Abstract

Purpose
This study evaluated the comparative clinical effectiveness and cost-effectiveness of robot-assisted minimally invasive esophagectomy (RAMIE) versus open esophagectomy (OE) and conventional minimally invasive esophagectomy (MIE) in a nationwide real-world setting.
Materials and Methods
A target trial emulation was conducted using the Korean National Health Insurance Service database, including patients who underwent first-time esophagectomy for esophageal cancer between 2010 and 2023, with survival followed through June 2024. Propensity score–matched cohorts were created for RAMIE versus OE (n=1,713 per group) and RAMIE versus MIE (n=1,162 per group). Clinical outcomes were compared, and a 5-year semi-Markov model was used to estimate quality-adjusted life-years (QALYs) and costs from a healthcare sector perspective with a 4.5% annual discount rate. Incremental cost-effectiveness ratios (ICERs), incremental net benefits (INBs), and probabilistic sensitivity analyses were calculated.
Results
RAMIE showed comparable or better short-term outcomes, including lower incidence of transfusion-requiring bleeding risk than OE (23.6% vs. 32.5%; relative risk [RR], 0.73; 95% CI, 0.65–0.81) and MIE (27.9% vs. 33.6%; RR, 0.88; 95% CI, 0.77–0.99). Long-term survival was superior to OE (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.72–0.88) and similar to MIE (HR, 0.93; 95% CI, 0.82–1.06). RAMIE yielded higher QALYs (Δ0.311 vs. OE; Δ0.126 vs MIE) and lower 5-year costs ($12,372–$19,765 vs. OE; $1,703–$9,097 vs. MIE), resulting in negative ICERs, positive INBs, and high probabilities of cost-effectiveness in sensitivity analyses.
Conclusion
RAMIE showed a favorable clinical and cost-effectiveness profile compared with OE and MIE, adding to the evidence base for its broader adoption.

• Keywords: Esophageal neoplasms, Esophagectomy, Robotic surgical procedures, Minimally invasive surgical procedures, Real world data, Databases, Factual, Propensity score, Cost-benefit analysis, Survival analysis