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.
Abstract
Esophageal Cancer: Surgical Treatment of Esophageal Cancer – long term outcomes
Esophagectomy can provide cure for esophageal cancer yet is associated with high rates of perioperative morbidity. Assessing frailty in the preoperative setting provides superior insight into patients’ physiological reserve and their ability to survive adverse postoperative events. This study evaluates the long-term impact of frailty on survival outcomes.
A single institution retrospective analysis (2000-2014) was conducted on 398 patients who underwent esophagectomy for esophageal cancer. Clinical characteristics analyzed included BMI, comorbidities, performance status, and preoperative chemoradiation. Frailty was measured using the modified Frailty Index (mFI-5) score and was defined as mFI-5 ≥2. Cox regression models were used to evaluate relevant covariates including frailty status, age, surgical approach, comorbidities, induction therapy, pathologic stage, and histology on long-term survival outcomes.
The cohort had mean age 62.8 ± 11.7, was predominantly male (81.2%) and overweight/obese (66%). 61% received preoperative chemotherapy and 54% also had radiotherapy. mFI-5 scores were 0 (28%), 1 (41%), 2 (25%), 3-4 (6.4%). Cardiovascular and pulmonary complication rates were 31% and 22%. Mortality was 4.9%. On univariate analysis, mFI-5 frailty score, age, CAD, pTNM stage, induction therapy, and squamous histology were significantly associated with worse survival. When categorizing mFI-5 as a binary variable (0-1 vs 2+) and age in 5-year increments, on multivariate analysis frailty, age, induction therapy, worse pathological stage, and squamous histology were significantly associated with worse survival (Table). The hazard ratios were similar among the covariates. Long-term survival was significantly lower in the frail cohort compared to the non-frail cohort, with median overall survival 1.97 vs 4.96 years (Figure, p<0.001).
Postoperative survival after esophagectomy is significantly associated with patient preoperative frailty. These findings suggest 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.
Surgical timing, particularly esophagectomy performed in February, is associated with inferior long-term survival in ESCC patients, and concurrent low burnout levels during this period suggest that reduced surgical volume and altered case selection during the holiday season, rather than staff fatigue, may underlie this disparity.
Si-miao Lu, Yi Zhu, Yong-tao Han et al.· Diseases of the esophagus· 0 citations
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.
Lye-Yeng Wong, Ernest Chan, Tyler Wilson et al.· Diseases of the esophagus· 0 citations
It is suggested that mFI-5 and ASA-PS alone provide limited discrimination for predicting 30-day mortality and support the development of esophagectomy-specific risk prediction models incorporating objective clinical, physiological, functional, and procedure-specific variables.
W. Chaochankit, S. Sunpaweravong, C. Sungworawongpana· Frontiers in Oncology· 0 citations
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.
Sheuli Chowdhury, Camille Le Gardeur, Elliot S. Ballato et al.· Diseases of the esophagus· 0 citations
Esophageal Cancer: Surgical Treatment of Esophageal Cancer – long term outcomes
With the aging of the global population, an increasing number of elderly patients undergo esophagectomy for esophageal cancer. Elderly populations exhibit considerable heterogeneity in overall health status due to differences in comorbidities. However, the factors influencing long-term outcomes after minimally invasive esophagectomy in this population have not been fully elucidated. This study aimed to identify prognostic factors associated with long-term survival in patients aged ≥75 years who underwent minimally invasive esophagectomy.
This retrospective study evaluated 110 patients aged ≥75 years who underwent minimally invasive esophagectomy (thoracoscopic or robot-assisted thoracoscopic esophagectomy) with lymph node dissection at Tohoku University Hospital in Sendai, Japan, between 2008 and 2021. Patients with pathological diagnoses other than squamous cell carcinoma or adenocarcinoma were excluded. Prognostic factors associated with overall survival, including patient, tumor, and surgical factors, were analyzed. Furthermore, the impact of these factors on esophageal cancer-specific mortality and non-cancer-related mortality was subsequently evaluated.
Postoperative pneumonia (p<0.01) and pathological non-R0 resection (p<0.001) were identified as independent predictors of worse overall survival after minimally invasive esophagectomy. Esophageal cancer-specific mortality did not differ significantly between patients with and without postoperative pneumonia (p=0.160). Relapse-free survival also did not differ significantly between the two groups (p=0.202). In contrast, non-esophageal cancer-related mortality was significantly higher in patients who developed postoperative pneumonia (p=0.018). Among non-esophageal cancer-related deaths, respiratory diseases were the predominant cause of death in the postoperative pneumonia group, accounting for 9 of 11 deaths (81.8%).
Reducing the incidence of postoperative pneumonia may be important for improving long-term outcomes after esophagectomy in elderly patients, particularly by decreasing non-cancer-related mortality. Careful preoperative risk assessment, strategies to minimize surgical morbidity, and structured postoperative rehabilitation with functional follow-up may contribute to improved long-term survival.
J. Takahashi, Y. Ozawa, Y. Taniyama et al.· Diseases of the esophagus· 0 citations
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.
K. Yamagata, S. Fukuzawa, Shohei Takaoka et al.· Diagnostics· 0 citations
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