Abstract
BACKGROUND: Severe postoperative complications (SPCs) adversely affect outcomes in esophageal squamous cell carcinoma (ESCC) following neoadjuvant therapy. The prognostic significance of preserved ratio impaired spirometry (PRISm) and inflammation-based biomarkers such as the systemic inflammation response index (SIRI) and lymphocyte-to-monocyte ratio (LMR) remains unclear. METHODS: We retrospectively analyzed 224 ESCC patients who underwent esophagectomy after neoadjuvant therapy. PRISm was defined by FEV(1) < 80% predicted and FEV(1)/FVC ≥ 0.7. Preoperative inflammatory indices, including SIRI, NLR, and LMR, were collected. The primary endpoint was the incidence of SPCs (Clavien-Dindo grade ≥ III); secondary endpoints included overall survival (OS) and recurrence-free survival (RFS). Multivariate regression was used to identify independent predictors. Nomograms were developed and validated using ROC curves, calibration plots, and decision curve analysis (DCA). RESULTS: PRISm and decreased SIRI independently predicted higher SPC risk (p < 0.05). The SPC nomogram demonstrated good discrimination (AUC = 0.726). PRISm was also associated with significantly worse OS and RFS (p < 0.001). Elevated SIRI and low LMR correlated with poor long-term outcomes. OS and RFS nomograms showed good calibration and outperformed TNM staging in clinical utility. CONCLUSION: PRISm and systemic inflammatory markers are independent predictors of complications and prognosis in ESCC after neoadjuvant therapy. The proposed nomograms offer practical tools for individualized preoperative risk stratification and may support tailored perioperative management, especially in older or high-risk patients.