Optimal Perioperative Course After Esophagectomy. Different Variables May Have Different Weight in Textbook Outcome

Abstract Background ‘Textbook outcome’ (TO) refers to a set of criteria that define a complication-free recovery. The evaluation of textbook outcome has become an essential metric for assessing the quality of care in esophagogastric surgery, providing a comprehensive measure of surgical success. Moreover, it has been shown that achieved TO after esophagectomy was associated with better survival. There is growing interest in critically evaluating whether all the components of TO are equally important, and whether these criteria should be revised or expanded. This study aims to critically analyze the prevalence of textbook outcome after esophagectomy performed in a tertiary center. Methods This was a retrospective monocentric analysis on a prospectively collected database. A descriptive analysis has been performed. Numbers and percentages were used for reporting categorical variables. Results 498 consecutive patients undergoing esophagectomy were included into the analysis. The overall achievement of TO was 44.3%. The parameter most frequently not achieved was a length of stay of less than 14 days (65.2%). On the other hand, oncological outcomes, specifically R0 resection and the number of lymph nodes retrieved, were achieved with percentages of 97.2% and 89%, respectively. ‘No complications Clavien Dindo = IIIa’ was achieved in 87.3% and ‘no anastomotic leakage’ in 94.4%. ‘No in hospital mortality’ rate was 99.3%, ‘no intraoperative complication’ was 99.4%. The overall achievement of TO, excluding the parameter ‘lenght of stay’, was 60.0%. Conclusion The achievement of textbook outcome in esophageal surgery ranges from 30 to 65% in National Audits and high-volume centers. Our data suggest that the length of stay cannot have the same impact on patients’ outcomes compared to death, major complications (CD =IIIa) or anastomotic leakage. The existing criteria for textbook outcome in esophageal surgery should be implemented. A different weight should be given to outcomes with greater impact on the patient postoperative course, short-term and long-term outcomes. Quality-of-life outcomes could be added.