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REVISED TEXTBOOK OUTCOME FOR COLECTOMY: A NOVEL TARGET FOR ERAS PROGRAMS
Matthew P. Zeller
*1, Rachel Ma
3, Joseph Wetherell
1, Andrea P. Solis- Pazmino
3, Moshe Barnajian
3, Jessica Felton
1,2, Yosef Nasseri
3, Joshua H. Wolf
1,21Surgery, Sinai Hospital, Baltimore, MD; 2The George Washington University School of Medicine and Health Sciences, Washington, ; 3Cedars-Sinai Medical Center, Los Angeles, CA
Purpose:A textbook outcome (TO) is a composite of multiple desired outcomes, indicating the "perfect" result for a given operation. Previous definitions of TO in colon surgery have utilized length of stay (LOS) targets longer than what is considered ideal in the ERAS era. In this study, we aimed to redefine TO for colectomy using contemporary LOS standards. We hypothesized that the incidence of TO has increased over time in parallel with nationwide ERAS expansion, and aimed to identify factors associated with this new TO definition.
Methods:We performed a retrospective observational study using the NSQIP database from 2012 to 2022. Adult patients 18 years and older who underwent elective partial or total colectomy were included. Patients who underwent rectal resection, emergent colectomy, or multi-visceral surgery, and patients with synchronous cancers, preoperative sepsis, or ASA status >3 were excluded. TO was defined as LOS ?3 days, and absence of 30-day morbidity, mortality, readmission, or reoperation. Patient characteristics were compared between TO and non-TO patients using t-test and Chi-square. Covariate-adjusted multivariable logistic regression models were used to identify factors associated with TO.
Results:A total of 139,299 patients met inclusion criteria, with 68.9% achieving TO. From 2012 to 2022, there was a significant improvement in the incidence of TO over time (58.7 to 71.7%, p<0.001) with a plateau after 2019. The incidences over time for subgroups, divided by surgical approach, also improved over the interval (p<0.001)(Figure 1). Variables positively and negatively associated with achieving TO on adjusted multivariate regression analysis are displayed in Figure 2. The strongest variables positively associated with TO were robotic (OR 4.25, 95% CI 4.05-4.46, p<0.0001) and laparoscopic approach (OR 2.89, 95% CI 2.79-2.99, p<0.0001). Variables most negatively associated with achieving TO included discharge to a non-home destination (OR 0.213, 95% CI 0.189-0.230), age >80 (OR 0.546, 95% CI 0.520-0.572), frailty score 3+ (OR 0.513, 95% CI 0.458-0.576), bleeding as indication (OR 0.421, 95% CI 0.319-0.557), and ostomy creation (OR 0.553, 95% CI 0.524-0.584), all p<0.0001.
Discussion:We proposed a new definition of TO that better reflects modern LOS standards. This modified TO has increased over the last decade, though incidence has stabilized since 2019. Our results highlight the importance of MIS surgery in achieving ideal outcomes and suggest that proactive efforts to correct patient frailty and decrease non-home discharges could lead to more consistent TO. Since the goal of ERAS is a complication-free postop course with a short LOS, TO is an ideal metric for tracking programmatic success for hospital-based ERAS programs, and identifying opportunities for targeted improvements in select patient populations.
Figure 1. Percent Textbook Outcome (TO) for colectomy subdivided by approach achieved over time.
Figure 2. Multivariate regression analysis of variables and their odds ratio for achieving textbook outcome.
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