Prolonged surgical time and hypoalbuminemia as risk factors for adverse outcomes after esophagectomy: a multicenter study with age-stratified and spline-based analysis.

BACKGROUND

Esophagectomy is associated with high morbidity. Prolonged surgical time, low body mass index, and hypoalbuminemia have been implicated as potential risk factors. However, their age-specific and nonlinear associations with postoperative outcomes remain unclear.

METHODS

This multicenter retrospective study included 338 patients who underwent elective esophagectomy for histologically confirmed esophageal cancer between 2018 and 2024. The primary outcome was a composite of severe complications within 30 days, including mortality, reoperation, renal replacement therapy, or mechanical ventilation. Multivariable logistic regression was used to evaluate risk factors, with age-stratified analysis (< 70 vs. ≥ 70 years) and restricted cubic spline modeling applied to assess nonlinear associations.

RESULTS

The primary outcome occurred in 15.4% of patients. In the overall cohort, prolonged surgical time (OR 1.061 per 10 min, p < 0.001) and hypoalbuminemia (OR 0.312, p = 0.002) were independent predictors. Among patients < 70 years, operative time, hypoalbuminemia, and male sex were significant risk factors. Among those ≥ 70 years, operative time and low body mass index were associated with increased risk. Spline analysis revealed a continuous increase in the risk of complications with longer surgeries. A significant interaction was observed between body mass index and age (p = 0.024).

CONCLUSIONS

Prolonged surgical time and hypoalbuminemia are independent predictors of adverse outcomes after esophagectomy. The impact of body mass index varies by age, with low body mass index posing a greater risk in older patients. These findings highlight the need for individualized perioperative assessment based on age and physiological status.