Textbook Outcomes of Minimally Invasive Total Mesorectal Excision: A Composite Tool to Assess and Compare Outcomes or Benchmarking.

Background: Textbook outcome is an integrated measure including both clinical as well as oncological outcomes. Within minimally invasive rectal cancer surgery, if achievement of textbook outcome translates into improved oncological outcomes is not studied.

Objective: To evaluate textbook outcome and its associated factors for patients undergoing minimally invasive total mesorectal excision.

Design: Single center retrospective study.

Settings: The study was conducted at a high-volume tertiary referral cancer center in India.

Patients: All patients receiving elective laparoscopic or robotic total mesorectal excision from 2013- 2023 were included.

Main outcome measures: The number of patients achieving textbook outcome, institute's time trend, factors affecting textbook outcome and intermediate oncological outcomes were evaluated.

Results: Of the 1394 patients who underwent minimally invasive total mesorectal excision, 831 patients (60%) achieved textbook outcome. The conversion rate to open surgery is 0.2% with complications ≥ Clavien-Dindo 3 in 1.6% of patients. Twenty-seven percent patients had prolonged hospital stay with 30-day readmission rate being 3%. Four percent patients had a poor lymph node yield, R0 resection rate is 98% and adjuvant therapy delay is observed in 6% patients. The achievement of textbook outcome resulted in improved 3- year overall survival (92.1% vs 83.7%, p <0.001) and disease-free survival (81.5% vs 75.7%, p = 0.007).

Limitation: The results of our study cannot be generalized to open total mesorectal excision, beyond total mesorectal excision and extended total mesorectal excision, where benchmark criteria definitions vary.

Conclusion: Textbook outcomes for minimally invasive total mesorectal excision was achieved in 60% rectal cancer patients at a high-volume tertiary cancer institute. It could be used for benchmarking, thus improving results of minimally invasive total mesorectal excision and also as a quality indicator in nationwide surgical audits. See Video Abstract.