Pragmatic Context Aware Approach Enhances Textbook Outcome Assessment in Rectal Cancer

Background Textbook Outcome (TO) has emerged as a comprehensive quality metric in surgical oncology, integrating multiple dimensions of optimal patient care. However, limited data exist regarding TO achievement and features in rectal cancer surgery. This study aims to assess TO rates and predictive factors in rectal adenocarcinoma surgery. Methods This retrospective cross-sectional study included 309 consecutive patients who underwent elective curative resection for primary rectal adenocarcinoma between January 2018 and December 2022. TO was defined as achieving all the following criteria: no postoperative mortality or reintervention within 90 days from surgery, no postoperative complications (Clavien-Dindo grade ≥ 2), tumor-free margins (R0 resection), and no readmissions within 90 days. Univariate and multivariate logistic regression analyses were performed to identify factors associated with failure to achieve TO. Results Textbook outcomes were achieved in 136 patients (44.0%). The lowest achievement rate was observed for 90-day postoperative complications (48.0%), while 90-day survival showed the highest rate (96.6%). Multivariate analysis identified four independent factors associated with failure to achieve TO: T4 tumor stage (OR 5.355, 95% CI 1.827–15.69, p = 0.002), abdominoperineal resection (OR 3.37, 95% CI 1.380–7.923, p = 0.007), peroperative blood transfusion (OR 3.642, 95% CI 1.640–8.087, p = 0.001), and surgery performed by non-specialist colorectal surgeons (OR 2.645, 95% CI 1.002–6.976, p = 0.049). Conclusion The TO achievement rate of 44% and postoperative complications were the primary barrier to achieve TO. Advanced tumor stage, abdominoperineal resection, blood transfusion, and lack of surgical specialization significantly impacted TO achievement. These findings provide valuable insights for quality improvement initiatives and establish baseline metrics for future comparative studies in similar healthcare settings.