Redefining textbook outcome in contemporary colon surgery

Textbook outcome (TO) is a composite measure of surgical quality, but existing definitions in colon surgery predate the widespread adoption of minimally invasive surgery and contemporary, perioperative recovery pathways. We sought to redefine TO using a contemporary and data-driven length-of-stay (LOS) standard and evaluate its incidence, temporal trends, and predictors after elective colectomy.

We performed a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2022. Adult patients undergoing elective colectomy were included. TO was defined as LOS ≤ 3 days and the absence of 30-day morbidity, mortality, readmission, or reoperation. The LOS threshold was informed by cohort-level LOS distribution analysis, demonstrating a modal LOS of 3 days. Trends in TO achievement and factors associated with TO were analyzed using multivariable logistic regression.

Among the 139,064 patients included, 44.5% achieved TO. TO rates improved significantly from 29.3% in 2012 to 50.2% in 2022 (P <.001), with rates plateauing after 2019. Minimally invasive approaches were strongly associated with TO, particularly robotic (odds ratio [OR], 8.30; 95% CI, 7.90-8.73) and laparoscopic (OR, 4.21; 95% CI, 4.03-4.39) surgery. Reduced odds of TO were associated with age > 80 years (OR, 0.46; 95% CI, 0.43-0.48), frailty index ≥ 3 (OR, 0.48; 95% CI, 0.42-0.55), nonhome discharge (OR, 0.21; 95% CI, 0.19-0.23), indication of bleeding (OR, 0.53; 95% CI, 0.38-0.72), and ostomy creation (OR, 0.52; 95% CI, 0.49-0.55), all P <.001.

A contemporary TO definition incorporating LOS ≤ 3 days identifies a rigorous and clinically relevant recovery benchmark after elective colectomy. TO achievement improved substantially over the study period. Minimally invasive approaches, particularly robotic surgery, were strongly associated with TO achievement, whereas advanced age, frailty, and nonhome discharge were associated with a lower likelihood of TO. Our contemporary TO definition may provide a patient-centered framework for evaluating perioperative recovery quality and contextualizing outcomes in modern colon surgery.