Thoracoscopic esophagectomy outperformed open surgery for upper and middle esophageal squamous cell carcinoma, improving both overall and disease-free survival.

• In upper tumors, thoracoscopic surgery cut mortality risk by 55% (HR 0.45) and recurrence risk by 45% (HR 0.55).
• In middle tumors, overall survival improved by 36% (HR 0.64) and disease-free survival by 30% (HR 0.70).
• Outcomes were similar for lower esophageal tumors.

Thoracoscopic approaches also reduced blood loss and increased lymph node yield, though at the cost of longer operations and higher expenses.