Oncological outcomes of the TIME trial in esophageal cancer: is it the era of minimally invasive esophagectomy?

Esophageal cancer is one of the most common digestive tract cancers worldwide. Although multimodality therapy has been used in the treatment of esophageal cancer, there is still a poor prognosis (1). For decades, esophageal resection remains the mainstream of multimodality treatment for esophageal cancer, but traditional open esophagectomy (OE) is associated with high perioperative morbidity and mortality. The unstopping advances in surgical devices and techniques have contributed to the transition from OE approach to minimally invasive esophagectomy (MIE) approach, which has demonstrated advantages in reducing postoperative pulmonary complications and improving short-term quality-of-life (QoL) verified by some prospective trials (2,3). However, debate is ongoing as to whether MIE is equivalent to open resection regarding long-term oncologic outcomes. Although many retrospective studies reported equivalent or even superior long-term outcomes of MIE over OE (4-6), we could not ignore the fact that conclusion was underpowered due to the biases, such as selection of cases, surgeon’s experience and non-uniform surgical procedure. With the intent to solve the predicament, the long-term results of multiple prospective randomized clinical trials, including MIRO (7), TIME (2) and ROMIO (8) have been waiting all the time.