Evaluation of Textbook Outcomes and Long-Term Prognosis Following Esophagectomy: A Retrospective Cohort Study

Abstract Background A textbook outcome (TBO) has become a quality benchmark for perioperative esophagectomy. In 2021, by international consensus, TBO was redefined to include: R0 resection, retrieval of ≥20 lymph nodes, absence of intraoperative complications, no major complications (Clavien-Dindo ≥ III), no anastomotic leak, ICU/MCU readmission, prolonged hospital stay (≥ 14 days), in-hospital mortality, or readmission related to the surgical procedure. Using this updated definition, this study aims to evaluate the proportion of patients achieving TBO at a high-volume tertiary care centre and explore the association between TBO achievement and long-term outcomes, as well as early postoperative quality of life measured by FACT-E. Methods This retrospective study included patients who underwent esophagectomy for cancer at our institution from January 2021 onward. Patients were excluded if they had missing data related to any TBO criterion or long-term outcomes. TBO was achieved when all the defined criteria were met. Long-term outcomes of interest included overall survival, recurrence, and metastasis at 1-, 2-, and 3-year post-esophagectomy follow-ups. Descriptive statistics were used to quantify TBO rates and failure reasons. Univariate analyses were conducted to compare differences between TBO and non-TBO groups. Associations between 1-month postoperative FACT-E scores and TBO status were assessed to compare differences between groups. Results Of 380 patients identified, 156 (41%) met inclusion criteria, with 44 (28%) achieving TBO. Post-operative complications of Clavien Dindo ≥ III (93%) and prolonged hospital stay (92%) were the most common reasons for non-achievement. Recurrence and metastasis rates were consistently lower in TBO achievers, including at 3 years (14% vs. 29%, p = 0.1757; 7% vs. 14%, p = 0.3527, respectively). Although not statistically significant, 3-year survival was higher in TBO achievers (79% vs. 55%, p = 0.1294). FACT-E scores at 1 month postoperatively did not differ significantly (TBO: median 115 range 83–165; non-TBO: median 111 range 39–154, p = 0.1336). Conclusion Among patients with complete data, approximately one in four achieved a TBO under the 2021 definition, highlighting the challenge of attaining all perioperative quality benchmarks in esophagectomy. Complication severity and prolonged hospitalization were the most common reasons for failure. While not statistically significant, the trends towards lower recurrence, metastasis, and improved survival in TBO achievers underscore the potential prognostic value of TBO. Further research is needed to better understand how optimizing perioperative care can enhance long-term prognosis in esophageal cancer patients.