Achieving a Textbook Outcome in Colon Cancer Surgery Is Associated with Improved Long-Term Survival

Round 1

Reviewer 1 Report

Thank you for this interesting article. There are so many dimensions that compromise cancer care. In looking at your patient population it appears that a large majority of the patient's underwent open resections as opposed to laparoscopic which is many places is the standard of care. This may have affected the LOS seen in your population. Were this cases more exclusively the T4 tumors or emergency cases that were included? I think that would be helpful information.  

Author Response

Dear Editor,

we would like to thank the Reviewer for their time and effort and their constructive comments. The main issue highlighted is the surgical approach and proportion of patients undergoing open resections, compared to minimally invasive surgery. Indeed, this is a valid question from a clinical point of view, as it may have implications regarding length of hospital stay, and therefore Textbook Outcome failure rates.

Unfortunately, there is no formal, structured colorectal surgery fellowship programme in Greece. The junior surgeons participating in the study were trained primarily by the open approach, whereas minimally invasive resections were performed by two senior surgeons. Moreover, advanced pT4 cancers and emergency cases are routinely performed by laparotomy. 

Calculating length of hospital stay by surgical approach, this was 9.7±5.7 days for open procedures (median 7 days) and 9.7±9.6 days for laparoscopic (median 7 days). Therefore, from a methodological/statistical point of view, this has not influenced the overall Textbook Outcome rates. The study period covers 10 years, and inevitably surgical skills as well as short-term patient outcomes have gradually improved.

Furthermore, length of stay is influenced by other factors, among them the implementation of enhanced recovery protocols. As acknowledged in the Discussion, this has been a selective policy based on individual surgeons' preference. Due to administrative reasons, we do not have the data to perform subgroup analyses regarding implementation of ERAS and the influence on Textbook Outcome rates, which may have been interesting. 

on behalf of the authors

Mr Dimitrios Manatakis

Reviewer 2 Report

This is a retrospective single center review of colon cancer patients who underwent curative surgery. Six parameters were studied in this cohort and defined as a 'textbook outcome' if patients met all six parameters. Patients who did achieve the textbook outcome fared better than those that did not with regard to 5 year OS and DFS.

Overall this paper was well written and the concepts were easy to understand and to the point. I have no issues with the content or the research methods. 

The paper however is very limited in scope and uses an arbitrary 'textbook outcome' based on a prior paper from 2013. I find mortality and unplanned stoma to be a rare enough occurrence that it adds little to study. Reintervention and hospital stay overlap greatly with complications, and therefore this paper really boils down to complications are directly related to long term oncologic outcomes, which is well known and has been well studied. The authors do acknowledge this in the discussion as a major limitation of the paper.

Author Response

Dear Editor,

we would like to thank the Reviewer for their time and effort, as well as their constructive comments on our manuscript. The main issue highlighted is the definition of and parameters chosen for the construction of the Textbook Outcome composite quality marker. Indeed, we acknowledged in the Discussion that there is a degree of overlapping. As there is limited literature on the subject of Textbook Outcome in colorectal cancer, our research meeting recommended using the original 6 parameters by Kolfschotten et al, so that there is a basis for comparison of our outcomes against the literature, rather than arbitrarily choosing another set of variables.

We strongly feel that such composite quality markers have a significant role in assessing patient care. If published papers reveal these merits, then a consensus meeting will be required to fine-tune the definition and choose the constituent variables. Similar consensus meetings have been the case with Textbook Outcome in oesophageal (Kalff et al, Textbook outcome for esophageal cancer surgery: an international consensus-based update of a quality measure, Dis Esophagus, 2021, 34(7), liver (Goergec et al, An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS), Ann Surg) and breast cancer (Shammas et al, Textbook Outcomes in DIEP flap breast reconstruction: a Delphi study to establish consensus, Breast Cancer Res Treat, 2022). 

However, even these Delphi consensus meetings have not completely eliminated this overlapping. For example, both postoperative major morbidity and hospital readmission have been included, while it is obvious that any readmission following discharge is almost definitely for postoperative complications. Generally, the main focus of these expert meetings is towards effectiveness (as expressed by radical resection) on one hand (negative margins and adequate lymph node yield in our paper) and safety and efficiency on the other (as expressed by postoperative mortality, major morbidity, reintervention, stoma, readmission). 

Moreover, as discussed in the manuscript, establishing a standard, universal definition of Textbook Outcome allows for direct comparisons. On the other hand, a relative flexibility may be advantageous depending on the specific setting. For example, evaluation of peri-operative care and patient outcomes has different goals among high-income versus low-income countries.

Allowing for this limitation, the main strength of our manuscript is that we excluded non-CME patients, therefore operative technique is uniform among all consultants, and the length of follow-up, thus presenting long-term oncological outcomes, which is very limited in the Textbook Outcome literature to date.

on behalf of the authors,

Mr Dimitrios Manatakis

Round 2

Reviewer 2 Report

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Author Response

Dear Editor,

we would like to thank the Reviewer for their time and effort in reviewing our paper. 

with best regards,

Mr Dimitrios Manatakis