Background <p>Esophageal cancer has a poor prognosis despite advances in multimodal treatment. Sarcopenia and low visceral adiposity have each been linked to adverse outcomes in some malignancies, but their combined impact on postoperative morbidity and survival after esophagectomy remains unclear.</p> Methods <p>We retrospectively analyzed 450 consecutive patients (2009–2019) who underwent curative esophagectomy. Preoperative computed tomography was used to assess the skeletal muscle mass index (SMI) and visceral adipose tissue index (VAI). Patients were classified according to sarcopenia status and low versus non-low VAI and stratified into groups: NN (normal SMI/normal VAI), NLA (normal SMI/low VAI), SN (low SMI [sarcopenia]/normal VAI), or SLA (low SMI [sarcopenia]/low VAI). Postoperative complications, overall survival, and disease-free survival were evaluated, with multivariate analyses identifying independent predictors.</p> Results <p>Postoperative complications occurred in 50.9% of patients and were more common in those with sarcopenia than in those without (<i>p</i>&lt;0.0001), whereas low VAI alone was not associated with increased morbidity. Among the four groups, complication rates were highest in the SN and SLA groups (<i>p</i>=0.0002). Overall survival differed among the groups, with the poorest survival observed in the SLA group (<i>p</i>&lt;0.0001). On multivariate analysis, SLA was an independent predictor of poorer overall survival (hazard ratio 1.851; 95% confidence interval 1.105–3.101, <i>p</i>=0.0193). Disease-free survival did not significantly differ among the groups. Non-cancer-related deaths were more common in the NLA, SN, and SLA groups than in the NN group.</p> Conclusions <p>Sarcopenia combined with low visceral adiposity increases postoperative morbidity and worsens overall survival, driven mainly by non-cancer-related causes.</p>