Preoperative risk stratification for pulmonary complications after neoadjuvant therapy and esophagectomy in locally advanced esophageal squamous cell carcinoma: a retrospective cohort study.

Purpose: Postoperative pulmonary complications (PPCs) are a major cause of morbidity among patients with esophageal squamous cell carcinoma (ESCC) undergoing esophagectomy. Risk stratification is crucial for patients receiving neoadjuvant therapy (NAT), as their perioperative course differs. We aimed to identify preoperatively available factors associated with PPCs after neoadjuvant therapy and esophagectomy and to develop a practical model for preoperative risk stratification. Methods: We retrospectively analyzed consecutive adults with locally advanced ESCC who underwent NAT [chemotherapy (NCT) or immunochemotherapy (NICT)] followed by curative-intent esophagectomy (2023-2024). PPCs were defined Results: Among 232 eligible patients, 69 (29.7%) experienced PPCs. In the final model, smoking history was associated with higher odds of PPCs, whereas hypertension, NICT versus NCT, preoperative nebulization, and preoperative respiratory exercise were associated with lower odds. The model showed acceptable discrimination [apparent Area Under the Curve (AUC), 0.783; optimism-corrected AUC, 0.764] and acceptable calibration after bootstrap internal validation. Decision-curve analysis suggested potential net benefit across a range of threshold probabilities. The model was presented as a nomogram for individualized preoperative risk estimation. Conclusions: A model based on five preoperatively available variables showed acceptable performance for PPC risk stratification after neoadjuvant therapy and esophagectomy in locally advanced ESCC. The nomogram may support individualized preoperative risk estimation, but external validation and prospective impact assessment are required before clinical implementation.