eP227 - Don’t Worry, Everything Is Going According to Plan - Textbook Outcomes in Robotic-Assisted Low Anterior Resection for Rectal Cancer

Purpose/Background: Successful treatment of rectal cancer can be variably defined. Rectal cancer research often evaluates a focused aspect of patient care or a treatment approach. When these works are viewed independently, a broader analysis of the patient’s anticipated postoperative course can be inadvertently masked. A solution is to define a textbook outcome (TBO). However, accurately defining a TBO is challenging and subject to debate. We hypothesized that the length of stay (LOS) target would significantly influence the number of patients achieving TBO after robotic-assisted low anterior resection (LAR) without fecal diversion for rectal cancer and that patients who do not have a TBO would be predicted by well described perioperative risk factors for complications.Methods/Interventions: All patients who underwent robotic-assisted LAR for rectal cancer were identified using the 2015 – 2021 NSQIP database (CPT: 44207, ICD-10: C20). Baseline demographics and 30-day outcome data were collected. To attempt to control for case complexity and tumor height, patients who underwent fecal diversion, did not have an anastomosis, or had concurrent resection of other intra-abdominal or pelvic organs were excluded. TBO was defined by the absence of: conversion to open surgery, all NSQIP-defined postoperative complications, insufficient nodal harvest, LOS > 5 days, readmission, reoperation, and/or death. Variables were analyzed by 𝛘2, t-tests, and ANOVA as appropriate. Binary regression analysis was performed to identify risk factors associated with non-TBO. A separate analysis evaluated the impact of lowering the LOS target in the non-TBO cohort.Results/Outcomes: A total of 888 patients were identified who met all criteria. 43% did not achieve a TBO. The most frequent factors that led to non-TBO were LOS > 5 days, readmission, and reoperation respectively. Non-TBO patients on average did not achieve 3 measures (range 1-11). Non-TBO patients were more likely to be elderly (p=0.018), active smokers (p=0.008), ASA 3+ (p < 0.001), treated for hypertension (p < 0.001), and were exposed to chemotherapy (p < 0.001). Other baseline comorbidities, year of operation, functional status, and pathologic stage were similar (p>0.05 for all). Non-TBO operative times were on average 38 minutes longer (p < 0.001) with fewer lymph nodes harvested (p < 0.001). Binary logistic regression predicted 61% of non-TBO cases. Exposure to chemotherapy and higher ASA classification were most associated with non-TBO (OR 0.55 & 0.78 for TBO respectively, p < 0.025 for all). Reducing the LOS target to < 5, < 4, and < 3 days resulted in a decreased rate of TBO (50.3%, 38.3%, and 16.4% respectively). Earlier discharge in the non-TBO cohort did not increase the proportion of patient who required reoperation or developed NSQIP-defined complications, but did increase the readmission rate (Table 1).Conclusion/

Discussion: Over 40% of patients undergoing robotic-assisted LAR for rectal cancer will not achieve a TBO and on average will miss 3 target measures. Known perioperative risk factors for complications are predictive of non-TBO. Prolonged LOS was the most common measure missed in non-TBO patients and redefining the LOS target highly influenced the percentage of patients achieving TBO and readmission rate. Given the magnitude of the effect of adjusting a single TBO target, consensus on what defines a TBO in robotic-assisted rectal cancer surgery should be pursued prior to studying TBO as a marker of quality care nationally/internationally.Effect of Reducing Length of Stay Target on Complications in Non-Textbook Outcome PatientsTBO=Textbook outcome, LOS=Length of Stay, SD=Standard Deviation, NfNumber