Archives of Osteoporosis

, 14:6 | Cite as

Risk factors for loss of bone mineral density after curative esophagectomy

  • Jessie A. Elliott
  • Sean Casey
  • Conor F. Murphy
  • Neil G. Docherty
  • Narayanasamy Ravi
  • Peter Beddy
  • John V. Reynolds
  • Carel W. le RouxEmail author
Original Article



Micronutrient and fat malabsorption and altered enteroendocrine signaling occur after esophagectomy for cancer; however, the impact of malnutrition on bone health in this cohort has not been previously investigated. In this study, the prevalence of osteoporosis increased after curative surgery, associated with disease-specific, treatment-related, and population risk factors.


Improved oncologic outcomes in esophageal cancer (EC) have resulted in increased survivorship and a focus on long-term quality of life. Malnutrition and micronutrient malabsorption are common among patients with EC, but the effect on bone metabolism is not known. The aim of this study was to characterize changes in bone mineral density (BMD) following curative esophagectomy.


Consecutive disease-free patients who underwent esophagectomy with gastric conduit for pathologically node-negative disease from 2000 to 2014 were included. BMD was assessed at vertebral levels T12-L5 by computed tomography using a simple trabecular region-of-interest attenuation technique, and serum markers of nutritional status and bone metabolism were examined. Independent risk factors for osteoporosis were identified by multivariable logistic regression.


Seventy-five consecutive patients were studied. Osteoporosis was present in 25% at diagnosis. BMD declined at 1 and 2 years postoperatively (144.3 ± 45.8 versus 128.6 ± 46.2 and 122.7 ± 43.5 Hounsfield Units (HU), P < 0.0001), with increased osteoporosis prevalence to 38% and 44% (P = 0.049), respectively. No significant postoperative change in vitamin D, calcium, or phosphate was observed, but alkaline phosphatase increased significantly (P < 0.001). While female sex (P = 0.004) and ASA grade (P = 0.043) were independently associated with osteoporosis at diagnosis, age (P = 0.050), female sex (P = 0.023), smoking (P = 0.024), and pathologic T stage (P = 0.023) were independently predictive of osteoporosis at 1 year postoperatively.


Osteoporosis is prevalent among disease-free patients post-esophagectomy for EC, associated with disease-specific, treatment-related, and population risk factors. Strategies which minimize BMD decline should be considered to avoid fragility fractures in this cohort.


Bone Bone mineral density Esophagectomy Esophageal cancer Malnutrition Malabsorption 


Compliance with ethical standards

Conflicts of interest


Supplementary material

11657_2018_556_MOESM1_ESM.pdf (74 kb)
Supplementary Figure 1 Serial L1 CT-predicted bone mineral density among matched control subjects. Among age- and sex-matched control subjects who underwent serial CT approximately one year apart, L1 BMD was unchanged (149.1 ± 41.5 HU vs 146.8 ± 36.2 HU, P = 0.45; R2 = 0.95, P < 0.0001). Dotted line represents the study BMD threshold for osteoporosis (110 HU). Paired t test, linear regression (PDF 73 kb)
11657_2018_556_MOESM2_ESM.pdf (35 kb)
Supplementary Figure 2 Factors associated with L1 CT-predicted bone mineral density at one year post esophagectomy. Univariable analysis of factors associated with bone mineral density as determined by CT of the L1 vertebra at one year post esophagectomy demonstrated that lower L1 BMD was associated with increasing age (top left), lower serum creatinine (middle left), greater serum alkaline phosphatase (middle right), but was unrelated to serum calcium, phosphate or albumin levels. Dotted line represents the study BMD threshold for osteoporosis (110 HU), female subjects are represented by orange symbols and male subjects by blue symbols. Pearson correlation (PDF 34 kb)
11657_2018_556_MOESM3_ESM.docx (19 kb)
Supplementary Table 1 (DOCX 18 kb)


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2019

Authors and Affiliations

  • Jessie A. Elliott
    • 1
    • 2
  • Sean Casey
    • 2
  • Conor F. Murphy
    • 1
    • 2
  • Neil G. Docherty
    • 1
    • 3
  • Narayanasamy Ravi
    • 2
  • Peter Beddy
    • 4
  • John V. Reynolds
    • 2
  • Carel W. le Roux
    • 1
    • 3
    Email author
  1. 1.Metabolic Medicine, University College DublinConway Institute of Biomedical and Biomolecular ResearchDublin 4Ireland
  2. 2.Department of Surgery, Trinity Centre for Health SciencesTrinity College Dublin and St. James’s HospitalDublin 8Ireland
  3. 3.Department of Gastrosurgical Research and Education, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
  4. 4.Department of RadiologySt. James’s HospitalDublin 8Ireland

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