Impact of advanced age on postoperative recovery after esophagectomy

Esophagectomy remains a highly invasive procedure associated with substantial postoperative morbidity. With an aging patient population, the role of chronological age in predicting postoperative recovery remains controversial. Increasing evidence suggests that physiologic reserve, rather than age alone, may better reflect surgical risk. This study aimed to evaluate short-term postoperative outcomes according to age and to investigate whether computed tomography (CT)-derived thoracic muscle thickness provides additional insight into postoperative recovery.

We conducted a retrospective cohort study of 299 consecutive patients who underwent esophagectomy between December 2020 and June 2025. Patients were categorized into two groups (<75 and ≥75 years). Preoperative CT scans were used to measure thoracic muscle thickness at T5, T8, and T10, with the mean value calculated as average thoracic muscle thickness. The primary endpoint was prolonged postoperative length of stay (LOS >15 days). Postoperative LOS was additionally analyzed as a continuous measure of recovery, and pulmonary complications were evaluated as a key secondary outcome.

Of the 299 patients, 42 (14.0%) were aged ≥75 years. Older patients had a higher prevalence of hypertension and lower albumin levels and thoracic muscle thickness. However, postoperative outcomes were comparable between age groups, including median LOS (13 vs. 13 days, P=0.89) and pulmonary complication rates (16.7% vs. 14.4%, P=0.65). In multivariable analyses, age ≥75 years was not independently associated with prolonged LOS [odds ratio (OR) 0.82, 95% confidence interval (CI): 0.36-1.90, P=0.65] or pulmonary complications (OR 1.09, 95% CI: 0.43-2.76, P=0.85). Lower thoracic muscle thickness showed an inverse association with adverse outcomes, although these associations did not reach statistical significance.

Chronological age ≥75 years was not an independent predictor of short-term postoperative recovery after esophagectomy. These findings support a shift from age-based to physiology-based risk assessment, highlighting the importance of nutritional status, comorbidity burden, and imaging-derived markers of muscle reserve. CT-derived thoracic muscle thickness may serve as a practical adjunct for perioperative risk stratification and warrants further validation in prospective studies.