Improved operative mortality after esophagectomy in patients aged ≥ 75 years over a decade: a nationwide Japanese retrospective cohort study.

BACKGROUND

Esophagectomy is associated with substantial morbidity and mortality, particularly in older patients. Although minimally invasive surgery (MIS) has been widely adopted, its contribution to improve operative outcomes in this population remains unclear. This study aimed to evaluate temporal trends in short-term outcomes after esophagectomy in patients aged ≥ 75 years and determine whether the increasing adoption of MIS contributed to improved operative mortality.

METHODS

Using the Japanese National Clinical Database, we analyzed patients aged ≥ 75 years who underwent radical esophagectomy for esophageal cancer between 2014 and 2024. The primary and secondary endpoints were operative mortality and severe postoperative complications (Clavien-Dindo grade ≥IIIa), respectively. Multivariable logistic regression analyses were performed, including sensitivity analyses additionally adjusted for MIS.

RESULTS

Among 7,678 patients, patient complexity increased over time, with higher proportions of octogenarians, patients with American Society of Anesthesiologists Physical Status ≥ 3, and patients receiving preoperative chemotherapy. Open thoracotomy decreased from 53.1% to 6.5%, whereas robot-assisted esophagectomy increased from 0% to 34.8%. Operative mortality decreased from 4.7% to 2.4%, with a risk-adjusted odds ratio (OR) of 0.49 (95% confidence interval [CI] 0.35-0.67; P < 0.001). Risk of severe postoperative complications remained unchanged (adjusted OR = 1.12, 95% CI 0.98-1.29; P = 0.11). Mortality reduction remained significant after adjustment for MIS (OR = 0.58, 95% CI 0.41-0.83; P = 0.003).

CONCLUSIONS

Despite increasing patient complexity, operative mortality after esophagectomy in older patients improved substantially over the past decade. This improvement was unlikely to be explained by the increasing use of MIS alone and may reflect broader advances in perioperative management and other system-level factors. These findings have important implications for surgical care in aging populations worldwide.