Abstract
BACKGROUND: Postoperative pneumonia remains one of the most common and serious complications after esophagectomy for esophageal squamous cell carcinoma, significantly impairing recovery and survival outcomes. Accurate preoperative risk stratification is critical, yet no widely validated scoring system currently exists for ESCC-specific surgical cohorts. The ARISCAT score, a preoperative risk index developed to estimate pulmonary complication risk in general surgery, has not been previously assessed in ESCC patients. This study aimed to evaluate the prognostic value of the ARISCAT score and its integration with other perioperative indicators for predicting postoperative pneumonia. METHODS: This retrospective cohort study included 366 patients with histologically confirmed resectable ESCC who underwent curative thoraco-laparoscopic McKeown esophagectomy at a high-volume thoracic surgery center between January 2019 and December 2022. The ARISCAT score and other clinical parameters, including tumor length, length of hospital stay, PNI, and LMR, were collected preoperatively. Postoperative pneumonia was diagnosed based on radiologic, clinical, and laboratory criteria within 30 days after surgery. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of pneumonia. Restricted cubic spline modeling was used to assess non-linear associations. RESULTS: Postoperative pneumonia occurred in 99 of 366 patients (27.0%). Patients with pneumonia had significantly higher ARISCAT scores (59.6 ± 8.9 vs. 44.4 ± 7.6), longer tumor lengths (4.5 ± 0.7 cm vs. 3.8 ± 0.6 cm), and prolonged hospital stays (17.6 ± 2.8 vs. 13.6 ± 2.3 days), along with lower PNI and LMR values (all p < 0.001). In multivariate analysis, the ARISCAT score was independently associated with postoperative pneumonia (adjusted OR = 1.40, 95% CI 1.22-1.60, p < 0.001). Other independent predictors included tumor length (adjusted OR = 12.44), length of hospital stay (adjusted OR = 2.64), PNI (adjusted OR = 0.79), and LMR (adjusted OR = 0.18). RCS analysis revealed linear dose-response relationships for ARISCAT and tumor length, while LMR and hospital stay showed non-linear associations with pneumonia risk. No significant interaction effects were observed across subgroups. CONCLUSIONS: The ARISCAT score is an independent and robust predictor of postoperative pneumonia in ESCC patients undergoing McKeown esophagectomy. This study represents the first comprehensive evaluation of the ARISCAT score in an ESCC-specific surgical cohort, and uniquely demonstrates that its integration with inflammatory (LMR) and nutritional (PNI) markers significantly enhances preoperative risk stratification. These findings offer valuable clinical insights for personalized perioperative management.