Esophagectomy is an essential component of curative treatment for patients with resectable esophageal cancer. Compared with other gastrointestinal malignancies, esophagectomy is associated with higher perioperative morbidity and mortality and longer postoperative hospital stays. Because the perioperative course influences both short-term recovery and long-term oncologic outcomes in multiple cancers, composite measures that capture the overall quality of the surgical episode have been developed.
The concept of textbook outcome (TO), and the related textbook oncological outcome (TOO), was introduced to provide a multidimensional assessment of the perioperative surgical course. Rather than relying on single endpoints such as mortality or complication rate alone, TO/TOO combine several perioperative elements into a single composite metric intended to reflect an ideal or uncomplicated surgical pathway. This approach has been applied in a variety of malignancies, including esophageal cancer.
In 2017 a TO specifically for esophageal cancer (EC) was defined. That original definition comprised 10 short-term surgical outcome items: curative resection, no intraoperative complications, R0 resection, an adequate number of harvested lymph nodes, no severe postoperative complications, no reintervention, no intensive care unit readmission, no hospital readmission, no prolonged hospital stay, and no mortality. These elements were chosen to capture key technical, pathologic, and recovery-related aspects of the perioperative course.
A consensus-based update in 2021 revised the TO definition for EC, consolidating and modifying the short-term surgical parameters into nine revised items. The 2021 redefinition represents an international effort to refine the metric and improve its applicability across centers. The specific revisions and the rationale for change were reported in the literature and reflect evolving priorities in perioperative measurement and quality assurance.
Multiple studies have evaluated associations between achieving TO and oncologic outcomes after esophagectomy. Published observational data indicate that patients who meet the composite TO criteria after esophagectomy experience better overall survival than those who do not achieve TO. These findings suggest that the perioperative pathway, when optimized and free of major adverse events, may translate into improved long-term outcomes for patients with resectable EC.
The TO framework offers a standardized, multidimensional quality metric that can be used for benchmarking, quality improvement, and potentially for informing patients about expected perioperative courses. Implementing TO measurement in clinical practice could help centers identify the specific aspects of care that limit optimal recovery—such as complication prevention, lymph node retrieval, or readmission reduction—and target interventions accordingly.
Although studies have demonstrated an association between achieving TO and improved survival, it is important to recognize limitations in the current evidence base. Observational designs, variation in how individual TO components are defined and measured across studies, and differences in patient populations and institutional practices can affect comparability. Before broad implementation, clinicians and quality leaders should carefully review the characteristics of the studies that support TO, including which specific items were included, how thresholds (for example, number of lymph nodes or definition of prolonged length of stay) were set, and whether adjustments were made for case mix and risk.
Future work should focus on harmonizing definitions, validating TO components across diverse practice settings, and clarifying the causal pathways linking perioperative quality to long-term oncologic outcomes. Prospective studies, consensus development, and incorporation of TO into registries or quality programs may help determine how best to use the metric to improve patient-centered care. Thoughtful implementation will require engagement from surgeons, anesthesiologists, oncologists, nursing, and administrative leaders to ensure accurate measurement and appropriate response to identified gaps.
Textbook outcome provides a composite measure designed to reflect an ideal perioperative course after esophagectomy for esophageal cancer. Initially defined in 2017 with 10 items and updated in 2021 to a nine-item definition, TO has been associated in observational studies with improved overall survival. The measure holds promise for benchmarking and quality improvement, but stakeholders should understand study characteristics, definitions, and limitations prior to widespread adoption. Further validation and harmonization are needed to optimize its clinical utility and to guide interventions that improve both short- and long-term outcomes after esophagectomy.