OGC SO10 - Modification of the Complications Parameter for ‘Textbook Outcome’ in Oesophageal Cancer Surgery

Abstract Background Surgical resection is cornerstone of curative treatment for most patients with oesophageal cancer. ‘Textbook outcome’ (TBO), a composite outcome measure, was proposed to benchmark quality of care for patients undergoing oesophagogastric cancer surgery. One required parameter for TBO is the absence of ‘severe’ complications (defined as Clavien-Dindo (CD) grade ≥2). In recent years there has been debate regarding whether a CD grade 2 complication should be considered a significant deviation from the desired post-operative course. This study aimed to assess whether revised a TBO parameter of CD≥3 is associated with improved overall survival in patients undergoing oesophagectomy for cancer. Method Data were collected for consecutive patients who underwent oesophagectomy for cancer at a single tertiary centre in the United Kingdom, between January 2018 and February 2020. Patients were identified from a prospectively maintained regional database with additional datapoints sought from electronic patient records. These included baseline clinicopathological characteristics, treatment details and the previously defined postoperative outcomes required for assessment of TBO. The primary outcome of interest was overall survival. Results Ninety-one patients (68.1% male, median 67 years (IQR: 59-72)) underwent oesophagectomy. Most had clinical stage III (61.5%) or IVA disease (28.6%) and underwent neoadjuvant chemotherapy (82.4%). When classified using the CD≥2 parameter, 15.4% achieved TBO compared with 41.8% when using CD≥3. Improved overall survival was observed in patients with a TBO using CD≥3 complication parameter (p=0.033). Survival was comparable between TBO and non-TBO group with the CD≥2 cut-off (p=0.550). TBO using CD≥3 remained associated with better survival, following adjustment for confounding variables, (HR:0.50 (95%CI:0.26-0.97), p=0.042)) while TBO using CD≥2 was not (HR:0.81 (95%CI:0.33-2.00, p=0.648)). Conclusion This study demonstrates that an association between TBO and overall survival in our patient population was only evident when the parameter requiring no ‘severe complication’ was re-defined as CD≥3. Consideration of TBO for specialist units may be useful for benchmarking quality and for prognostication.