E481: Trends in Textbook Outcome after Esophageal Cancer Resection in the United States, 2016-2021

Textbook outcome after esophagectomy is a composite outcome measure that identifies patients who experience an ideal uncomplicated postoperative course.  Esophagectomy for esophageal malignancy is a treatment modality with considerable morbidity, and patients who achieve a textbook outcome have improved long-term survival compared to those who do not. Understanding the predictors and trends of textbook outcome allows surgeons and centers to identify specific areas for potential improvement.

Methods: We used data from the American College of Surgeons National Surgical Quality Improvement Program Participant User File (ACS NSQIP PUF), which includes preoperative and 30-day postoperative outcomes from accredited centers. We included all patients who underwent esophagectomy from 2016 to 2021 for suspected or proven esophageal malignancy. Textbook outcome subcomponents included R0 resection, no intraoperative complication, no postoperative complication of Clavien-Dindo III or greater, no anastomotic leakage, no ICU readmission, length of stay ≤ 14 days, no in-hospital mortality, and no 30-day readmission. We tested for time series trends in overall textbook outcome and subcomponents, and used logistic regression with multiply imputed data to identify independent preoperative predictors of textbook outcome.

Results: Between 2016 to 2021, 6,168 esophagectomies were performed for cancer. The overall rate of textbook outcome was 52%, and quarterly rates of textbook outcome ranged from 46% to 57%. There was no observed trend in achieving overall textbook outcome after esophageal resection from 2016 to 2021 (Mann-Kendall test p=0.08), nor in textbook outcome subcomponents (multivariate Mann-Kendall test p = 0.85). The independent predictors of textbook outcome included operative time, diabetes mellitus, disseminated cancer, current smoking, minimally invasive approach, history of severe COPD, hypertension, immunosuppresive therapy, bleeding disorders, and preoperative white blood cell count, albumin, and hematocrit.

Conclusions: Textbook outcome after esophageal cancer resection has not seen substantial improvement in recent years. Textbook outcome subcomponents should be considered by surgeons and centers as metrics for targeted quality improvement.