Feasibility and short-term outcomes of curative esophagectomy in octogenarian patients with esophageal cancer: a real-world retrospective study

Abstract

Background

The role of surgical treatment in patients aged ≥ 80 years with esophageal cancer remains controversial, and real-world evidence remains scarce. This study aimed to evaluate the perioperative safety and mid-term survival outcomes of octogenarian patients following radical esophagectomy.

Methods

This single-center retrospective cohort study consecutively enrolled patients aged ≥ 80 years who underwent radical esophagectomy at our institution between 2020 and 2025. Data on baseline characteristics, perioperative complications, 30-day and 90-day postoperative mortality, overall survival (OS), and disease-free survival (DFS) were collected. Multivariable logistic and Cox regression analyses were performed to identify independent prognostic factors.

Results

A total of 110 patients were included, with a mean age of 81.8 years; 67.3% were male, and 58.2% had COPD. The most common postoperative complications were pulmonary infection (49.1%) and arrhythmia (42.7%); 16 patients (14.5%) required transfer to the ICU because of severe complications. The perioperative mortality rate was 9.1% (10/110). The 90-day postoperative mortality rate was 13.6%. Multivariable logistic regression analysis demonstrated that higher BMI was a protective factor against 90-day mortality. After a median follow-up of 20 months, the 1-year and 2-year OS rates were 81% and 56%, respectively. Multivariable Cox regression analysis indicated that age was the only independent predictor of overall survival (HR, 1.22).

Conclusion

Curative esophagectomy may remain feasible in carefully selected octogenarian patients, although perioperative morbidity and mortality remain substantial; therefore, treatment decisions should be based on comprehensive multidisciplinary evaluation rather than age alone.

Introduction

Esophageal cancer is among the most lethal malignancies of the digestive tract worldwide, with squamous cell carcinoma representing the predominant histological subtype in China [1, 2]. With the acceleration of population aging, the proportion of octogenarian patients (aged ≥ 80 years) has increased steadily in recent years [3, 4]. This population frequently presents with multiple comorbidities and diminished cardiopulmonary reserve, resulting in significantly reduced tolerance to surgical trauma and perioperative stress [5]. However, there is a lack of standardized treatment strategies for this patient population, thereby making it one of the most challenging subgroups in the management of esophageal cancer.

Radical resection remains the cornerstone treatment for achieving long-term survival in patients with locally resectable esophageal cancer [6]. However, the appropriateness of radical surgery in octogenarian patients remains controversial. Several single-center studies have suggested that carefully selected super-elderly patients can achieve acceptable perioperative safety and favorable long-term survival outcomes [7–10]. In contrast, large-scale national database studies have demonstrated that increasing age is associated with significantly higher perioperative mortality and rates of severe complications, a diminishing survival benefit from surgery, and a persistently low proportion of octogenarian patients undergoing surgical treatment in clinical practice [11–14]. These discrepancies across evidence sources have resulted in a lack of clear, evidence-based guidance for clinical decision-making in this population.

Previous studies have suggested that postoperative complications in elderly patients are predominantly cardiopulmonary events [8, 9, 15], and that real-world treatment pathways for octogenarian patients often deviate from standardized protocols, characterized by a relatively low utilization rate of neoadjuvant therapy and the performance of surgery following failure of non-surgical treatments. These characteristics may collectively influence perioperative safety and survival outcomes; however, systematic data specifically focused on patients aged ≥ 80 years remain limited.

Therefore, based on a large single-center real-world retrospective cohort, this study systematically evaluated perioperative safety, complication profiles, and mid-term survival outcomes in patients aged ≥ 80 years undergoing radical esophagectomy, and further explored key clinical factors influencing prognosis, with the aim of providing evidence-based support for surgical decision-making in this high-risk population.

Materials and methods

Patients

This single-center retrospective cohort study consecutively enrolled patients who underwent esophagectomy in the Department of Thoracic Surgery at our institution between 2020 and 2025. The study protocol was approved by the Institutional Ethics Committee of our institution and was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Given the retrospective design of the study, the requirement for written informed consent was waived by the Institutional Ethics Committee (Approval Number: 2026ER142-1). The inclusion criteria were as follows: (1) age ≥ 80 years; (2) pathologically confirmed esophageal malignancy; (3) receipt of curative-intent esophagectomy at our institution, irrespective of the administration of neoadjuvant or salvage therapy; and (4) availability of complete perioperative medical records and follow-up data. The exclusion criteria were: (1) emergency or palliative surgery (R2 resection); (2) concomitant malignancies; and (3) severely incomplete clinical data precluding adequate evaluation. Demographic characteristics, comorbidities, oncological variables, surgical details, perioperative outcomes, and follow-up data were extracted from the institutional electronic medical record system.

Preoperative assessment and surgery

All potential surgical candidates underwent a comprehensive preoperative assessment. Tumor staging assessment included contrast-enhanced chest computed tomography (CT), upper gastrointestinal endoscopy with biopsy or endoscopic ultrasonography (EUS), abdominal ultrasonography or contrast-enhanced CT/magnetic resonance imaging (MRI), and cervical lymph node ultrasonography; selected patients additionally underwent whole-body PET-CT to determine the clinical TNM stage according to the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. Surgical risk assessment encompassed cardiopulmonary function (including pulmonary function tests, arterial blood gas analysis, echocardiography, and electrocardiography), nutritional status (e.g., serum albumin and prealbumin levels), optimization of comorbidities (such as hypertension and diabetes), and routine geriatric evaluation focusing on cardiopulmonary reserve, nutritional status, functional independence, and comorbidity optimization. Based on these assessment findings, each case was reviewed by a multidisciplinary team (MDT). Surgery was performed only after consensus was reached that the tumor was amenable to curative resection and that the patient, following optimization, was physiologically fit to tolerate major surgical trauma. Surgical procedures consisted predominantly of minimally invasive McKeown esophagectomy (thoracoscopic-laparoscopic approach), whereas a limited number of patients underwent conventional open esophagectomy. All procedures were performed with the intent to achieve complete tumor resection and systematic regional lymph node dissection.

Outcomes

The primary endpoints were overall survival (OS) and disease-free survival (DFS). Overall survival was defined as the interval from the date of surgery to death from any cause, whereas disease-free survival was defined as the interval from the date of surgery to the first occurrence of recurrence, metastasis, or death from any cause. Secondary endpoints assessed perioperative safety, including postoperative complications (with particular attention to cardiopulmonary events, anastomotic leakage, infections, and respiratory failure), postoperative intensive care unit admission rate, length of postoperative hospital stay, and all-cause mortality within 30 and 90 days postoperatively. Postoperative complications were defined and categorized according to the Esophagectomy Complications Consensus Group (ECCG) criteria whenever applicable.

Statistical analysis

Categorical variables were summarized as frequencies and percentages. Continuous variables with a normal distribution were expressed as mean ± standard deviation, whereas those with a non-normal distribution were presented as median (interquartile range [IQR]). Survival analyses were performed using the Kaplan–Meier method, and corresponding survival curves were generated. All patients were included in the intention-to-treat analysis, and perioperative deaths were treated as events. To better delineate stage-specific prognosis, a time-segmented analytical approach was adopted: first, logistic regression was performed to identify factors associated with 90-day postoperative mortality; second, among patients who survived beyond 90 days (n = 95), postoperative day 90 was defined as the new time zero, and a Cox proportional hazards model was applied to evaluate long-term prognostic factors. All patients were included in the primary Kaplan–Meier survival analysis, including those who died within 90 days postoperatively. This strategy was adopted to reduce the confounding influence of perioperative mortality on long-term oncologic outcome assessment and to better identify factors associated with conditional long-term survival among patients who successfully recovered from the early postoperative period. Variables with P < 0.10 in univariable analysis and clinically relevant covariates were included in multivariable models. All statistical analyses were conducted using SPSS version 25.0 and R version 4.3.2, and a two-sided P value < 0.05 was considered statistically significant.

Results

Baseline characteristics

The patient screening process of this study is shown in Fig. 1, and finally included a total of 110 patients aged ≥ 80 years who underwent curative esophagectomy for esophageal cancer were ultimately included in the analysis. As shown in Table 1, the mean age was 81.8 ± 2.3 years, and 67.3% of the cohort were male. Regarding comorbidities, chronic obstructive pulmonary disease (COPD) was the most prevalent condition (58.2%), followed by cardiac disease (30.0%) and hypertension (23.6%). Most tumors were squamous cell carcinomas (84.5%) and were predominantly located in the middle thoracic esophagus (63.6%). Preoperative clinical staging indicated predominantly locally advanced disease, with 91.8% (101/110) of patients classified as stage II or III. Notably, seven patients (6.4%) received systemic therapy prior to surgery; among them, two underwent salvage surgery after disease progression following definitive chemoradiotherapy, whereas the remaining patients were not initially considered surgical candidates but were subsequently deemed operable after post-treatment multidisciplinary evaluation and, upon expressing a strong preference for surgery, ultimately underwent curative resection. All patients underwent preoperative multidisciplinary evaluation and were deemed physiologically fit to tolerate surgery.

Fig. 1.

Flowchart of the study

Table 1.

Baseline characteristics

Variables	Total (n = 110)
Age, mean ± SD, years	81.78 ± 2.26
BMI, median (range)	22.13 (19.81–24.05)
Sex
Male	74 (67.3%)
Female	36 (32.7%)
Smoking history
Yes	39 (35.5%)
No	71 (64.5%)
Drinking history
Yes	40 (36.4%)
No	70 (63.6%)
Comorbidities
Hypertension	26 (23.6%)
Diabetes	10 (9.1%)
Cardiac disease	33 (30.0%)
COPD	64 (58.2%)
Pathology
Squamous Cell Carcinoma	93 (84.5%)
Adenocarcinoma	12 (10.6%)
Neuroendocrine tumor	3 (2.7%)
Others	2 (1.8%)
Tumor location
Upper	11 (10.0%)
Middle	70 (63.6%)
Lower	29 (26.4%)
Clinical T stage
T1 + 2	22 (20.0%)
T3	79 (71.8%)
T4a	9 (8.2%)
Clinical N stage
N0	50 (45.5%)
N1	55 (50.0%)
N2-N3	5 (4.5%)
Clinical TNM stage
II	49 (44.5%)
III	52 (47.3%)
IVA	9 (8.2%)
Neoadjuvant therapy	7 (6.4%)
Type of Surgery
McKeown	98 (89.1%)
Open	12 (10.9%)
Pathological TNM stage
I	20 (18.2%)
II	43 (39.1%)
IIIA	7 (6.4%)
IIIB	36 (32.7%)
IV	4 (3.6%)

BMI body mass index

Surgical characteristics and perioperative outcomes

All procedures were performed with the intent to achieve R0 resection, and the majority of patients underwent minimally invasive esophagectomy using the McKeown approach (89.1%). The mean operative time was 228.58 ± 60.83 min, and the mean intraoperative blood loss was 113.00 ± 56.82 mL. The mean number of harvested lymph nodes was 15.19 ± 7.88. The mean postoperative length of hospital stay was 13.17 ± 7.21 days. On pathological examination, 36.3% (40/110) of patients were classified as stage IIIB or IV (Tables 1 and 2). The incidence of perioperative complications is summarized in Table 2. Postoperative complications were predominantly cardiopulmonary events, with pulmonary infection (49.1%, 54/110) and arrhythmia (42.7%, 47/110) representing the most frequent occurrences. Severe complications included respiratory failure (15.5%, 17/110), anastomotic leakage (14.5%, 16/110), and symptomatic pulmonary embolism (1.8%, 2/110). Sixteen patients (14.5%) required admission to the intensive care unit because of severe postoperative complications.

Table 2.

Pathological and Surgery

Variables	Total (n = 110)
Harvested lymph nodes, mean ± SD	15.19 ± 7.88
Operation time, mean ± SD, min	228.58 ± 60.83
Blood loss, mean ± SD, ml	113.00 ± 56.82
POLS, mean ± SD, days	13.17 ± 7.21
Postoperative complications
Pulmonary infection	54 (49.1%)
Anastomotic leakage	16 (14.5%)
Chylothorax	2 (1.8%)
Arrhythmia	47 (42.7%)
Pulmonary embolism	2 (1.8%)
Respiratory failure	17 (15.5%)
Postoperative ICU admission	16 (14.5%)
Perioperative mortality	10 (9.1%)
30-days mortality	12 (10.9%)
90-days mortality	15 (13.6%)

POLS Postoperative Length of Stay

The perioperative (in-hospital) mortality rate was 9.1% (10/110). The primary cause of death in most cases was uncontrolled severe pulmonary infection, which rapidly progressed to respiratory and cardiac failure, ultimately resulting in multiple organ failure. The cumulative all-cause mortality rates at 30 and 90 days postoperatively were 10.9% (12/110) and 13.6% (15/110), respectively. As shown in Fig. 2, multivariable logistic regression analysis for 90-day mortality demonstrated that higher body mass index (BMI) (OR = 0.81, 95% CI: 0.66–0.99, P = 0.048) was a protective factor against 90-day mortality.

Fig. 2.

Multivariable logistic regression analysis for 90-day postoperative mortality

Survival analysis

The median follow-up duration for the entire cohort was 20 months (95% CI: 13.75–26.25 months). As shown in Fig. 3, the 1- and 2-year OS rates were 81% and 56%, respectively, whereas the corresponding 1- and 2-year DFS rates were 72% and 50%. To evaluate the prognostic significance of relevant variables, a Cox proportional hazards regression model was constructed using postoperative day 90 as the new time zero (see Table 3). Univariate analysis demonstrated that age (HR = 1.28, 95% CI: 1.07–1.53; P = 0.007), history of alcohol consumption (HR = 2.39, 95% CI: 1.03–5.57; P = 0.042), clinical N-positive stage (HR = 3.25, 95% CI: 1.31–8.11; P = 0.011), and pathological stage III–IV (HR = 7.83, 95% CI: 1.71–35.33; P = 0.007) were significantly associated with worse OS. After multivariable adjustment, age remained an independent predictor of OS (HR = 1.22, 95% CI: 1.01–1.48; P = 0.036).

Fig. 3.

Kaplan–Meier curves for overall survival (A) and disease-free survival (B) in super-elderly (≥ 80 years) patients

Table 3.

Univariate and multivariate Cox regression model

Variables	Overall survival
	Univariate analysis		Multivariate analysis
	HR (95% CI)	P-value	HR (95% CI)	P-value
Age (years)	1.28 (1.07–1.53)	0.007	1.22 (1.01–1.48)	0.036
BMI	1.07 (0.93–1.23)	0.353
Sex (reference: female)
Male	1.75 (0.68–4.49)	0.247
Smoking history (reference: No)
Yes	2.07 (0.89–4.82)	0.090	1.25 (0.24–6.47)	0.791
Drinking history (reference: No)
Yes	2.39 (1.03–5.57)	0.042	1.31 (0.24–7.02)	0.754
Hypertension (reference: No)
Yes	1.07 (0.36–3.16)	0.905
Diabetes (reference: No)
Yes	0.04 (0-21.96)	0.322
Cardiac disease (reference: No)
Yes	1.39 (0.59–3.25)	0.451
COPD (reference: No)
Yes	1.29 (0.55-3.00)	0.558
Tumor location (reference: Upper)		0.767
Middle	1.61 (0.38–6.84)	0.517
Lower	1.76 (0.38–8.04)	0.467
Clinical T stage (reference: T2-T3)
T4a	1.08 (0.25–4.68)	0.910	1.00 (0.21–4.92)	0.997
Clinical N stage (reference: N0)
N+	3.25 (1.31–8.11)	0.011	2.27 (0.77–6.71)	0.138
Neoadjuvant therapy (reference: No)
Yes	0.56 (0.07–4.19)	0.572
Surgery (reference: McKeown)
Open	0.55 (0.13–2.36)	0.421
Pathologic TNM stage (reference: I)		0.003		0.126
II	2.06 (0.42–10.21)	0.165	1.49 (0.26–8.47)	0.648
III-IV	7.83 (1.71–35.33)	0.007	3.91 (0.71–21.51)	0.117

BMI body mass index

Discussion

This study, based on a large real-world retrospective cohort, systematically evaluated perioperative safety and mid-term survival outcomes in octogenarian patients with esophageal cancer undergoing curative resection. The results demonstrated that, under strict patient selection and standardized perioperative management, this population could achieve clinically meaningful survival benefits (2-year OS, 56%); however, the incidence of perioperative complications and short-term mortality was markedly increased, with a complication profile predominantly characterized by cardiopulmonary events. Multivariable analysis further demonstrated that age, rather than tumor stage, was an independent predictor of OS, suggesting that in this octogenarian population, host-related factors may exert a greater influence on long-term prognosis than traditional oncologic indicators.

Previous studies evaluating the surgical safety of elderly patients with esophageal cancer have primarily focused on individuals aged 70–75 years or older, whereas evidence specifically addressing the octogenarian (≥ 80 years) remains limited and is largely derived from small single-center series [7–10]. The current literature has not reached a consensus regarding whether this population should undergo curative resection. Several highly selective single-center series have reported that, after rigorous screening, patients aged ≥ 80 years undergoing esophagectomy can achieve perioperative mortality rates, complication rates, and long-term survival outcomes comparable to those observed in younger patients [7–10]. For example, Morita et al. [10] reported a 30-day postoperative mortality rate of 0% among 16 patients aged ≥ 80 years, with no significant difference in 5-year survival compared with patients aged 70–79 years; similarly, another study [9] found no significant difference in overall survival between patients aged ≥ 80 years and those aged < 80 years (53.2 vs. 77.6 months, P = 0.58).

However, large-scale studies based on national or population-level databases have offered a more cautious perspective. Data from the National Cancer Database (NCDB) showed [14] that among patients aged ≥ 80 years, the 30-day and 90-day mortality rates after esophagectomy were 5.6% and 11.4%, respectively, both significantly higher than those in younger patients, whereas the proportion undergoing surgical treatment was significantly lower (11.5% vs. 33.3%, P < 0.001). The National Inpatient Sample (NIS) further reported [13] that in-hospital mortality after surgery reached 19.9% in patients aged > 80 years, substantially higher than in those aged 65–69 years (8.8%). A nationwide registry study from the Netherlands likewise confirmed [12] that patients aged ≥ 80 years had significantly higher rates of major complications and 30-day mortality after surgery. Moreover, an analysis of a Japanese national database [11] suggested that among patients with clinical stage II–III disease, esophagectomy conferred a significant survival benefit in those aged ≥ 75 years, whereas no significant advantage was observed in patients aged ≥ 80 years. These discrepancies suggest that patients aged ≥ 80 years do not represent a homogeneous population, and that the benefit of surgery depends heavily on individual physiological reserve, tumor burden, and the comprehensive management capacity of the treating center. Against this controversial backdrop, the present study provides complementary real-world evidence from China: although surgical treatment may still confer a measurable mid-term survival benefit in the octogenarian population, the observed perioperative mortality was notably higher than that reported in some highly selective single-center series and more consistent with population-level database findings, suggesting that surgical risks in real-world practice may have been underestimated in prior single-center experiences.

The relatively high perioperative and 90-day mortality observed in the present cohort likely reflects multiple interacting factors inherent to this octogenarian population. First, compared with several highly selective single-center reports [7–10], our cohort represented a real-world population with a particularly high prevalence of COPD(58.2%) and locally advanced disease༈91.8%༉. Second, despite the predominant use of minimally invasive approaches, reduced physiological reserve and limited tolerance to postoperative pulmonary complications may substantially amplify the clinical consequences of otherwise manageable adverse events in younger patients. Third, some patients underwent surgery after previous non-surgical treatment failure or delayed referral, which may also have contributed to increased perioperative risk. Collectively, these findings underscore the importance of careful patient selection, prehabilitation, pulmonary optimization, and intensive perioperative multidisciplinary management in octogenarian patients undergoing esophagectomy.

Analysis of perioperative complications revealed a substantial overall complication burden in this cohort, with pulmonary infection (49.1%) and respiratory failure (15.5%) representing the predominant complications. Among the 10 patients who died during the perioperative period, most deaths were precipitated by postoperative pulmonary infection, which subsequently progressed to respiratory failure and, in some cases, led to cardiac decompensation and ultimately multiple organ failure. This finding is consistent with trends reported in both domestic and international literature [16, 17], although the severity observed in our cohort appears greater. Previous studies have confirmed that patients aged ≥ 80 years experience significantly higher rates of postoperative cardiopulmonary complications than younger individuals: Markar et al. [9] reported increased incidences of postoperative arrhythmia (31.3%) and pneumonia (18.8%) in patients aged ≥ 80 years; Miyata et al. [15] observed that the risk of postoperative pulmonary and cardiovascular complications increased with advancing age; and a nationwide registry study from the Netherlands [12] demonstrated a 30-day major complication rate as high as 39.4% in patients aged > 80 years. In the present study, the incidences of pulmonary infection (49.1%) and arrhythmia (42.7%) were even higher than those previously reported, which may be attributable to the exceptionally high prevalence of COPD (58.2%) in this cohort. COPD not only increases the risk of postoperative pulmonary infection but also reflects diminished physiological reserve and an elevated chronic inflammatory burden, rendering patients more vulnerable to pulmonary complications under infectious or surgical stress [18–20]. Therefore, in octogenarian patients with esophageal cancer, perioperative management should not be limited solely to the technical prevention of surgical complications [16, 21], but should instead adopt a comprehensive strategy focused on pulmonary infection prevention, preservation of respiratory function, and early identification of cardiopulmonary vulnerability.

In the multivariable Cox regression analysis, age, rather than tumor stage, emerged as the only independent predictor of overall survival, suggesting a fundamental shift in the determinants of prognosis among octogenarian patients. Although the traditional oncologic paradigm emphasizes the dominant role of TNM staging in determining survival outcomes, perioperative complications and non–cancer-related mortality increase substantially in the octogenarian population. A nationwide Japanese database study [11] similarly reported that among patients aged ≥ 80 years, the survival advantage of surgery over chemoradiotherapy was no longer evident; moreover, studies of elderly patients with other solid tumors [22] have suggested that comorbidity burden may outweigh tumor stage in its impact on survival. In addition, data from the NCDB [13] indicate that even when patients aged ≥ 80 years with esophageal cancer undergo surgical resection, long-term survival remains limited by substantial non–cancer-related mortality. Multiple studies have consistently demonstrated that advanced age is an independent predictor of overall survival [17, 23]. Cooper et al. [17] further identified age ≥ 80 years as the strongest independent predictor of overall survival (HR, 4.48).

Therefore, we propose that in octogenarian patients with esophageal cancer, long-term outcomes reflect the combined influence of tumor burden and age, with age often exerting a predominant effect in real-world settings. Clinically, this finding implies that prognostic counseling and treatment decision-making for this population should not rely solely on tumor stage but instead incorporate multidimensional assessments encompassing age, physiological reserve, comorbidity burden, nutritional status, and frailty.

In this study, only 6.4% of patients received preoperative neoadjuvant therapy, and the majority underwent salvage surgery, reflecting the highly nonstandardized treatment pathways for octogenarian patients with esophageal cancer in real-world practice. Several previous studies [8, 9, 15] have similarly demonstrated that the use of neoadjuvant therapy declines significantly with advancing age, and data from the NCDB indicate that only 2.0% of patients aged ≥ 80 years receive multimodal treatment [14]. This pattern may partly stem from clinical concerns regarding treatment tolerance and the risk of toxicity, which may in turn compromise the anticipated oncologic benefit. In octogenarian populations, delayed surgical intervention and modification of therapeutic regimens may increase perioperative risk and limit long-term survival benefits, representing critical aspects of real-world practice that warrant careful evaluation and optimization. For patients aged ≥ 80 years who are unable to tolerate surgery or who decline surgical treatment, definitive chemoradiotherapy remains an important alternative therapeutic strategy. However, its toxicity profile and treatment-related mortality risk in the octogenarian population should not be underestimated [24–26]. Therefore, treatment decisions should be made within a multidisciplinary team framework, incorporating a comprehensive assessment of tumor burden, physiological reserve, and patient preferences, rather than relying on age alone as the sole decision-making criterion.

The principal limitations of this study are the inherent selection bias associated with this retrospective surgical cohort. Only patients who were ultimately considered physiologically fit enough to undergo esophagectomy after multidisciplinary evaluation were included in the present study. Therefore, the observed survival outcomes may partly reflect the favorable baseline functional status of carefully selected surgical candidates rather than the isolated effect of surgery itself. In addition, because a contemporaneous non-surgical control cohort was not included, direct comparisons between surgery and definitive chemoradiotherapy or radiotherapy alone could not be performed. During the same study period, a substantial proportion of octogenarian patients at our institution were managed non-surgically because of frailty, poor cardiopulmonary reserve, advanced disease stage, or patient preference. Future multicenter comparative studies incorporating both surgical and non-surgical treatment strategies are warranted to better define the optimal management approach for this unique population. Although routine geriatric evaluation was performed during preoperative assessment, standardized frailty-related variables such as the frailty index, Charlson comorbidity index, or formal comprehensive geriatric assessment scores were not consistently recorded in the retrospective database and therefore could not be incorporated into the current analysis. We acknowledge that frailty may have substantial prognostic significance in super-elderly surgical patients and that the absence of standardized frailty metrics represents an important limitation of the present study.

Conclusion

These findings indicate that in octogenarian patients with esophageal cancer, curative surgery is not an absolute contraindication; however, its potential benefit is highly dependent on careful patient selection and meticulous perioperative risk management. This conclusion provides real-world evidence to inform the ongoing clinical debate regarding whether patients aged ≥ 80 years should be offered surgical treatment.

Abbreviations

CT

Computed tomography

EUS

Endoscopic Ultrasonography

MRI

Magnetic Resonance Imaging

AJCC

American joint committee on cancer

MDT

Multidisciplinary treatment

OS

Overall survival

DFS

Disease-free survival

COPD

Chronic obstructive pulmonary disease

BMI

Body mass index

NCDB

National cancer database

NIS

National inpatient sample

Authors' contributions

MF completed the study design. BX contributed to methodology, visualization, and writing of the original draft. JX contributed to investigation, methodology. XJ and TL contributed to data curation, methodology. HW and XR contributed to data curation. JL and GS contributed to funding acquisition, supervision, and writing (review and editing).

Funding

This study was funded by the Nanchong City University Science and Technology Strategic Cooperation Special Fund (Grant No. 22SXQT0095) and the Scientific Research Foundation for Advanced Talents, Affiliated Hospital of North Sichuan Medical College (Grant No. 2023GC006).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was reviewed and approved by The Ethics Committee of Affiliated Hospital of North Sichuan Medical College (Approval Number: 2026ER142-1). According to national legislation and institutional requirements, written informed consent was not required for participation in this study.

Consent for publication

The requirement for informed consent to use clinical information was waived, because this was a retrospective study without intervention or preserved specimens.

Competing interests

The authors declare no competing interests.