Textbook Outcome Research Articles

Fragmentation of practice: The adverse effect of surgeons moving around

BackgroundWhether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an “ideal” postoperative outcome. MethodMedicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013–2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into “low,” “average,” “above average,” or “high” rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis. ResultsAmong 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69–80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77–0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23–1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11–1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11–1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17–1.42) (all P < .05). ConclusionPatients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.

Achievement of textbook outcomes and comparisons with benchmark values after laparoscopic left lateral sectionectomy.

Laparoscopic left lateral sectionectomy (LLLS) is considered a standard approach for patients. Textbook outcomes (TOs) with benchmark values have been developed to help centers assess their outcomes of LLLS. The aim of our study was to identify factors associated with achieving TOs after LLLS. This is a retrospective cohort study including 195 patients undergoing LLLS between January 2004 and December 2018. Our outcomes were compared to benchmark values and graded as similar, better, or worse. A TO was achieved in 106 patients (54.4%). The main determinant for achieving a TO was prolonged hospital stay. Year of surgery [P = 0.002; odds ratio (OR) 3.913, 95% confidence interval (CI) 1.666-9.188], American Society of Anesthesiologists (ASA) score (P = 0.015; OR 0.104, 95% CI 0.017-0.650), body mass index (BMI) score (P = 0.075; OR 1.135, 95% CI 0.988-1.304), inflow clamping > 40min (P = 0.037; OR 0.090, 95% CI 0.009-0.867) and operation time (P = 0.002; OR 0.991, 95% CI 0.985-0.997) were the factors associated with achieving a TO. Our outcomes were similar to the benchmark values for all criteria, except for the transfusion rate (our study vs benchmark values; 6.2% vs 3.8%), which was worse in our patients. We achieved better outcomes with a lower conversion rate (4.6% vs 7.2%), fewer patients requiring massive transfusion (4.1% vs 8.3%), lower rate of prolonged inflow clamping (3.9% vs 6.3%), lower overall complication rate (11.9% vs 19.8%), lower reoperation rate (0% vs 3.4%), and fewer patients with a positive margin (1.5% vs 10.8%). Year of surgery, ASA score, inflow clamping > 40min and operation time were independently associated with failure to achieve a TO. TOs are useful tools to measure the surgical outcomes and compare surgical performance with benchmark values. TOs also offer a new method to retrospectively compare outcomes.

Social Vulnerability Subtheme Analysis Improves Perioperative Risk Stratification in Hepatopancreatic Surgery

BackgroundThere has been increased interest in understanding how social determinants of health (SDH) may affect care both in the medical and surgical setting. We sought to define the impact of various aspects of social vulnerability on the ability of patients to achieve a “textbook outcome” (TO) following hepatopancreatic surgery. MethodsMedicare beneficiaries who underwent hepatopancreatic resection between 2013 and 2017 were identified using the Medicare database. Social vulnerability was defined using the Centers for Disease Control Social Vulnerability Index (SVI), which is comprised of four subthemes: socioeconomic (SE), household composition and disability (HCD), minority status and language (MSL), and housing type and transportation (HTT). TO was defined as the composite endpoint: absence of 90-day mortality or readmission, absence of an extended length of stay (LOS), and no complications during the index admission. Cluster analysis was used to identify vulnerability cohorts, and multivariable logistic regression was utilized to assess the impact of these SVI subthemes on the likelihood to achieve a textbook outcome. ResultsAmong 37,707 Medicare beneficiaries, 64.9% (n = 24,462) of patients underwent pancreatic resection while 35.1% (n = 13,245) underwent hepatic resection. Median patient age was 72 years (IQR: 68–77), just over one-half were male (51.9%; n = 19,558), and the median CCI was 3 (IQR: 2–8). Cluster analysis revealed five distinct SVI profiles with wide variability in the distribution of SVI subthemes, ranging from 15 (profile 1 IQR: 7–26) to 83 (profile 5 IQR: 66–93). The five profiles were grouped into 3 categories based on median composite SVI: “low vulnerability” (profile 1), “average vulnerability” (profiles 2 and 3), or “high vulnerability” (profiles 4 and 5). The rate of TO ranged from 44.6% in profile 5 (n = 4022) to 49.2% in profile 1 (n = 4836). Multivariable analyses comparing patients categorized into the two average SVI profiles revealed that despite having similar composite SVI scores, the risk of adverse postoperative outcomes was not similar. Specifically, patients from profile 5 had lower odds of achieving a TO (OR 0.89, 95%CI: 0.83–0.95) and higher odds of 90-day mortality (OR 1.29, 95%CI: 1.15–1.44) versus patients in profile 4. ConclusionDistinct profiles of SVI subtheme characteristics were independently associated with postoperative outcomes among Medicare beneficiaries undergoing HP surgery, even among patients with similar overall composite SVI scores.

Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study

<h3>Objective</h3> The Dutch Surgical Aneurysm Audit (DSAA) initiative was established in 2013 to monitor and improve nationwide outcomes of aortic aneurysm surgery. The objective of this study was to examine whether outcomes of surgery for intact abdominal aortic aneurysms (iAAA) have improved over time. <h3>Methods</h3> Patients who underwent primary repair of an iAAA by standard endovascular (EVAR) or open surgical repair (OSR) between 2014 and 2019 were selected from the DSAA for inclusion. The primary outcome was peri-operative mortality trend per year, stratified by OSR and EVAR. Secondary outcomes were trends per year in major complications, textbook outcome (TbO), and characteristics of treated patients. The trends per year were evaluated and reported in odds ratios per year. <h3>Results</h3> In this study, 11 624 patients (74.8%) underwent EVAR and 3 908 patients (25.2%) underwent OSR. For EVAR, after adjustment for confounding factors, there was no improvement in peri-operative mortality (aOR [adjusted odds ratio] 1.06, 95% CI 0.94 – 1.20), while major complications decreased (2014: 10.1%, 2019: 7.0%; aOR 0.91, 95% CI 0.88 – 0.95) and the TbO rate increased (2014: 68.1%, 2019: 80.9%; aOR 1.13, 95% CI 1.10 – 1.16). For OSR, the peri-operative mortality decreased (2014: 6.1%, 2019: 4.6%; aOR 0.89, 95% CI 0.82 – 0.98), as well as major complications (2014: 28.6%, 2019: 23.3%; aOR 0.95, 95% CI 0.91 – 0.99). Furthermore, the proportion of TbO increased (2014: 49.1%, 2019: 58.3%; aOR 1.05, 95% CI 1.01 – 1.10). In both the EVAR and OSR group, the proportion of patients with cardiac comorbidity increased. <h3>Conclusion</h3> Since the establishment of this nationwide quality improvement initiative (DSAA), all outcomes of iAAA repair following EVAR and OSR have improved, except for peri-operative mortality following EVAR which remained unchanged.

Defining Textbook Outcome in liver surgery and an assessment of hospital variation: a nationwide population-based study.

Introduction Textbook outcome (TO) is a composite outcome measure covering the surgical care process in a single outcome measure. TO has an advantage over single outcome parameters with low event rates, which have less discriminating impact to detect differences between hospitals. This study aimed to define TO for liver surgery, assess factors associated with TO, and address hospital and network variation after case-mix correction. Methods This was a population-based retrospective study of all patients who underwent liver resection for malignancy in the Netherlands in 2019 and 2020. TO was defined as absence of severe postoperative complications, mortality, prolonged length of stay, and readmission, and obtaining a tumour-free pathological margin. Multivariable logistic regression was used for case-mix adjustment. Results 2377 patients were included. TO was accomplished in 1380 (80%) patients with colorectal liver metastases, in 192 (76%) patients with other liver metastases, in 183 (74%) patients with hepatocellular carcinoma and 86 (51%) patients with biliary cancers. Factors associated with lower TO rates for CRLM included ASA score ≥3 (aOR 0.70, CI 0.51 – 0.95 p=0.02), extra-hepatic disease (aOR 0.64, CI 0.44 – 0.95, p=0.02), tumour size >55mm on preoperative imaging (aOR 0.56, CI 0.34 – 0.94, p=0.02), Charlson Comorbidity Index ≥2 (aOR 0.73, CI 0.54 – 0.98, p=0.04), and major liver resection (aOR 0.50, CI 0.36 – 0.69, p<0.001). After case-mix correction, no significant hospital or oncological network variation was observed. Conclusion TO differs between indications for liver resection and can be used to evaluate hospital and network performances.

Factors Related to Textbook Outcome in Laparoscopic Liver Resections: A Single Western Center Analysis

Introduction: Laparoscopic liver resections (LLR) have proven their advantages especially regarding hospital stay and postoperative morbidity. Textbook outcome (TO) is a novel reliable measure of the outcome in liver surgery. The aim of this study is to investigate the factors related to the TO in a cohort of patients submitted to LLR. Methods: Patients submitted to LLR at a single western center from 2013 to 2020 were included. TO was considered in patients fulfilling all 6 of the following characteristics: absence of intraoperative incidents, Clavien–Dindo >= grade III complications, reinterventions, readmission within 30 days, in-hospital mortality, and R0 resection. Results: A total of 403 patients were included; TO was achieved in 330 patients (81.9%). Analysis of each TO item showed an incidence of 6.9% (28 cases) of intraoperative incidents, 4.5% (19 cases) of severe complications, 0.7% (3 cases) of postoperative reintervention, 1% (4 cases) of readmission, 0 % of mortality, and 9.2% (37 cases) of R1 resection. The median length of stay was 5 days (IQR 2 days). Univariate analysis showed that factors associated with TO were: malignant histology (OR 0.22; p<0.001), operative time (OR 0.99; p<0.001), concomitant surgery (OR 0.31; p<0.001), major hepatectomy (OR 0.30; p<0.001), age (OR 0.95; p<0.001), blood transfusions (OR 0.15; p<0.001), blood loss (OR 0.997; p<0.001), Pringle maneuver (OR 0.41; p=0.003). Conclusions: According to our results, TO is a reliable measure of the outcome after LLR, the complexity of surgery and age of patients seem to be the most predictive factors for TO.

Textbook Outcome Is Associated with Improved Survival after Resection of Colorectal Liver Metastases

Introduction: “Textbook outcomes” are composite measures of care which may be superior in assessing quality compared to traditional methods. The aim of this study was to define textbook outcomes (TBO) specific to surgical resection of colorectal liver metastases (CRLM) and assess their impact on survival. Methods: Consecutive patients undergoing liver resection for CRLM from 2009-2020 were studied. Cox proportional hazards regression was used to identify perioperative outcomes associated with overall survival (OS), which were then retained with key postoperative outcomes to define a TBO for resection of CRLM. The impact of achievement of a TBO on OS was then determined. Results: TBO was achieved in 72.1% (197/273) of patients. Major morbidity (Clavien-Dindo ≥3) at 27.5% was the most frequent reason not to achieve a TBO. Multivariable analysis showed that age >65 years, ASA Grade III-IV and resection of >2 segments independently predicted failure to achieve a TBO. TBO was associated with improved 3-year (77% vs. 55%), 5-year (60.7% vs. 42.5%) and median (93 months vs. 44 months) overall survival (p = .006). Conclusion: TBO is a useful composite measure in surgery for CRLM. It can highlight areas which may be targeted for quality improvement and may be useful as a tool to examine variation between centres. Achieving a TBO is associated with a significant improvement in survival.

Textbook Outcome as a Quality Metric in Liver Transplantation

Introduction: Quality in liver transplantation (LT) is measured using 1-year patient and graft survival. Because patient and graft survival now exceed 90%, more informative metrics are needed. Textbook outcomes (TOs) describe ideal patient outcomes following surgery. The aims of this study were to define TO following LT, asses the relationship between TO and long-term survival, and apply TO as a center-level metric.

Textbook Outcomes after Robotic Liver Resections in the Elderly

Introduction: Meta-analysis of the current evidence on surgical outcomes after liver surgery in the elderly favors laparoscopic (LLR) over open liver resections. This study aims to investigate the surgical outcomes of robotic liver resections (RLR) regarding textbook outcomes (TO) in the elderly. Methods: Consecutive patients (>65 years of age) undergoing RLR for all indications between March 2018 and July 2021 were included in a single centre prospective database and retrospectively analysed. TO after liver resection (TOLS) was defined as no intraoperative incidents (Oslo grade 2/3), no bile leakage (ISGLS Grade B/C), no postoperative complication (Clavien-Dindo ≥3), no readmission within 30 days, no in-hospital mortality and no R1 resection margins (1mm or less). TOLS+ was defined as TOLS with the addition of no prolonged hospital stay (>7 days in major and >4 days in minor resections). TOLS+ rates were assessed and associated factors were investigated. Results: A total of 35 patients (average age 73.5 years; 21 male; 74.3% colorectal metastasis; 40% ≥2 lesions; 62.9% major resections; 80.0% underwent previous abdominal surgery from whom 21.2% hepatic surgery) were included in the analysis of whom 60.0% achieved TOLS. Whenever TOLS was reached, TOLS+ was reached in 85.7% of the cases. Conclusion: RLR in the elderly has excellent postoperative outcomes on surgery-related parameters compared to LLR, even after major resections. High TOLS and TOLS+ rates were achieved after RLR in high-risk elderly. The most limiting factors for reaching TOLS+ were the achievement of R0 resection margins and the absence of prolonged hospital stay.

Textbook Outcomes after Major Robotic Liver Surgery in High-Risk Patients

Introduction: Recently, textbook outcomes after liver surgery (TOLS) has been defined for laparoscopic (LLR) and open liver resection (OLR) and found to be a useful tool for assessing patient-level hospital performance and optimizing patient outcomes after LLR and OLR. This study aims to compare robotic liver resection (RLR) with LLR regarding TOLS in major liver resections. Methods: Consecutive patients undergoing major RLR (Southampton criteria) for all indications between March 2018 and July 2021 were included in a single centre prospective database and retrospectively analysed. TOLS was defined as no intraoperative incidents (Oslo grade 2/3), no bile leakage (ISGLS Grade B/C), no postoperative complication (Clavien-Dindo ≥3), no readmission within 30 days, no in-hospital mortality and no R1 resection margins (1mm or less). TOLS+ was defined as TOLS with the addition of no prolonged hospital stay (>7 days). TOLS+ rates were assessed and associated factors were investigated. Results: A total of 44 patients (average age 65 years; 24 were male; 79.5% colorectal metastasis; 59.1% ≥2 lesions, 79.5% underwent previous abdominal surgery from whom 34.3% hepatic surgery) were included in the analysis of whom 45.5% achieved TOLS. Whenever TOLS was reached, TOLS+ was reached in 89.9% of the cases. Conclusion: RLR had excellent postoperative outcomes on surgery-related parameters. Whenever TOLS was reached, high TOLS+ rates were achieved in high-risk major RLR. The most limiting factor for reaching TOLS+ was the achievement of R0 resection margins, which correlated with a high R1vasc percentage in this cohort.

Textbook Outcome Following Liver Transplantation

Introduction: Textbook outcome (TBO) is a patient-oriented composite criterion achieved when all desired main health outcomes are realized. The aim was to assess the incidence and the independent factors associated with TBO following LT.

Have Elderly Patients a Lower Percentage of Textbook Outcome in Hepatobiliopancreatic Surgery?

Introduction: HPB surgeries are technically demanding procedures. The aging of the population, means that elderly patients, usually with comorbidities, require sometimes HPB complex surgeries. Textbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the

Association between Achieving Textbook Outcomes and Better Survival after Laparoscopic Liver Resection in Patients with Hepatocellular Carcinoma

Introduction: Textbook outcomes (TO) are important to assess the quality of surgical procedures. Laparoscopic liver resection (LLR) is considered a standard treatment for hepatocellular carcinoma located in the anterolateral segments of the liver. We investigated the factors affecting achievement of TO for LLR and its impact on survival.

Treatment and Textbook Outcome in Patients with Cholelithiasis: Results of Three Multicenter Prospective Trials

Introduction: Current guidelines advise cholecystectomy as treatment for symptomatic cholelithiasis. However, not all patients present with characteristic biliary symptoms, as some have atypical abdominal symptoms. This study defined a textbook outcome (TO) and evaluated outcomes of patients with gallstone disease.

First Four Years of a Nationwide Audit: Did Clinical Practice and Outcomes in Pancreatic Surgery Improve?

Introducion: The Dutch Pancreatic Cancer Audit (DPCA) has been established to monitor and improve nationwide outcomes of pancreatic surgery. This study aimed to describe changes in clinical practice and outcomes of pancreatic surgery in the first four years of the DPCA. Methods: Consecutive patients who underwent pancreatoduodenectomy or distal pancreatectomy were registered in the mandatory nationwide DPCA. Results were analyzed in the time periods 2014-2015 and 2016-2017. Trends in patient, tumor, and treatment characteristics were assessed using univariable regression analyses. Short-term surgical outcomes were investigated using multilevel multivariable logistic regression analyses. Results: Out of 3508 patients, 2780 (79.2%) underwent pancreatoduodenectomy and 728 (20.8%) distal pancreatectomy. The median (IQR) annual hospital volume for pancreatoduodenectomy was 36 (28-44). Out of 19 centers, 17 performed ≥20 and 4 centers performed ≥40 pancreatoduodenectomies annually. Two low-volume hospitals stopped pancreatic surgery. Nationwide in-hospital mortality decreased from 3.6% to 2.8% (OR 0.65, 95%CI 0.43-0.98, p=0.04). Failure to rescue improved from 12.8% to 10.2% (OR 0.61, 95%CI 0.40-0.95, p=0.03). The rates of textbook outcome (59.0%), postoperative pancreatic fistula (ISGPS B/C, 14.8%), readmission (16.7%), and median hospital stay (11 days) did not change significantly. The use of neoadjuvant therapy (5.8% vs 10.4%, p<0.01) and minimally invasive pancreatoduodenectomy (6.7% vs 20.5%, p<0.01) increased whereas the use of adjuvant therapy (67.3%) did not change. Conclusion: Considerable changes were noted in the first four years of the DPCA, including improved in-hospital mortality and failure to rescue rates, and increased use of neoadjuvant therapy and minimally invasive pancreatoduodenectomy.

Composite quality assessment and survival rates in patients after surgical treatment of esophageal and colon cancer

Quality assurance in county clinics plays a key role in the successful realization of the Federal project named "Battle with cancer" across the country. Comparisons between healthcare organizations demonstrate that certain hospitals perform superiorly while characterized by one quality measure, but inferiorly by another. There is a need for the introduction of integrated cancer care quality criteria in real practice. In recent years, the composite quality criteria called “textbook outcomes” were developed to better reflect the entity of cancer care. This paper provides clear examples of composite criteria for assessing the quality of esophageal and colon cancer surgery. Summarizing quality indicators are easily applicable tools to clinical practice. These parameters when developed properly could, particularly in considered examples, be associated with the long-term survival among cancer patients. The use of “textbook outcome” will probably help to reduce unreasonable differences in the quality of medical care provided by different organizations by choosing targeted measures to improve the skills of medical personnel as well as financial aid and/or human resources.

P-OGC86 Textbook Outcome following Oesophagectomy for Oesophageal Cancer: An International Cohort Study

Abstract Background Although textbook outcome (TO) has been proposed as a tool for the assessment of oncological surgical care, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess TO in an international setting. Methods Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 - December 2018. TO was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with TO, and results are presented as odds ratio (OR) and 95% confidence intervals (CI95%). Results This study included 2,159 patients with oesophageal cancer, of whom 39.7% achieved a TO. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a TO for patients with oesophageal cancer, compared to other TO parameters. Multivariable analysis identified male gender, increasing Charlson comorbidity index, and higher AJCC T and N staging to be associated with a significantly lower likelihood of TO. After accounting for these factors, high volume centres (&amp;gt;50 cases/year; OR: 1.36, CI95%: 1.06 - 1.75, p = 0.015), presence of 24-hour on-call rota for oesophageal surgeons (OR: 2.11, CI95%: 1.33 - 3.35, p = 0.001) and radiology (OR: 1.56, CI95%: 1.08 - 2.26, p = 0.019), total minimally invasive esophagectomies (OR: 1.60, CI95%: 1.25 - 2.05, p &amp;lt; 0.001), and chest anastomosis above azygous (OR: 2.17, CI95%: 1.58 - 2.98, p &amp;lt; 0.001) were independently associated with a significantly increased likelihood of TO. Conclusions TO is achieved in less than 40% of patients having oesophagectomy for cancer. Improvements in centralisation, hospital resources (i.e. daily 24-hour on-call esophagogastric surgeons and radiologists), access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve TO. Understanding how these individual parameters help improve quality of patient care should be the focus of future research.

P-OGC87 Robotic Techniques in Esophagogastric Cancer Surgery: An Assessment of Short- and Long-term Clinical Outcomes

Abstract Background Robotic esophagogastric cancer surgery is gaining widespread adoption. This population-based cohort study aimed to compare rates of textbook outcomes (TO) and survival from robotic minimally invasive techniques for esophagogastric cancers. Methods Data from the United States National Cancer Database (NCDB) (2010-2017), was used to identify patients with non-metastatic esophageal and gastric cancers receiving open (esophagus, n = 11,442; stomach, n = 22,183), laparoscopic (esophagus (LAMIE), n = 4,827; stomach (LAMIG), n = 6,359) or robotic (esophagus (RAMIE), n = 1,657; stomach (RAMIG), n = 1,718) surgery. TO were defined as lymph nodes examined &amp;gt;15, margin-negative resections, length of stay &amp;lt;21 days, no 30-day readmission, and no 90-day mortality. Multivariable logistic regression and Cox analyses were used to account for treatment selection bias. Results Patients receiving robotic surgery were more commonly treated within high volume, academic centers and with advanced clinical T and N stage disease. From 2010 to 2017, TO rates increased for esophageal and gastric cancer treated by all surgical techniques. RAMIE (odds ratio (OR):1.41, (CI 95% : 1.27-1.58) and RAMIG (OR:1.30, CI 95% : 1.17-1.45) had significantly higher TO rates compared to open surgery. For esophagectomy, TO (hazard ratio (HR):0.64, CI 95% : 0.60-0.67) and RAMIE (HR:0.92, CI 95% : 0.84-1.00) were both associated with long-term survival. For gastrectomy, TO (HR:0.58, CI 95% : 0.56-0.60) and both LAMIG (HR:0.89, CI 95% : 0.85-0.94) and RAMIG (HR:0.88, CI 95% : 0.81-0.96) were all associated with long-term survival. Subset analysis in high volume centers confirmed similar findings. Conclusions Despite potentially adverse learning curve effects and more advanced tumor stages captured within the study period, both RAMIE and RAMIG, as performed in mostly high-volume centers, were associated with improved TO and long-term survival. Therefore, consideration for wider adoption but a well-designed phase III RCT is required to fully evaluate the benefits of robotic techniques in esophageal and gastric cancers.

P-P53 Textbook outcomes in pancreatoduodenectomy are improved in high volume specialist pancreas-only centres

Abstract Background Traditional single surgical quality indicators are commonly used however they are poor for assessing global outcomes for patients. Composite outcomes such as the ‘Textbook Outcome’ (TO) is a composite outcome to determine the success of the quality of the surgical process, and compare outcomes between institutions and patient groups, described by the Dutch Pancreatic Cancer Audit Group for Pancreatoduodenectomy (PD). They reported national TOs for PD of 58.3%, we compared this to TOs in a UK high volume specialist pancreas-only centre, Royal Stoke. Methods Patients who underwent PD from January 2017 to December 2020 were identified from our database. TO was defined as absence the following: post-operative pancreatic fistula (POPF) (grade B/C), post-pancreatectomy haemorrhage (PPH), bile leak, severe complications (Clavien Dindo grade III or more), 30-day readmission and 30-day mortality. Results 153 patients underwent PD during the 4-year study period. The median age was 71years (range 37-85 years), and there was a slight male preponderance (54.9%, 84/153). 47% had pancreatic ductal adenocarcinoma (72/153), 17% ampullary carcinoma (26/153), 9% cholangiocarcinoma (14/153), 9% duodenal carcinoma (14/153), and benign pathology included cases with IPMN and duodenal polyps with high grade dysplasia. There was a statistically significant difference in textbook outcome in our cohort compared to the Dutch Study (70.3%, 108/153 vs 58.3%, 895/1536; p=0.003086), with components of TO shown in Figure 1. Conclusions TO represent composite outcome for identifying good practice, areas for shared learning and areas for improvement. PD performed in high-volume pancreas-only specialist centers appear to have better outcomes following PD than lower-volume centres. Further investigation is required to assess why outcomes are different between centres, and identify how best practice can be shared.

P-P35 Textbook outcomes after pancreaticoduodenectomy in high risk patients: results from a high volume UK centre

Abstract Background Textbook Outcome (TO) after pancreaticoduodenectomy (PD) is a quality metric that may be used to compare outcomes between centres, but the effect of casemix on TO is unknown. The aim of this study was to determine if TO after PD is affected by casemix. Methods TO was evaluated in a prospectively maintained database of 830 consecutive patients who underwent PD between 2009-2019 in a high volume centre. TO was defined as an absence of POPF, bile leak, haemorrhage, Clavien III+ complications, readmission and hospital mortality. Frequency of TO was compared between high and low risk cases. High risk was defined as any of the following: age ≥ 75 years, significant comorbidity (Charlson index ≥5), vascular resection or additional procedures. Multivariable analysis using binary logistic regression analysis was performed to assess factors associated with TO. Results Overall, 599/830 patients (72%) had TO after PD. There has been no change during the study period (2009-2013 v 2014-2018: 70% v 75%; p = 0.148). There was no difference in TO in elderly patients (p = 0.774), severe comorbidity (p = 0.483), vascular resection (p = 0.187) or additional procedures (p = 0.189). On multivariable analysis, cardiac disease (OR 0.47, 95%CI 0.28-0.81; p = 0.006), pancreatic adenocarcinoma (OR 1.55 95%CI 1.02-2.35; p = 0.039) and hard gland (OR 3.12, 95%CI 2.06-4.736; p &amp;lt; 0.001) were independently associated with TO. Conclusions Acceptable Textbook Outcomes can be achieved in high risk patients and those undergoing complex surgery, when performed in high volume specialist centres with appropriate patient selection.