Textbook outcome for esophageal cancer surgery: an international consensus-based update of a quality measure

Textbook outcome for esophageal cancer surgery is a composite quality measure including 10 short-term surgical outcomes reflecting an uneventful perioperative course. Achieved textbook outcome is associated with improved long-term survival. This study aimed to update the original textbook outcome based on international consensus. Forty-five international expert esophageal cancer surgeons received a personal invitation to evaluate the 10 items in the original textbook outcome for esophageal cancer surgery and to rate 18 additional items divided over seven subcategories for their importance in the updated textbook outcome. Items were included in the updated textbook outcome if ≥80% of the respondents agreed on inclusion. In case multiple items within one subcategory reached ≥80% agreement, only the most inclusive item with the highest agreement rate was included. With a response rate of 80%, 36 expert esophageal cancer surgeons, from 34 hospitals, 16 countries, and 4 continents responded to this international survey. Based on the inclusion criteria, the updated quality indicator 'textbook outcome for esophageal cancer surgery' should consist of: tumor-negative resection margins, ≥20 lymph nodes retrieved and examined, no intraoperative complication, no complications Clavien-Dindo ≥III, no ICU/MCU readmission, no readmission related to the surgical procedure, no anastomotic leakage, no hospital stay ≥14 days, and no in-hospital mortality. This study resulted in an international consensus-based update of a quality measure, textbook outcome for esophageal cancer surgery. This updated textbook outcome should be implemented in quality assurance programs for centers performing esophageal cancer surgery, and could standardize quality measures used internationally.