Textbook outcome after robotic and laparoscopic Ivor Lewis esophagectomy is associated with improved survival: A propensity score-matched analysis

Background: Esophagectomy is central to curative therapy for esophageal cancer (EC). Perioperative outcomes affect both disease-free survival (DFS) and overall survival (OS) in patients undergoing oncologic esophageal surgery. The adoption of robotic techniques may improve surgical outcomes; however, the complex nature of perioperative outcomes is not adequately captured by individual quality measures.

Methods: All EC patients after minimally invasive esophagectomy (MIE) or robotic-assisted MIE (RAMIE) junction between 2015 and 2022 were included. Textbook outcome (TO) was defined as negative resection margin (R0), retrieval of >20 lymph nodes, no major complications, no reinterventions, no intensive care unit readmission, no 30-day readmission or mortality, and hospital stay <21 days. Individual propensity scores were calculated using a logistic regression model. Factors affecting TO were evaluated using a logistic regression model, and a multivariate Cox proportional hazards model was used to evaluate TO and survival.

Results: Of 236 patients included in this study, 106 (44.91%) achieved TO. TO was achieved in 71 patients after MIE (41.21%) and in 31 patients after RAMIE (57.41%; P = .036). RAMIE was associated with achievement of TO (odds ratio, 2.01; 95% confidence interval [CI], 1.07-3.80; P = .031) in the overall cohort. Achievement of TO was due to a reduction in major complications in the RAMIE group. Patients with perioperative TO had higher 3-year DFS and OS rates (univariate analysis [UV]: hazard ratio [HR], 2.49; 95% CI, 1.18-5.26; P = .016; multivariate analysis [MV]: HR, 4.30; 95% CI, 1.60-11.55; P = .004) compared to those without perioperative TO and disease-free survival (UV: HR, 2.28; 95% CI, 1.24-4.19; P = .008; MV: HR, 2.82; 95% CI, 1.26-6.32; P = .011) at the 2-year follow-up.

Conclusions: RAMIE is associated with increased TO achievement. Achieving TO is associated with enhanced long-term survival in EC patients and warrants continued emphasis on surgical quality improvement.