Predictive performance of the Modified Frailty Index and ASA-PS classification for 30-day mortality after esophagectomy in patients with esophageal cancer

Modified 5-Item Frailty Index Is Associated with Postoperative Delirium but Not Survival in Patients Undergoing Surgery for Oral Squamous Cell Carcinoma

Because this retrospective study was limited by sample size, comorbidity-driven mFI-5 scoring, non-standardized delirium screening, and potential residual confounding, mFI-5 should be interpreted as a convenient screening marker rather than a stand-alone predictor.

P1.233. Impact of Preoperative Frailty on Long-Term Survival Following Esophagectomy for Esophageal Cancer

It is suggested that preoperative frailty assessment to target prehabilitation strategies, inform risk assessment, and support shared decision making are critical for improving long-term survival in esophageal cancer patients.

The geriatric 8 score as a predictor of postoperative outcomes in elderly patients undergoing esophagectomy.

Prediction of anastomotic leakage after esophagectomy for esophageal cancer: a nomogram study integrating systemic inflammation indices and clinical factors

Background Esophageal cancer remains one of the leading causes of cancer-related mortality worldwide. Anastomotic leakage (AL) following esophagectomy is a major postoperative complication that significantly impacts patient outcomes, including mortality, morbidity, prolonged hospital stays, and increased healthcare costs. Despite advances in surgical techniques and adjuvant therapies, predicting the risk of AL remains a challenge. Objective This study aims to develop and validate a predictive model for assessing the risk of AL in esophageal cancer patients undergoing esophagectomy, based on comprehensive clinical and laboratory variables. Methods This retrospective cohort study included 650 esophageal cancer patients who underwent esophagectomy between January 2015 and May 2025, divided into a training set (n = 455) and a validation set (n = 195) at 7:3 ratio. Baseline demographic, clinicopathological, and laboratory data were collected, with AL as the primary outcome, defined according to the Esophagectomy Complications Consensus Group (ECCG). Univariable and multivariable logistic regression, restricted cubic splines (RCS), and nomogram development to identify predictors, with model performance assessed using receiver operating characteristic (ROC) curve, calibration plots, and decision curve analysis (DCA). Results Seven significant predictors of AL were identified in the training set: age, neoadjuvant radiotherapy, C-reactive protein-albumin-lymphocyte (CALLY) index, hypertension, neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-monocyte ratio (NMR), and platelet-to-lymphocyte ratio (PLR). A nomogram model was developed, showing good discrimination (AUC = 0.813) and calibration in the training set. The validation cohort demonstrated moderate predictive accuracy (AUC = 0.763), with consistent net benefits observed across different risk thresholds in DCA. Conclusions In conclusion, this study established a potentially useful predictive model for AL risk, which may facilitate individualized risk stratification, guide perioperative decision-making, and ultimately contribute to reducing AL incidence and improving postoperative recovery.

PD09.06. Frailty in Patients Undergoing Esophagectomy for Cancer Is Associated With Complication Cascade and Failure to Rescue

Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Esophagectomy is poorly tolerated in frail patients. Frailty is associated with decreased resilience, resulting in "failure to rescue" (FTR) after a complication. This study investigates the intersection between frailty and FTR in patients undergoing this operation and introduces the concept of the Complication Cascade in the setting of esophagectomy. This is a single-institution retrospective study (2000-2014) for patients with esophageal cancer who underwent resection. We harmonized the modified 5-factor frailty (mFI-5) score with Society of Thoracic Surgeons variables including performance status and comorbidities. Surgical approaches and postoperative outcomes were reviewed. FTR was defined as death during index hospitalization following 31 operative complication. The Extended FTR (E-FTR) was defined as mortality during the index hospitalization, non-home discharge, and/or readmission within 30 days. Total number of non-fatal complications was used to inform the Complication Cascade (CC), a phenomenon that occurs when one complication appears to trigger additional complications. Logistic regression models were used to evaluate any risk factors associated with FTR and E-FTR, and linear regression models were used to evaluate factors associated with the total number of complications. The association between frailty score and CC was assessed using Chi-square tests. Of 388 patients, mean age was 62.8±11.7 and mFI-5 scores 0-4 were 28%, 41%, 25%, 5%, and 1%, respectively. Surgical approach included 63.7% open, 12.1% hybrid, and 21.6% minimally invasive. 15% of patients had non-home discharge and 11% were readmitted <30 days. Mortality was 4.9%, FTR 4.6%, and E-FTR 24%. On multivariate analysis, mFI-5 and surgical approach were associated with E-FTR and mean number of complications (Table). There were no significant associations between the measured variables and FTR. The total number of complications was linearly related to frailty score (p<0.001, ANOVA) and frailty score was significantly associated with FTR and E-FTR (Figure; p<0.001). Higher mFI-5 scores correlated with increased CC severity, suggesting that diminished preoperative reserve heightens susceptibility to compounding surgical complications. Preoperative frailty is a potent predictor of a patient's inability to recover from postoperative complications following esophagectomy. A higher frailty score correlates significantly with an increased risk of E-FTR. This is mechanistically related to lack of resilience and a resultant Complication Cascade. Integrating frailty assessment into preoperative risk stratification and targeted prehabilitation are essential for identifying high-risk patients and implementing individualized strategies to reduce operative risk and mitigate the progression of postoperative morbidity.

P1.199. Preoperative Frailty Testing for Esophagectomy: Stair-Climb Time as the Strongest Predictor of Major Complications

Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Esophageal cancer is increasingly common in an aging population. Esophagectomy remains a cornerstone of treatment but carries substantial perioperative risk. Accurate preoperative risk assessment is therefore essential. Commonly used tools (e.g. NSQIP frailty index perform poorly in predicting complications after esophagectomy. This study aimed to compare exercise-based and other validated frailty indices to determine the best predictor of major postoperative complications following minimally invasive esophagectomy (MIE) for esophageal cancer. We conducted a prospective cohort study of patients undergoing elective MIE at a tertiary referral center between October 2020 and January 2025. Preoperative frailty assessments included: two-floor stair-climb time, pulse and oxygen-saturation changes during stair climbing, grip strength, and the Edmonton Frail Scale (EFS) score. The primary outcome was a major complication (Clavien–Dindo grade ≥ III) within 30 days. Spearman correlations were calculated among frailty measures. Univariate T-test and multivariate analyses compared frailty metrics between patients with and without major complications. Receiver operating characteristic (ROC) curves assessed the discriminatory ability of each measure and combined models. A total of 105 patients were enrolled (age 64.4 ± 10.5 years; 81% male). Median LOS 9 (IQR 8-13) and ICU 4 (IQR 3-6). The anastomotic leak rate was 8.6% (n = 9), major complication rate 29.5% (n = 31), and 30-day mortality 1% (n = 1). Stair-climb time correlated significantly with grip strength (r = –0.42, p < 0.001) and EFS (r = 0.43, p < 0.001). Patients with major complications had significantly longer stair-climb times (48.2 ± 14.2 s vs 39.7 ± 10.3 s, p= 0.001). EFS scores trended higher in the major complication group but did not reach statistical significance (4.6 ± 2.7 vs 3.7 ± 2.1, p = 0.068). No significant differences were observed in pulse, oxygen saturation changes, or grip strength. (Table 1) In multivariate analysis, longer stair-climb time independently predicted major complications (OR 1.06,95% CI: 1.01-1.12, p = 0.031) with moderate discrimination (AUC of 0.688, 95% CI0.573–0.803) (Figure 1). Esophagectomy remains one of the highest risk surgeries, underscoring the need for reliable routine preoperative risk stratification tools. Of the frailty assessments studied, stair-climb time was the only measure significantly associated with major complications after MIE. As a simple global test of cardiopulmonary, neurologic, and musculoskeletal function, the stair-climb test offers a practical and effective way to enhance preoperative prognostication for patients undergoing MIE.