Charlson comorbidity index in predicting postoperative complications and long-term outcomes after esophagectomy: A multicenter retrospective study

Abstract

Background: Esophagectomy remains a high-risk surgical procedure associated with substantial postoperative complications and mortality. Preoperative risk stratification requires simple, reproducible tools to account for the cumulative comorbidity burden. Aim: To evaluate the association of comorbidity burden, assessed via the Charlson comorbidity index, with postoperative complications and long-term outcomes after esophagectomy in patients with esophageal cancer. Methods: This multicenter retrospective cohort study included a consecutive sample of 411 patients who underwent an Ivor Lewis or McKeown esophagectomy at four oncological centers in Russia between January 1, 2014 and May 1, 2026. Patients were stratified into two groups: Charlson 5 (n = 277) and Charlson ≥ 5 (n = 134). The primary endpoint was postoperative complications, defined as the occurrence of at least one of the following: anastomotic leakage, reoperation, in-hospital mortality, or 90-day mortality. Overall and progression-free survival were analyzed in 392 patients with confirmed follow-up data. Results: Postoperative complications occurred in 104/411 (25.3%) patients and were significantly more frequent in the Charlson ≥ 5 group compared to the Charlson 5 group: 35.8% vs 20.2%; odds ratio (OR) 2.20 (95% confidence interval (CI) 1.39–3.49; p 0.001). After adjusting for clinical-oncological and surgical factors, Charlson ≥ 5 maintained an independent association with the outcome: adjusted OR 2.03 (95% CI 1.22–3.39; p = 0.007). In the individual comorbidities model, coronary artery disease and chronic obstructive pulmonary disease were identified as significant predictors. Patients with Charlson ≥ 5 exhibited higher rates of anastomotic leakage (29/134 (21.6%) vs 33/277 (11.9%), p = 0.01), in-hospital mortality (22/134 (16.4%) vs 17/277 (6.1%), p 0.001) and 90-day mortality (29/134 (21.6%) vs 23/277 (8.3%), p 0.001). Median overall survival was 22 vs 40 months (p = 0.029), and median progression-free survival was 14 vs 30 months (p = 0.007). In the multivariable model, Charlson ≥ 5 was associated with worse progression-free survival: hazard ratio 1.38 (95% CI 1.01–1.89; p = 0.042). Conclusion: A Charlson comorbidity index score ≥ 5 was independently associated with postoperative complications and worse progression-free survival after esophagectomy. It can serve as an accessible tool for preoperative risk stratification.