BACKGROUND:Surgical site infections (SSIs) and delayed wound healing are common complications following stoma reversal. Negative pressure wound therapy (NPWT) has previously demonstrated reduced SSI rates in several other surgical procedures. This systematic review and meta-analysis aimed to evaluate the role of NPWT in reducing SSIs and wound healing time compared to standard dressings following stoma reversal. METHODS:A systematic review was performed according to PRISMA guidelines. Meta-analysis were performed using RevMan version 5.4 software. Primary outcomes were SSI rates and complete wound healing time (CWHT); secondary outcomes included length of hospital stay (LOS) and hematoma formation. Data was assessed for bias using Cochrane's Risk of Bias tool and synthesised through meta-analysis. RESULTS:Six randomised clinical trials published between 2016 and 2024 were included. These involved 332 patients, of whom 171 were randomised to NPWT (51.5%) and 161 to standard dressings (control) (48.5%). A non-significant difference was observed for mean patient age and American Society of Anaesthesiologists (ASA) grade (all P > 0.050). NPWT failed to demonstrate significant difference in SSI rates compared to standard care (odds ratio (OR): 1.02, 95% confidence interval (CI): 0.47-2.20, p = 0.96, however, significantly reduced CWHT (MD: -2.72, 95% CI: -4.08 to -1.35, p = 0.0001). Importantly, no differences were observed in the LOS, hematoma rates, or overall wound complications. CONCLUSION:While NPWT failed to significantly reduce SSIs incidence, there was a significant reduction in CWHT. Accordingly, the judicious use of NPWT may be adopted, with the most value likely for patients deemed to be high-risk.

INTRODUCTION:There are conflicting recommendations surrounding the use of intraoperative wound irrigation (IOWI) to reduce surgical site infections (SSIs) for patients undergoing laparotomy. This study aimed to perform a systematic review and network meta-analysis of randomised clinical trials (RCTs) to elucidate the most appropriate IOWI solution to reduce SSIs following laparotomy. METHODS:A systematic review and network meta-analysis (NMA) was performed as per preferred reporting items for systematic reviews and meta-analysis (PRISMA)-NMA extension. Data analytics were performed using shiny and R. RESULTS:11 RCTs were included involving 2943 patients. Overall, 1292 patients were randomised to normal saline (NS) (43.9%), 771 to povidone iodine (PI) (26.2%), 519 to polyhexidine (PH) (17.6%), 180 to electrolysed strongly acidic aqueous solution (ESAAS) (6.1%), 102 to none (control) (3.5%) and 79 to olanexidine (O) (2.7%). Non-significant differences in patient age, gender, body mass indices, or American Society of Anaesthesiologist grade were observed for each IOWI group (all P > 0.050). At NMA, IOWI using PH significantly reduced all cause SSIs in patients undergoing laparotomy (odds ratio (OR): 0.54, 95% confidence interval (CI): 0.36 - 0.80). Furthermore, IOWI using PH (OR: 0.54, 95% CI: 0.36 - 0.80) and ESAAS (OR: 0.36, 95% CI: 0.13 - 0.98) significantly reduced superficial SSI (SSSI) in patients undergoing laparotomy. For patients undergoing laparotomy in the elective setting, PH significantly reduced both SSI (OR: 0.41, 95% CI: 0.25 - 0.68) and SSSI (OR: 0.42, 95% CI: 0.22 - 0.82) rates. CONCLUSION:IOWI with PH reduces SSIs in patients undergoing laparotomy and should therefore be considered in patients undergoing this procedure.

The anticipated surgical and postoperative outcomes following robotic-assisted single anastomosis duodeno-ileal bypass with sleeve gastrectomy (R-SADI-S) are not well described in the surgical literature. To perform a systematic review to evaluate clinical and surgical outcomes in patients who have undergone R-SADI-S. A systematic review was performed in accordance with the PRISMA guidelines. Basic descriptive statistics were performed using SPSS v26.0. Overall, 4 studies including data from 160 patients were included. The mean age at the time of surgery was 38.1 years and 55.6

BACKGROUND:Achalasia is a primary motility disorder of the esophagus characterized by abnormal peristalsis and impaired lower esophageal sphincter relaxation. Multiple interventions are available to control the resultant symptoms of dysphagia, regurgitation, chest pain, and weight loss. There is a paucity of data regarding which treatment option provides the best outcome. Our objective was to perform a systematic review and meta-analysis of randomized clinical trials (RCTs) that have evaluated the clinical outcomes of Heller's myotomy, pneumatic dilatation, peroral endoscopic myotomy (POEM), and botulinum toxin injections in the management of primary achalasia. METHODS:A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. An electronic search of PubMed, Embase, and Cochrane databases was performed, yielding 7455 results, which were screened by 2 independent reviewers, followed by meta-analysis. RESULTS:Fifteen RCTs, comprising a total of 1170 patients, were included. Overall, botulinum toxin injections were associated with significantly lower treatment success at 1 year (odds ratio [OR], 0.10; 95% CI, 0.01-0.89). At 5 years, treatment success was significantly greater after Heller's myotomy (OR, 6.39; 95% CI, 1.24-32.89) and POEM (OR, 6.33; 95% CI, 2.83-14.0). Pneumatic dilatation resulted in a significantly higher lower esophageal sphincter pressure (mean difference, 4.72; 95% CI, 1.13-8.31) and greater abnormal esophageal acid exposure (OR, 2.63; 95% CI, 1.25-5.56). CONCLUSION:Heller's myotomy and POEM show comparable long-term efficacy, though POEM carries a higher, nonsignificant rate of esophagitis. Treatment selection should be individualized based on patient factors and local expertise, with further high-quality trials needed to guide optimal management.

Pneumonia is common following transthoracic esophagectomy (TTE). The diagnosis in the early postoperative period is partly subjective' and may vary among clinicians, with sensitivity reduced by post-operative inflammatory changes and altered thoracic anatomy. Despite its clinical importance, inter-observer agreement in diagnosing post-esophagectomy pneumonia has not been systematically evaluated. This retrospective study evaluated inter-observer variability among four senior specialists (surgeon, radiologist, intensivist, and pulmonologist) in diagnosing pneumonia from chest radiographs of 200 consecutive TTE patients. Using a web-based platform, blinded reviewers independently assessed anonymized chest radiographs from post-operative days 3 and 7 using a three-class scale (yes/no/maybe). When 'maybe' was selected, standardized clinical data (vital signs at 23:00 hours) were automatically provided. Cohen's kappa coefficient quantified pairwise agreement, while Fleiss' kappa assessed overall concordance. Of the 200 patients, pneumonia was documented in 54 (27%) per American Thoracic Society (ATS) criteria. Initial radiographic assessment showed fair inter-observer agreement (κ = 0.207-0.230) compared to the radiologist reference. Diagnostic uncertainty ('maybe' responses) occurred in 307/1600 assessments (19.2%), varying significantly by specialty: surgeon, 41.5%; radiologist, 22.0%; intensivist, 13.0%; pulmonologist, 14.0% (P < 0.001). After clinical correlation, agreement improved modestly: surgeon κ = 0.334, intensivist κ = 0.398, pulmonologist κ = 0.356 (all P < 0.001), but remained in the 'fair' range. Overall multi-rater agreement (Fleiss' κ) improved from 0.270 to 0.421 (+56% improvement, P < 0.001), transitioning from fair to moderate agreement. When clinical data points were made available for equivocal cases, 124 responders (40.4%) changed their initial assessment from 'maybe' to 'yes', indicating a preference for therapy, while 89 (29.0%) changed their unsure response to 'no'. Considerable inter-observer variability in pneumonia diagnosis after TTE exists, with 'fair' interrater agreement in documenting radiologic pneumonia, and 'poor' consistency in determining antibiotic use according to the ATS criteria. Current pneumonia diagnostic criteria are fundamentally limited by poor radiographic inter-observer agreement, indicating the timely need for standardization of definition terminology and supports the development of integrated diagnostic protocols.

BACKGROUND:The prevalence of adenocarcinoma of the esophagogastric junction has increased, likely driven by lifestyle factors such as obesity, gastro-esophageal reflux disease, and smoking. However, the long-term outcomes of different curative surgical approaches have yet to be comprehensively evaluated. OBJECTIVES:To perform a systematic review and meta-analysis evaluating the surgical approaches to resection of Siewert II/III Adenocarcinoma of the Esophagogastric junction. SETTING:Integration of data from upper gastrointestinal surgical units across the world. METHODS:A systematic review was performed as per PRISMA guidelines. Statistical analysis was performed with MetaInsight. RESULTS:A total of 16 studies, comprising 4256 patients, were included in the meta-analysis. The findings suggest that robotic surgical approaches demonstrate equipoise to both laparoscopic and open techniques for resection, with comparable overall survival (OS) at both 3 and 5 years (3-year OS: OR 1.17, 95% CI [0.10-14.06]; 5-year OS: OR 0.66, 95% CI [0.39-1.12]). Additionally, a nonsignificant trend toward improved disease-free survival (DFS) was observed for robotic surgery at both 3 and 5 years (OR 1.17, 95% CI [0.10-14.06] for both time points). CONCLUSION:Laparoscopic approaches to surgical resection have proven to be as effective as open surgery for achieving R0 resection. Based on our meta-analysis results, we can conclude that robotic approaches to resection is equivalent to laparoscopic approaches. PROSPECTIVE REGISTER:International Prospective Register of Systematic Reviews (PROSPERO): CRD42024590940.

BACKGROUND:The optimal oesophagogastric anastomosis technique for oesophageal cancer surgery remains unclear. The aim of this study was to perform a network meta-analysis (NMA) of randomised clinical trials (RCTs) to compare oesophagogastric anastomosis techniques for oesophageal cancer surgery. METHODS:A systematic review and NMA were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines-NMA extension. Statistical analyses were performed using R and Shiny. RESULTS:Overall, 16 RCTs were included (14 provided data eligible for NMA). These included 2520 patients and 4 different anastomosis techniques: 1055 (41.9 %) patients underwent circular stapled (CS), 1232 (48.9 %) underwent handsewn (HS), 100 (3.9 %) underwent triangulated stapled (TS) and 133 (5.3 %) underwent linear stapled (LS). Fourteen studies reported on open surgery, while one reported on both open and minimally invasive techniques. At NMA, no significant difference was observed regarding anastomotic leak rates among all techniques, while HS significantly reduced anastomotic leaks following cervical technique (odds ratio (OR): 0.32, 95 % confidence interval (CI): 0.13-0.78). Moreover, HS (OR: 0.58, 95 % CI: 0.38-0.90) and LS (OR: 0.21, 95%CI: 0.06-0.71) significantly reduced anastomotic stricture rates, while LS significantly reduced anastomotic strictures following intrathoracic anastomotic technique (OR: 0.17, 95%CI: 0.06-0.90). CONCLUSION:HS reduced anastomotic leaks following cervical anastomoses, while HS and LS reduced overall anastomotic strictures (with LS significantly reducing strictures following intrathoracic anastomoses). Importantly, institutional and surgeon expertise should be considered prior to adopting these results into contemporary practice for open oesphagectomy, with a call for the harmonisation of trials to align with contemporary, minimally invasive approaches.

Oesophageal reconstruction is a complex operation that continues to present a surgical challenge associated with significant morbidity and its associated sequelae. The conventional gastric conduit remains the gold standard reconstructive technique when available. Alternative conduits for oesophageal replacement become necessary when the stomach is unavailable with common options for conduit creation being the jejunum and the colon. The aim of this systematic review and network meta-analysis was to interrogate outcomes in oesophageal reconstruction with gastric pull-up, colonic interposition and jejunal flap. A systematic review of three electronic databases (PubMed, EMBASE and SCOPUS) was undertaken. An NMA as per the PRISMA-NMA guidelines. Statistical analysis was carried out using R and Shiny. In a total of 19 studies, 3927 patients were included; 79.5

The optimal hypoabsorptive surgical approach for management of severe obesity remains unclear. To perform a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing Roux-en-y gastric bypass (RYGB), SADI-S (single anastomosis duodeno-ileal bypass with sleeve gastrectomy), one anastomosis gastric bypass (OAGB) and duodenal switch (DS). A systematic review was performed as per PRISMA-NMA guidelines. Statistical analyses were performed using R and shiny. 12 RCTs (with 5 sequential analyses) were included, involving 986 patients [471 RYGB (47.8

METHODS:This prospective, multi-centre RCT was conducted in accordance with the CONSORT guidelines for prospective, parallel group randomised studies. Adult patients undergoing elective laparoscopic surgery at two teaching hospitals in Dublin, Ireland were recruited and assigned to one of three closure methods (sutures (SU), staples (ST) or tissue glue (TG)) with primary outcome being cosmesis and secondary outcomes being closure speed, wound complications, cost effectiveness and sustainability outcomes being assessed by a blinded outcomes assessor. RESULTS:A total of 147 patients were recruited and randomised with a total of 138 being examined in the final analysis (SU = 48, ST = 63, TG = 27). Patient demographics were similar across all groups for gender, mean age, body mass index and American Society of Anaesthesiologists grade (all p > 0.050). For cosmesis, SU had the lowest overall mean observer (p < 0.001) and patient (p = 0.005) scar scores. Furthermore, when evaluating the breakdown for Observer Scar Score (OSS), SU had the lowest vascularity (p = 0.001), pigmentation (p = 0.006), thickness (p < 0.001), relief (p = 0.003) and pliability (p < 0.001). For patient scar score (PSS), SU had the lowest irregularity (p = 0.035). SU was the most cost-effective (p < 0.001) and had the lowest total produced non-recyclable waste (p < 0.001). ST had the shortest closure time (p < 0.001). Overall, there was a no difference in wound complication rates (SU = 6.3 %, ST = 6.4 %, TG = 18.5 %; p = 0.130). CONCLUSION:In conclusion, SU was the most effective method for laparoscopic port site closure with regards to cosmesis, cost-efficiency and surgical sustainability. ST was the marginally quicker method of closure and demonstrated equipoise in terms of complication rate. We advocate for SU as the current 'gold standard' with reduced non-recyclable waste generated and a valuable training opportunity for junior trainees. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT03843866.

PURPOSE:Abdominoperineal resection (APR) frequently results in a large volume perineal defect. Flap reconstruction is commonly undertaken to reduce the rate of perineal complications associated with primary closure. Several techniques can be employed including vertical rectus abdominis (VRAM), gluteal myocutaneous and gluteal fasciocutaneous flaps. We aimed to compare perineal complication rates between flap reconstruction techniques. METHODS:A systematic review was conducted following PRISMA guidelines. Databases were searched for studies reporting perineal complications following flap reconstruction post-APR. Demographic data for each study was extracted along with overall perineal complication rate, infectious complication, flap necrosis, dehiscence, and failure. RESULTS:In total, 31 studies with 764 patients were included. Rectal cancer was the underlying pathology in 71.3 % (545/764), anal cancer in 23.6 % (180/764), and other in 5.1 % (39/764). VRAM flap reconstruction was performed in 57.2 % of cases (437/764), gluteal myocutaneous in 25.1 % (192/764), and gluteal fasciocutaneous in 17.7 % (135/764). Infection, dehiscence, haematoma, seroma, and flap failure rates were comparable among the different groups. Flap necrosis occurred in 4.6 % of the VRAM group and was significantly higher than in the other groups (P = 0.028). The rate of reoperation (9.1 %) was also significantly higher in the VRAM group (P = 0.038). Perineal hernia formation occurred in 14.9 % of the gluteal fasciocutaneous group and was significantly higher than in the other groups (P < 0.001). CONCLUSION:Flap necrosis and reoperation rates are higher after VRAM flap reconstruction. Perineal hernia rates are higher in gluteal fasciocutaneous flap reconstruction. A randomised controlled trial is needed to further investigate the outcomes of flap reconstruction.

Transversus abdominus plane (TAP) blocks have become increasingly popular, due to a perceived reduction in post-operative pain following laparoscopic surgery. Their value following sleeve gastrectomy remains unclear. To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) evaluating the efficacy of TAP block in patients undergoing laparoscopic sleeve gastrectomy. Integration of data from bariatric surgery units across the world. A systematic review was performed as per PRISMA guidelines. Meta-analysis was performed using Review Manager v5.4. Eleven RCTs including 776 patients were included with 338 randomized to TAP block (50.0

BACKGROUND:After the ESOPEC trial showed a survival benefit for fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT)-treated adenocarcinomas of the esophagus (EAC) and the gastroesophageal junction (GEJ) compared with Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS), a European, high-volume center study for stage cT2cN0 EAC and GEJ was undertaken, as it has been published that a third of these patients are understaged and could benefit from a multimodal approach PATIENTS AND METHODS: Retrospective analysis of prospective databases from ten high-volume European centers was performed. Inclusion criteria were GEJ Siewert type I/II or EAC with cT2cN0 status at diagnosis undergoing multimodal treatment with FLOT or CROSS. Primary endpoint was overall survival (OS) RESULTS: Between 2012 and 2023, 133 patients met the inclusion criteria, of whom 73 (54.9%) received CROSS and 60 (45.1%) underwent treatment with FLOT. In both groups, patients were mainly male (p = 0.08), older than 70 years (p = 0.24), and had American Society of Anesthesiologists (ASA) II classification (p = 0.45). Regarding surgical treatment, more patients underwent gastrectomy in the FLOT than in the CROSS cohort (23.3% versus 6.8%, p = 0.007). There were no differences regarding pT, pN, and pM category (p > 0.05). Median survival was not reached, while mean survival was 74.6 months (95% CI 60.5-88.7 months) for CROSS versus 100.8 months (95% CI 72.5-94.5 months, p = 0.028) for FLOT. The 3-year survival was 87% in the FLOT group versus 59% in the CROSS group. In multivariable analyses, FLOT was independent factor for survival (p < 0.001) CONCLUSIONS: For cT2cN0 staged EAC and GEJ type I /II patients FLOT chemotherapy showed a survival benefit and should be the preferred treatment in a multimodal approach.

Enhanced Recovery After Surgery (ERAS) protocols are evidence-based care improvement pathways which are perceived to expedite patient recovery following surgery. Their utility in the setting of oesophagectomy remains unclear. The aim of this study was to perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the impact of ERAS protocols on recovery following oesophagectomy compared to standard care. A systematic review was performed in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines. Meta-analysis was performed using Review Manager (Version 5.4). Six RCTs including 850 patients were included in this meta-analysis. Overall complication rate (Odds Ratio (OR): 0.35, Confidence Interval (CI): 0.21, 0.59, P < 0.0001), pulmonary complications (OR: 0.40, CI: 0.24, 0.67, P = 0.0005), post-operative length of stay (LOS) (OR -1.88, CI -2.05, -1.70, P < 0.00001) and time to post-operative flatus (OR: -5.20, CI: -9.46, -0.95, P = 0.02) favoured the ERAS group. There was no difference noted for anastomotic leak (OR: 0.55, CI: 0.24, 1.28, P = 0.17), cardiac complications (OR: 0.86, CI: 0.30, 2.46, P = 0.78), gastrointestinal complications (OR: 0.51, CI: 0.23, 1.17, P = 0.11), wound complications (OR: 0.85, CI: 0.28, 2.58, P = 0.78), mortality (OR: 1.37, CI: 0.26, 7.4, P = 0.71), and 30-day re-admission rate (OR: 1.29, CI: 0.30, 5.47, P = 0.73) between ERAS and standard care groups. ERAS implementation improved post-operative complications, LOS, and time to flatus following oesphagectomy. These results support the robust adoption of ERAS in patients indicated to undergo oesphagectomy.

INTRODUCTION:Mentorship is perceived to influence the nuanced decisions of medical students on the precipice of their chosen career path. No previous study has evaluated whether formalised mentorship ab initio impacts medical students attitudes towards a career in surgery. METHODS:A crossover, randomised controlled trial (RCT) was performed. Medical students were randomised to: (1) lack of exposure to a mentor (control/crossover arm) and assessment using a questionnaire, and (2) exposure to a mentor (intervention arm) and assessment. The control/crossover arm were then exposed to a mentor and underwent re-assessment and comparison with their initial results. RESULTS:Overall, 43 students were enrolled with no significant difference observed in student age, gender, or nationality (all P > 0.050). In the intervention arm, students were less likely to feel a lack of mentorship in surgery (P = 0.021) or be discouraged by the 'unknowns' of surgical training (P = 0.001). Furthermore, mentorship provided them with significant clarity regarding training (P = 0.032) and made the recommendation for mentorship more likely (P < 0.001). Following crossover, students felt significantly more interested in a surgical career (P = 0.001). Students also felt less concerned regarding competition (P = 0.032), the 'unknowns' (P = 0.007), workload (P = 0.006), and lack of direction (P = 0.016) within surgical training, while also reporting less concern regarding a lack of mentorship (P = 0.010) and less insecurity about their ability to succeed in surgery (P = 0.003). Lastly, crossover provided students with clarity regarding training (P = 0.033), while making mentor recommendation more likely (P = 0.001). CONCLUSION:Formalised mentorship has a positive impact upon medical students' attitudes through structured support towards a career in surgery. Medical education institutions should consider the inclusion of formalised mentorship programmes in their curricula.

OBJECTIVE:To evaluate the progression rate of Barrett esophagus (BE) to esophageal adenocarcinoma (EAC) using a prospectively maintained national registry, quality-assured endoscopy, and expert pathology. BACKGROUND:BE is the sole pathologic precursor of EAC. Targeting prevention and early diagnosis through quality-assured BE programs has a compelling rationale. METHODS:A Barrett's Registry and Bioresource was founded in 2011, and data to November 2024 were prospectively documented in a web-based system (Dendrite, UK). Endoscopy and pathology (of specialized intestinal metaplasia) were strictly quality assured per current guidelines. Expert gastrointestinal pathologists classified non-dysplastic BE (NDBE), indefinite for dysplasia (IND), low-grade dysplasia (LGD), and high-grade dysplasia (HGD). Endoscopic eradication therapies were monitored. Multivariable regression models evaluated risk factors for progression, and Kaplan-Meier curves were constructed for overall progression, and progression excluding the first year after the index biopsy. RESULTS:Nine thousand four hundred thirty-six patients were registered, with a median follow-up of 4.4 years, and 5331 had at least one follow-up endoscopy. Overall, 252 cases (4.7%, 95% CI: 1.70-2.18) of HGD and 255 cases (4.7%, 95% CI: 1.72-2.20) of EAC were diagnosed. Among these, 150 cases (2.8%. 95% CI: 1.05-1.44) of HGD and 148 (2.7%, 95% CI: 1.05-1.44) of EAC were diagnosed more than 1 year after the index endoscopy. The overall incidence of HGD/EAC combined was 2.42% (95% CI: 2.14-2.73), 6.59% (95% CI: 5.14-8.46), and 13.79% (95% CI: 11.94-15.93) per year in NDBE, IND, and LGD, respectively. Independent risk factors include male sex [hazard ratio (HR): 0.655, 95% CI: 0.56-0.896, P <0.004], age (HR: 1.027, 95% CI: 1.02-1.04, P <0.001) and Barrett's length (HR: 1.635, 95% CI: 1.33-2.01, P <0.001). 604 (6.4%) patients underwent RFA, with a complete eradication of SIM in 80.5% and 10 (1%) patients required resectional surgery. Cancer-specific survival in the total cohort was 100%. CONCLUSIONS:A structured high-volume Barrett's program, underpinned by quality assurance, provides data that highlights a strategy that provides proof of concept in targeting prevention and early detection, and is anticipated to reduce mortality.

BACKGROUND:Esophagectomy remains the standard of care for patients with resectable locally advanced malignancies of the esophagus. AIM:To compare perioperative and long-term outcomes across open (OE), hybrid (HE), minimally invasive (LMIE), and robotic-assisted esophagectomy (RAMIE) for esophageal pathologies using randomised controlled trial (RCT) data. METHODS:A systematic search of the EMBASE, SCOPUS and PUBMED databases was performed to identify RCTs comparing OE, HE, LMIE and RAMIE. Descriptive statistics were performed using SPSS v26.0. RESULTS:Sixteen RCTs with 2729 total patients were included. Overall, 50.6 % of patients underwent OE (1381/2729), 5.4 % underwent HE (148/2729), 31.4 % underwent LMIE (856/2729) and 12.6 % underwent RAMIE (344/2729). LMIE and RAMIE demonstrated reduced pulmonary complications and hospital stay compared with OE. RAMIE achieved superior lymph node dissection rates, compared to LMIE. HE demonstrated lower complication rates than OE, with comparable lymph node yields. In-hospital mortality remained low across all groups, with no significant differences, though LMIE and RAMIE had demonstrated better short-term recovery. Meta-analysis of 9 RCTs showed higher 30-day mortality with OE compared to MI (RR 1.84, 95 % CI 1.02-3.34; I2 = 0 %). Long-term survival and disease-free survival rates were largely comparable across all techniques. Quality of life (QOL) metrics one year post-surgery indicated that LMIE and RAMIE provided better physical functioning, pain reduction, and social functioning than OE. CONCLUSION:LMIE and RAMIE were superior in terms of blood loss, pulmonary complications, hospital stays, improved QOL, and lymph node yield compared to OE. Notwithstanding these concerted benefits, equipoise was demonstrated in terms of rates of surgical site infection, chyle leak, mortality, survival and oncological outcomes. Thus, minimally invasive techniques should be considered where surgeon and institution expertise allow.