Patient Perspectives on Defining Textbook Outcomes Following Major Abdominal Surgery

Textbook outcome and textbook oncological outcome in esophagogastric cancer surgery - A systematic scoping review

INTRODUCTION

Quality assurance in esophagogastric surgery, particularly in an oncological context, is important, especially as long-term survival is highly affected by the short-term outcomes. Textbook Outcome (TO) and Textbook Oncological Outcome (TOO) serve as multidimensional metrics to assess surgical quality by evaluating various perioperative factors, as well as oncological outcomes. TO and TOO have been associated with improved long-term survival.

AIM

This study aimed to examine the incidence of, and the definitions of TO and TOO used in esophagogastric oncological surgery.

METHODS

This systematic scoping review followed the PRISMA 2020 guidelines and the PRISMA scoping review extension. The AMSTAR-2 was used to rate the review. A comprehensive systematic search was performed in Medline, Embase, and Web of Science and results were screened through Covidence. Quality assessment was conducted using the Newcastle-Ottawa scale.

RESULTS

A total of 55 observational cohort studies on esophagogastric cancer surgery were included. A total of 245,075 patients was included in the assessment of the achievement of TO and TOO. The rate of TO achievement ranged from 20.4 to 84.2 %, while the rate of TOO achievement ranged from 21.3 to 57.6 %. TO and TOO definitions varied widely, combining a median of nine (range: 4-11) parameters with a total of 45 different parameters being reported.

CONCLUSION

This systematic scoping review showed significant variations in incidence and in the definitions used for TO and TOO in esophagogastric cancer surgery between the included studies. This highlights the importance of standardizing the definitions of TO and TOO.

Use of textbook outcome as a quality metric in hepatopancreaticobiliary surgery: a systematic review and meta-analysis

BACKGROUND

Textbook outcomes (TOs) represent the optimal course after surgery. To date, no meta-analysis has assessed the pooled TOs of patients undergoing hepatopancreatobiliary (HPB) surgery and the effect of TO achievement on patient outcomes. This systematic review and meta-analysis aimed to assess TO achievement across different studies and to characterize the effect of TO achievement on patient-related outcomes, including disease-free survival (DFS) and overall survival (OS).

METHODS

PubMed, Embase, and Scopus databases were searched (1990-2024). The criteria used to define TO and the median overall TO in HPB surgery were obtained. In addition, a random-effects meta-analysis was conducted to assess the effect of TO achievement on 5-year OS and DFS.

RESULTS

A total of 27 studies involving 517,304 patients met inclusion criteria. The main criteria used to define TO included absence of readmission and mortality within 30 days after discharge, severe postoperative complications, prolonged hospital stay, and negative surgical margin (R0). Of note, the main factors related to TO achievement were younger patient age and lower American Society of Anesthesiologists score. Overall, the median rates of TOs achieved across procedures were 62.0% (IQR, 48.0%-69.0%) for hepatic procedure, 54.0% (IQR, 41.0%-68.0%) for biliary procedure, 46.0% (IQR, 42.0%-46.5%) for combined hepatopancreatic procedure, 45.0% (IQR, 30.5%-59.0%) for pancreatic procedure, 33.0% (IQR, 32.2%-34.0%) for liver transplantation, and 19.5% (IQR, 16.8%-22.3%) for combined hepatobiliary procedure. TO achievement was associated with improved odds of 5-year OS (odds ratio [OR], 1.22 [95% CI, 1.20-1.24]) and 5-year DFS (OR, 1.26 [95% CI, 1.16-1.37]).

CONCLUSION

Overall, hepatic and biliary operations had the highest TO achievement, followed by pancreatic procedures. In contrast, hepatobiliary surgery and liver transplantation had the lowest TO. There was a significant discrepancy in the definition of TO across different studies, highlighting the need for consensus on the definition of TO.

Textbook Neoadjuvant Experience: Defining a Novel Composite Outcomes Measure for Patients with Pancreatic Cancer Undergoing Neoadjuvant Therapy

BACKGROUND

Neoadjuvant therapy (NT) is increasingly used for patients with pancreatic ductal adenocarcinoma (PDAC). Disease progression, toxicity, and failure to undergo surgical resection are common during NT, yet little research has focused on efforts to optimize care delivery. We sought to define and validate a novel composite outcomes metric that characterizes the successful delivery of NT.

STUDY DESIGN

All patients with localized PDAC receiving NT in an intention-to-treat fashion between 2018 and 2023 were retrospectively evaluated. A textbook neoadjuvant experience (TNE) was defined as the absence of mortality, disease progression, or hospital admission during NT as well as the completion of all intended NT and successful surgical resection.

RESULTS

Among 306 patients with localized PDAC, the median age was 66 years and 58.5% were men. Overall, only 85 (28%) experienced a TNE which was more common among patients with potentially resectable (45 of 96, 47%) than borderline resectable (33 of 112, 29%) or locally advanced (7 of 98, 7%) disease. Patients with a TNE experienced greater overall survival than those individuals without a TNE (median not reached vs 16.4 months [95% CI 14.9 to 17.9 months], p < 0.001). On multivariable Cox regression analysis, a TNE was the strongest predictor of improved overall survival (hazard ratio 0.33, 95% CI 0.20 to 0.54, p < 0.001).

CONCLUSIONS

A TNE is infrequently achieved among patients with PDAC undergoing NT but is significantly associated with improved long-term outcomes. Future research aimed at optimizing outcomes of NT delivery should incorporate this novel composite metric that may more accurately reflect patient and provider expectations of treatment.

Textbook oncologic outcome is an easy-to-use composite quality measure that is strongly associated with survival in advanced-stage ovarian cancer

OBJECTIVE

Textbook oncologic outcome (TOO) has been validated in surgical oncology as a composite quality measure correlated with oncologic outcomes. We aimed to assess the association between TOO and overall survival (OS) in patients undergoing primary treatment for advanced epithelial tubo-ovarian cancer (AEOC).

METHODS

Patients undergoing surgery for AEOC between 2008 and 2019 were identified in the National Cancer Database (NCDB). Primary debulking surgery (PDS) and interval debulking surgery (IDS) cohorts were analyzed separately. TOO was defined as achieving complete debulking, length of hospital stay <10 days, no 30-day readmission, no death within 90 days, and initiation of adjuvant chemotherapy within 42 days. The Kaplan-Meier method was used to estimate 5-year OS by TOO status and Cox regression to evaluate the relationship between TOO and death within 5 years.

RESULTS

A total of 21,657 patients were included: 51.4% in the PDS cohort and 48.6% in the IDS cohort. TOO was achieved (TOO+) in 20.5% of the PDS cohort and 39.2% of the IDS cohort. For the PDS cohort, achieving TOO was associated with improved 5-year OS: 59.0% TOO+ vs. 39.5% TOO- (HR 0.53, 95% CI 0.49-0.57). For the IDS cohort, a similar benefit was seen for 5-year OS: 43.9% TOO+ vs. 31.2% TOO- (HR 0.67, 95% CI 0.63-0.70). Multivariable analysis demonstrated that patients achieving TOO were at lower risk of death within 5 years in both the PDS cohort (HR 0.58, 95% CI 0.54-0.62) and the IDS cohort (HR 0.69, 95% CI 0.65-0.73).

CONCLUSIONS

The TOO composite measure is associated with improved long-term survival and could be a useful quality assessment tool for patients undergoing primary treatment for AEOC, irrespective of surgical timing. This tool reflects the ability to deliver risk-based individualized decision-making using a multidisciplinary approach.

Textbook outcome in low rectal cancer after neoadjuvant chemoradiotherapy: Post hoc analysis of the LASRE randomized clinical trial

BACKGROUND

Textbook outcome has been incorporated into quality assessment measures in various oncological settings; however, it has not been applied to patients with low rectal cancer after neoadjuvant chemoradiotherapy (nCRT). This study aimed to examine the prevalence and predictors of achieving a textbook outcome in patients undergoing surgical resection of low rectal cancer after nCRT.

PATIENTS AND METHODS

This study was a post hoc subgroup analysis of the prospective multicentric LASRE trial, which specifically enrolled patients with rectal cancer located within 5 cm from the dentate line at diagnosis, tumors with diameters less than 6 cm, and patients who underwent radical laparoscopic or open resection. A total of 597 patients who had clinically staged cT3-4aN0-2M0 tumors with diameters less than 6 cm and who underwent neoadjuvant chemoradiotherapy followed by radical resection were included.

RESULTS

Textbook outcome was achieved in 60.0 % of patients. Multivariate logistic regression analysis revealed that body mass index >25 kg/m2 (OR = 0.594, P = 0.01), tumor distance from the anal verge >40 mm (OR = 5.518, P < 0.001), operative time >202 min (OR = 0.675, P = 0.04), and laparoscopic approach (OR = 1.497, P = 0.04) were independently predictive factors for the achievement of a textbook outcome in low rectal cancer patients undergoing nCRT and radical resection. A predictive nomogram for achieving a textbook outcome was constructed, yielding a C-index of 0.727.

CONCLUSIONS

Laparoscopic resection exhibited promising potential in improving the probability of achieving a textbook outcome.

The Value of Textbook Outcome in Benchmarking Pancreatoduodenectomy for Nonfunctioning Pancreatic Neuroendocrine Tumors

BACKGROUND

Textbook outcome (TO) is a composite variable that can define the quality of pancreatic surgery. The aim of this study is to evaluate TO after pancreatoduodenectomy (PD) for nonfunctioning pancreatic neuroendocrine tumors (NF-PanNETs).

PATIENTS AND METHODS

All patients who underwent PD for NF-PanNETs (2007-2016) in different centers were included in this retrospective study. TO was defined as the absence of severe postoperative complications and mortality, length of hospital stay ≤ 19 days, R0 resection, and at least 12 lymph nodes harvested.

RESULTS

Overall, 477 patients were included. The TO rate was 32%. Tumor size [odds ratio (OR) 1.696; p = 0.013], a minimally invasive approach (OR 12.896; p = 0.001), and surgical volume (OR 2.062; p = 0.023) were independent predictors of TO. The annual frequency of PDs increased over time as well as the overall rate of TO. At a median follow-up of 44 months, patients who achieved TO had similar disease-free (p = 0.487) and overall survival (p = 0.433) rates compared with patients who did not achieve TO. TO rate in patients with NF-PanNET > 2 cm was 35% versus 27% in patients with NF-PanNET ≤ 2 cm (p = 0.044). Considering only NF-PanNETs > 2 cm, patients with TO and those without TO had comparable 5-year overall survival rates (p = 0.766) CONCLUSIONS: TO is achieved in one-third of patients after PD for NF-PanNETs and is not associated with a benefit in terms of long-term survival.

A Multi-institutional Analysis of a Textbook Outcome Among Patients Undergoing Microvascular Breast Reconstruction

BACKGROUND

Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps.

METHODS

For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis.

RESULTS

Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood.

CONCLUSION

Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.

The impact of surgical-oncologic textbook outcome in patients with stage I to III pancreatic ductal adenocarcinoma: A cross-validation study of two national registries

BACKGROUND

Using national registries, we aimed to evaluate oncologic textbook outcomes in pancreatic ductal adenocarcinoma patients.

METHODS

Patients with stage I to III pancreatic ductal adenocarcinoma and surgical resection from 2010 to 2020 in the US and Germany were identified using the National Cancer Database and National Cancer Registries data. The surgical-oncologic textbook outcome was defined as complete oncologic resection with no residual tumor and ≥12 harvested lymph nodes. The composite endpoint was defined as surgical-oncologic textbook outcome and receipt of perioperative systemic and/or radiation therapy.

RESULTS

In total, 33,498 patients from the National Cancer Database and 14,589 patients from the National Cancer Registries were included. In the National Cancer Database, 28,931 (86%) patients had complete oncologic resection with no residual tumor, and 11,595 (79%) in the National Cancer Registries. 8,723 (26%) patients in the National Cancer Database and 556 (4%) in the National Cancer Registries had <12 lymph nodes harvested. The National Cancer Database shows 26,135 (78%) underwent perioperative therapy and 8,333 (57%) in the National Cancer Registries. Surgical-oncologic textbook outcome was achieved in 21,198 (63%) patients in the National Cancer Database and in 11,234 (77%) patients from the National Cancer Registries. 16,967 (50%) patients in the National Cancer Database and 7,878 (54%) patients in the National Cancer Registries had composite textbook outcome. Median overall survival in patients with composite textbook outcomes was 32 months in the National Cancer Database and 27 months in the National Cancer Registries (P < .001). In contrast, those with non-textbook outcomes had a median overall survival of 23 months in the National Cancer Database and 20 months in the National Cancer Registries (P < .001).

CONCLUSION

Surgical-oncologic textbook outcomes were achieved in > 50% of stage I to III pancreatic ductal adenocarcinoma for both the National Cancer Database and the National Cancer Registries. Failure to achieve textbook outcomes was associated with impaired survival across both registries.

Evaluation of optimum classification measures used to define textbook outcome among patients undergoing curative-intent resection of gastric cancer

BACKGROUND

Textbook outcome (TO) is a composite measure reflecting various aspects of services provided to patients with solid malignancies. We sought to evaluate the importance of various TO components previously proposed for gastric cancer.

METHODS

Prospectively maintained electronic databases of 1,743 patients treated in two academic surgical centres were reviewed. Six candidate definitions of TO were evaluated based on their ability to accurately predict patients' prognosis by Cox proportional hazards modelling.

RESULTS

TO definition combining 10 measures corresponding to complete tumour resection with an uneventful postoperative course showed the best goodness of fit by achieving the lowest values of Akaike (AIC) and Bayesian (BIC) information criteria and the best predictive performance based on the highest value of c-index. The overall median survival was significantly longer for patients with than without textbook outcome (69.0 vs 20.1 months, P < 0.001). TO maintained its prognostic value in a multivariate model controlling for age, sex, comorbidities, treatment, and tumour related variables and was associated with a 39% lower risk of death (HR 0.61, 95%CI 0.51 - 0.73, P < 0.001). Nine variables identified as predictors of TO were used to develop a nomogram showing very good correlation between the predicted and actual probability of achieving TO. The AUC of ROC obtained from the nomogram was 0.752 (95% CI 0.727 to 0.781).

CONCLUSIONS

A uniform definition of textbook outcome provides clinically relevant prognostic information and could be used in quality improvement programs for gastric cancer patients.

Patients' perceptions of the definition of a textbook outcome following liver transplantation

BACKGROUND

A textbook outcome (TO) describes the results of a successful liver transplantation (LT) in which all aspects of the LT and posttransplant courses were uneventful. We compared patient perceived experience of a TO with clinically defined TO.

METHODS

This was a single-institution cohort study with retrospective chart review including patients who underwent LT from 2019 to 2021. Patients were asked to complete the survey at a scheduled posttransplant visit. The survey was designed to assess their viewpoints on the definition of a TO. A clinically defined TO was defined as no mortality, no severe complications, no need for reintervention, no prolonged hospital and intensive care unit stays, and no readmission.

RESULTS

Of the 182 patients who were contacted, 132 (72.5%) completed the survey. Overall, 98 patients (74%) considered that they had experienced a TO. The clinically defined TO rate was 22.0%. Multivariate analysis showed that patients who did not experience severe complications were more likely to consider that they had a TO (P = 0.01; odds ratio: 3.2; 95% confidence interval: 1.3-7.9).

CONCLUSIONS

From patients' perspectives, survival and avoidance of complications were the major characteristics of a TO.

Digestive cancer surgery in low-mid income countries: analysis of postoperative mortality and complications in a single-center study

PURPOSE

This study aimed to analyze postoperative and 90-day morbidity and mortality and their risk factors in all digestive cancer curative intent resections of a single digestive surgical department in a low-mid income country.

METHODS

All consecutive patients who underwent a surgical resection for digestive cancer with a curative intent between January 1, 2021, and December 31, 2021, were included. This is a retrospective analysis of a prospective cancer surgery database managed during the period. Patterns and factors associated with increased morbidity and mortality were analyzed and presented in tabular and descriptive forms.

RESULTS

Seventy-six patients were included, 38 (50%) were men with a mean age of 59 years (±13.5). Forty patients (52.63%) had tumors locally advanced, staged CT3-CT4 on preoperative imagery. Thirty-three of our population (43.42%) had laparoscopic surgery (conversion rate at 12.12%). In immediate preoperative, the morbidity rate was 36.84%; among each, 7 patients (9.21%) had serious complications (>2 Clavien-Dindo grade), and mortality rate was 5.26%. At 90 days after surgery, morbidity remained the same, and mortality increased to 7.9%. Risk factors for increased morbidity and mortality were female gender, obesity, high levels of carcinoembryonic antigen, hypoalbuminemia, laparotomy approach, hand sewn anastomosis, prolonged operating time, and wide drainage (p < 0.05).

CONCLUSIONS

This study provides figures on mortality and morbidity related to digestive cancer curative surgery in a low-mid income country digestive department and discusses risk factors increasing postoperative complications and death.

The value of analyzing textbook outcomes after laparoscopic hepatectomy-a narrative review

Background and Objective

Guidelines are required because of the wide variability in care provided to patients with similar characteristics and similar medical conditions. Quality indicators were developed many years ago to assess the quality of care provided by hospitals. Since then, it has become evident that a composite set of factors can better characterize the patient's quality of care. The objectives of this review were to analyze the textbook outcomes (TO) applied in surgery, focusing on laparoscopic hepatectomy.

Methods

Data pertaining to quality indicators used in hospitals and their surgical applications were retrieved from medical literature by searching PubMed and Google Scholar for articles published between 1912 and 2022. Search terms included quality indicators, outcome indicators, TOs, TOs after surgery, TOs after hepatectomy, and clinical indicators.

Key Content and Findings

Since their inception, TO have been applied to various procedures and their impacts on patients have been assessed. TO and their implications have been studied for a variety of surgical procedures and were recently extended to laparoscopic hepatectomy. TO of laparoscopic left lateral sectionectomy and right hemihepatectomy were recently assessed, and benchmark values have been defined. TO are useful tools for assessing hospital performance and for optimizing the outcomes of patients undergoing laparoscopic hepatectomy.

Conclusions

At present, TO only consider surgeon-related factors. However, it is important to include the patient's perspective when defining TO. Although TO were recently applied to laparoscopic hepatectomy, there is still a need to further evaluate their application in this setting. Achieving TO was shown to have a positive impact on long-term outcomes and this needs to be studied for different liver resection procedures.

Reoperation following urgent and emergent colectomy in the State of Michigan

BACKGROUND

Reoperation is associated with unfavorable outcomes and increased healthcare utilization. This study seeks to investigate the incidence and factors related to reoperation in patients undergoing urgent/emergent colectomies.

METHODS

The Michigan Surgical Quality Collaborative (MSQC) database was used to identify patients undergoing urgent/emergent colectomies. Outcomes and risk factors of patients who underwent reoperation within 30 days were compared to those who did not.

RESULTS

16,004 patients undergoing urgent/emergent colon resection were identified. Reoperation occurred in 12.4% and was associated with increased 30-day mortality (16.7% vs. 9.6%, p < .0001), median hospital length of stay (17 vs. 10 days, p < .0001), readmission rate (21.0% vs. 12.1%, p < .001), and discharge to a location other than home (62.3% vs. 36.8%, p < .0001). Reoperation rate was highest for vascular-related indications (23.5%), and was associated with several clinical factors (male gender, low albumin, ASA classification, and presence of pre-operative sepsis, dialysis or ventilator dependence) CONCLUSIONS: Reoperation following urgent/emergent colectomy occurs frequently. Additional study into strategies to reduce reoperations in this population is warranted.

Textbook outcomes in DIEP flap breast reconstruction: a Delphi study to establish consensus

PURPOSE

Composite measures, like textbook outcomes, may be superior to individual metrics when assessing hospital performance and quality of care. This study utilized a Delphi process to define a textbook outcome in DIEP flap breast reconstruction.

METHODS

A two-round Delphi survey defined: (1) A textbook outcome, (2) Exclusion criteria for a study population, and (3) Respondent opinion regarding textbook outcomes. An a priori threshold of ≥ 70% agreement among respondents established consensus among the tested statements.

RESULTS

Out of 85 invitees, 48 responded in the first round and 41 in the second. A textbook outcome was defined as one that meets the following within 90 days: (1) No intraoperative complications, (2) Operative duration ≤ 12 h for bilateral and ≤ 10 h for unilateral/stacked reconstruction, (3) No post-surgical complications requiring re-operation, (4) No surgical site infection requiring IV antibiotics, (5) No readmission, (6) No mortality, (7) No systemic complications, and (8) Length of stay < 5 days. Exclusion criteria for medical and surgical characteristics (e.g., BMI > 40, HgbA1c > 7) and case-volume cut-offs for providers (≥ 21) and institutions (≥ 44) were defined. Most agreed that textbook outcomes should be defined for complex plastic surgery procedures (75%) and utilized to gauge hospital performance for microsurgical breast reconstruction (77%).

CONCLUSION

This Delphi study identified (1) Key elements of a textbook outcome for DIEP flap breast reconstruction, (2) Exclusion criteria for future studies, and (3) Characterized surgeon opinions regarding the utility of textbook outcomes in serving as quality metric for breast reconstruction care.

Textbook outcome in hepato-pancreato-biliary surgery: systematic review

BACKGROUND

Textbook outcome (TO) is a multidimensional measure reflecting the ideal outcome after surgery. As a benchmarking tool, it provides an objective overview of quality of care. Uniform definitions of TO in hepato-pancreato-biliary (HPB) surgery are missing. This study aimed to provide a definition of TO in HPB surgery and identify obstacles and predictors for achieving it.

METHODS

A systematic literature search was conducted using PubMed, Embase, and Cochrane Database according to PRISMA guidelines. Studies published between 1993 and 2021 were retrieved. After selection, two independent reviewers extracted descriptive statistics and derived summary estimates of the occurrence of TO criteria and obstacles for achieving TO using co-occurrence maps.

RESULTS

Overall, 30 studies were included. TO rates ranged between 16-69 per cent. Commonly chosen co-occurring criteria to define TO included 'no prolonged length of stay (LOS)', 'no complications', 'no readmission', and 'no deaths'. Major obstacles for achieving TO in HPB surgery were prolonged LOS, complications, and readmission. On multivariable analysis, TO predicted better overall and disease-free survival in patients with cancer. Achievement of TO was more likely in dedicated centres and associated with procedural and structural indicators, including high case-mix index and surgical volume.

CONCLUSION

TO is a useful quality measure to benchmark surgical outcome. Future definitions of TO in HPB surgery should include 'no prolonged LOS', 'no complications', 'no readmission', and 'no deaths'.