Textbook outcomes for oesophagectomy: A valid composite measure assessment tool for surgical performance in a specialist unit

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.

Comparison of textbook outcomes between laparoscopic and open liver resection for patients with hepatocellular carcinoma: a multicenter study

OBJECTIVE

We aimed to clarify whether laparoscopic liver resection (LLR) is better than open liver resection (OLR) concerning textbook outcome (TO) achievement for patients with hepatocellular carcinoma (HCC).

METHODS

Data from HCC patients who underwent liver resection from a multicenter database were retrospectively reviewed (n = 2617). Propensity score matching (PSM) was used to balance the baseline characteristics of the two groups. Logistic regression analysis was performed to identify the risk factors that are independently associated with TO.

RESULTS

Before PSM, more aggressive biological characteristics were observed in patients who underwent OLR. After PSM, 771 patients in each group were matched. The overall rate of TO achievement in patients with LLR (78.2%) was higher than that in patients with OLR (71.7%; P < 0.001) after PSM. Subgroup analysis further revealed that LLR was associated with a greater incidence of TO achievement than OLR was in patients who underwent minor liver resection (after PSM; LLR: 83.8% vs. OLR: 73.0%, respectively; P < 0.001) but was similar in those who underwent major liver resection (after PSM; LLR: 68.8% vs. OLR: 65.7%; P = 0.468). Multivariate logistic regression analysis suggested that the LLR (OR = 0.471, 95% CI 95% CI = 0.361-0.614, P < 0.001) was an independent protective factor against non-TO in patients who underwent minor liver resection but not in those who underwent major liver resection. After PSM, the 5-year overall survival (OS) rates of patients who underwent OLR (74.6%) and LLR (73.9%) were similar (P = 0.485). Patients with TO had significantly better OS than those without TO, regardless of whether they underwent LLR (TO: 76.5% vs. non-TO: 65.7%, P = 0.005) or OLR (TO: 76.8% vs. non-TO: 69.1%, P = 0.042).

CONCLUSION

LLR favored TO achievement in HCC patients who received minor liver resection but not in those who underwent major liver resection. Patients who achieved TO had better OS regardless of LLR or OLR.

Failure to rescue following oesophagectomy in Australia: a multi-site retrospective study using American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Failure to rescue (FTR), defined as death after a major complication, is increasingly being used as a surrogate for assessing quality of care following major cancer resection. The aim of this paper is to determine the failure to rescue (FTR) rate after oesophagectomy and explore factors that may contribute to FTR within Australia.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2023 at five Australian hospitals was conducted to identify patients who underwent an oesophagectomy. The primary outcome was FTR rate. Perioperative parameters were examined to evaluate predictive factors for FTR. Secondary outcomes include major complications, overall morbidity, mortality, length of stay and 30-day readmissions.

RESULTS

A total of 155 patients were included with a median age of 65.2 years, 74.8% being male. The FTR rate was 6.3%. In total, 50.3% of patients (n = 78) developed at least one postoperative complication with the most common complication being pneumonia (20.6%) followed by prolonged intubation (12.9%) and organ space SSI/anastomotic leak (11.0%). Multivariate logistic regression analysis was performed to determine any factors that were predictive for FTR however none reached statistical significance.

CONCLUSION

This study is the first to evaluate the FTR rates following oesophagectomy within Australia, with FTR rates and complication profile comparable to international benchmarks. Integration of multi-institutional national databases such as ACS NSQIP into units is essential to monitor and compare patient outcomes following major cancer surgery, especially in low to moderate volume centres.

Achieving a textbook outcome in patients undergoing gastric resections in a low incidence, high-volume Australian Upper GI unit

BACKGROUND

Textbook outcome (TBO) has been proposed as a composite measure of quality in esophagogastric surgery, and achieving a TBO has been associated with improved overall survival (OS). The Dutch Upper Gastrointestinal Cancer Audit group determined their TBO rate for gastrectomy to be 32.1%, using 10 parameters. Our study aimed to assess the TBO rate in patients who had a gastrectomy for cancer in an Australian Upper GI unit, allowing for comparisons with international specialist centers.

METHODS

Retrospective analysis of a prospectively maintained database of patients who had a gastrectomy for cancer performed by the surgeons in a single Australian center between 2013 and 2018. Postoperative complications were analyzed using Clavien-Dindo (CD) ≥2 and CD ≥3 definitions. Baseline factors and their association with TBO were analyzed using multivariable logistical regression. The association between TBO and survival rates was determined by Cox proportional hazards regression analysis.

RESULTS

In 136 patients, 84 (62%) achieved a TBO when complications were graded as CD ≥2. Greatest negative impact on TBO was the complication rate, lymph node yield, and length of stay. Patients more likely to achieve a TBO were younger, with an increased body mass index and absence of underlying respiratory disease. A nonsignificant trend toward improved OS was seen when TBO was achieved.

CONCLUSION

Our TBO rate compares favorably with published data from high-volume centers. Assessment of a unit's TBO may provide a stronger evaluation of quality when assessing where complex surgery should be performed within Australia.

Textbook outcome after esophagectomy: A retrospective study from a high-volume center

BACKGROUND

Textbook outcome is a composite quality measurement in esophageal cancer surgery. This study aimed to estimate the rate of textbook outcome esophagectomies at a high-volume center and investigate associations between textbook outcome and overall and recurrence-free survival.

METHODS

A retrospective single-center study was conducted at Copenhagen University Hospital, Rigshospitalet, Denmark, analyzing esophagectomies performed from November 1, 2016, to December 31, 2021. Patients with primary carcinoma of the gastroesophageal junction who underwent elective and curative esophagectomy were included. The rate of textbook outcome esophagectomies was calculated, and the impact of textbook outcome on overall and recurrence-free survival was analyzed using Kaplan-Meier and Cox regression.

RESULTS

A total of 433 patients were included in the study. Textbook outcome was achieved in 195 patients (45%). Achieving textbook outcome was independently associated with improved overall survival (HR 0.67; P = .011) and with a median overall survival of 57 months and 32 months for patients with or without textbook outcome, respectively. A trend for improved recurrence-free survival was observed for patients with textbook outcome (HR 0.74; P = .064).

CONCLUSION

The present study found a consensus-based textbook outcome rate of 45%. Textbook outcome was found to be directly associated with improved overall survival. These results emphasize the association between improved short-term outcomes and long-term survival.

Predictors of textbook outcome following oesophagogastric cancer surgery

Textbook outcome (TO) is a composite measure representing an ideal perioperative course, which has been utilized to assess the quality of care in oesophagogastric cancer (OGC) surgery. We aim to determine TO rates among OGC patients in a UK tertiary center, investigate predictors of TO attainment, and evaluate the relationship between TO and survival. A retrospective analysis of a prospectively collected departmental database between 2006 and 2021 was conducted. Patients that underwent radical OGC surgery with curative intent were included. TO attainment required margin-negative resection, adequate lymphadenectomy, uncomplicated postoperative course, and no hospital readmission. Predictors of TO were investigated using multivariable logistic regression. The association between TO and survival was evaluated using Kaplan-Meier analysis and Cox regression modeling. In sum, 667 esophageal cancer and 312 gastric cancer patients were included. TO was achieved in 35.1% of esophagectomy patients and 51.3% of gastrectomy patients. Several factors were independently associated with a low likelihood of TO attainment: T3 stage (odds ratio (OR): 0.41, 95% confidence interval (CI) [0.22-0.79], p = 0.008) and T4 stage (OR:0.26, 95% CI [0.08-0.72], p = 0.013) in the esophagectomy cohort and high BMI (OR:0.93, 95% CI [0.88-0.98], p = 0.011) in the gastrectomy cohort. TO attainment was associated with greater overall survival and recurrence-free survival in esophagectomy and gastrectomy cohorts. TO is a relevant quality metric that can be utilized to compare surgical performance between centers and investigate patients at risk of TO failure. Enhancement of preoperative care measures can improve TO rates and, subsequently, long-term survival.

Novel Textbook Outcomes following emergency laparotomy: Delphi exercise

BACKGROUND

Textbook outcomes are composite outcome measures that reflect the ideal overall experience for patients. There are many of these in the elective surgery literature but no textbook outcomes have been proposed for patients following emergency laparotomy. The aim was to achieve international consensus amongst experts and patients for the best Textbook Outcomes for non-trauma and trauma emergency laparotomy.

METHODS

A modified Delphi exercise was undertaken with three planned rounds to achieve consensus regarding the best Textbook Outcomes based on the category, number and importance (Likert scale of 1-5) of individual outcome measures. There were separate questions for non-trauma and trauma. A patient engagement exercise was undertaken after round 2 to inform the final round.

RESULTS

A total of 337 participants from 53 countries participated in all three rounds of the exercise. The final Textbook Outcomes were divided into 'early' and 'longer-term'. For non-trauma patients the proposed early Textbook Outcome was 'Discharged from hospital without serious postoperative complications (Clavien-Dindo ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation or death). For trauma patients it was 'Discharged from hospital without unexpected transfusion after haemostasis, and no serious postoperative complications (adapted Clavien-Dindo for trauma ≥ grade III; including intra-abdominal sepsis, organ failure, unplanned re-operation on or death)'. The longer-term Textbook Outcome for both non-trauma and trauma was 'Achieved the early Textbook Outcome, and restoration of baseline quality of life at 1 year'.

CONCLUSION

Early and longer-term Textbook Outcomes have been agreed by an international consensus of experts for non-trauma and trauma emergency laparotomy. These now require clinical validation with patient data.