotic complications through personalized surgical planning tailored to individual patient anatomy. The strong correlation between BMI and retrosternal route length provides mechanistic insight into historical observations of increased complications in obese patients while offering objective criteria for optimal route selection. The excellent overall outcomes achieved through SIMIE-RR approaches, combined with measurement-guided planning, represent significant advancement toward evidence-based, personalized surgical care in esophageal cancer treatment. These findings establish a foundation for broader implementation of objective, measurement-based surgical planning that could transform esophageal surgery practice through systematic integration of advanced imaging technology with clinical decision-making processes, ultimately improving patient outcomes while reducing healthcare costs and complications through precision surgical approaches.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e This study was approved by the Ethics Committee of the Fujian Cancer Hospital ( K2024-373-01 ) and study was conducted under the guidance of the Declaration of Helsinki. All participants signed a written informed consent form.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis work received funding from the Medical Innovation Project of Fujian Province (grant Nos. 2024Y9633 and 2024Y9632).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eContributions: (I) Conception and design: Ruirong Lin; (II) Administrative support: Weimin Fang, Yibin Cai; (III) Provision of study materials or patients: Weikun Su, Guibin Wenig, Yijin Lin; (IV) Collection and assembly of data: Lin Chen ; (V) Data analysis and interpretation: Jiarong Zhang; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003eWe appreciate all the team members from Fujian Cancer Hospital, the Department of Thoracic Oncology for their help.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDue to privacy concerns, the data is not publicly available, but can be obtained from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, et al. 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What is the best reconstruction procedure after esophagectomy? A meta-analysis comparing posterior mediastinal and retrosternal approaches[J]. Annals Gastroenterological Surg. 2023;7(4):553\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFabbi M, Hagens ERC, van Berge Henegouwen MI, et al. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment[J]. Dis Esophagus. 2021;34(1):doaa039.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJanssen HJB, Nieuwenhuijzen GAP, Luyer MDP. Minimally invasive Ivor-Lewis esophagectomy with linear stapled side-to-side anastomosis[J]. Annals Esophagus, 2022, 5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuo D, Zhu XY, Han S, et al. Evaluating the use of three-dimensional reconstruction visualization technology for precise laparoscopic resection in gastroesophageal junction cancer[J]. World J Gastrointest Surg. 2024;16(5):1311.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRobb HD, Scrimgeour G, Boshier PR, et al. Current and possible future role of 3D modelling within oesophagogastric surgery: a scoping review protocol[J]. BMJ open. 2021;11(10):e045546.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"esophageal cancer, single-incision minimally invasive esophagectomy, three-dimensional reconstruction, retrosternal reconstruction","lastPublishedDoi":"10.21203/rs.3.rs-8126304/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8126304/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003eThe optimal reconstruction route following esophagectomy remains controversial, with limited objective criteria for route selection. This study investigated whether preoperative CT three-dimensional reconstruction can guide surgical route selection in single-incision minimally invasive esophagectomy (SIMIE) with retrosternal reconstruction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003eWe conducted a prospective analysis of 111 consecutive patients with esophageal cancer who underwent SIMIE with retrosternal route reconstruction between January 2024 and October 2025. Preoperative CT three-dimensional reconstruction measured both retrosternal reconstruction (RR) and posterior mediastinal reconstruction (PR) route lengths from esophagus at thyroid cartilage level to gastroduodenal artery. Primary outcomes included perioperative complications, particularly anastomotic leakage rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003eMean RR route length was 293.3±19.54 mm, significantly shorter than PR route length (315.4±19.13 mm, difference 22.1 mm, p\u0026lt;0.001). All patients completed SIMIE-RR successfully with mean operative time 209.5±25.7 minutes, blood loss 65.5±10.3 mL, and hospital stay 6.0±1.0 days. Anastomotic leakage occurred in 2 patients (1.8%), both having longer RR than PR routes on preoperative measurements. BMI demonstrated significant positive correlation with RR route length (r=0.6671, p\u0026lt;0.0001), while other patient characteristics showed no significant correlations. Total lymph node harvest achieved 34±10.2 nodes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003ePreoperative CT three-dimensional reconstruction effectively guides optimal route selection in SIMIE esophagectomy through objective pathway measurements. When RR route length exceeds PR length, particularly in patients with higher BMI, posterior mediastinal reconstruction may be preferable to reduce anastomotic complications.\u003c/p\u003e","manuscriptTitle":"Preoperative CT Three-dimensional Reconstruction Guides Single-incision Minimally Invasive Esophagectomy with Retrosternal Route Selection: A Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 18:27:02","doi":"10.21203/rs.3.rs-8126304/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-02T11:22:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T20:22:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T09:08:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"231891430231441213852513799302007462468","date":"2025-11-27T09:38:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20365328170885754800720163159127694945","date":"2025-11-27T08:30:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-27T08:23:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-24T13:13:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-24T13:10:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-11-16T09:17:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a77e2bd1-ff8f-4edb-a9b6-11eafa0651c8","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:07:58+00:00","versionOfRecord":{"articleIdentity":"rs-8126304","link":"https://doi.org/10.1186/s12893-026-03606-8","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-03-09 15:58:19","publishedOnDateReadable":"March 9th, 2026"},"versionCreatedAt":"2025-12-01 18:27:02","video":"","vorDoi":"10.1186/s12893-026-03606-8","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03606-8","workflowStages":[]},"version":"v1","identity":"rs-8126304","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8126304","identity":"rs-8126304","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}