Textbook Outcome Failure After Esophagectomy in Patients Aged 70 Years or Older Across the Robotic Transition: Procedural and Intraoperative Determinants and Their Prognostic Consequences.

BACKGROUND: Whether a data-driven age threshold stratifies textbook outcome (TO) failure after esophagectomy, its determinants, and its relation to survival are unknown. PATIENTS AND METHODS: We analyzed 856 consecutive minimally invasive esophagectomies. TO comprised R0 resection, adequate lymphadenectomy, no major complication, no re-operation, and hospital stay  ≤ 18 days. An age threshold was derived by receiver operating characteristic (ROC) analysis and tested across eras under inverse probability of treatment weighting (IPTW). Determinants were assessed by logistic regression with interaction testing; recurrence and nonrelapse mortality were competing events (n = 771). RESULTS: TO was achieved in 45.4%, improving from 39.6 to 51.2% (p = 0.001). Age discriminated TO failure weakly (area under the curve [AUC] 0.605); 70 years maximized Youden index (19.3%; sensitivity 53.5%, specificity 65.8%), stable across eras and under IPTW. Beyond it, TO failure was associated with cT4b conversion surgery (adjusted odds ratio (aOR) 2.24), operative time (1.08/30 min) and blood loss (1.12/50 mL), but no preoperative patient factor; age interactions were nonsignificant (p = 0.35). Age ≥ 70 years predicted worse overall survival (adjusted hazard ratio (aHR) 1.39, p = 0.028) but not recurrence (subdistribution HR 1.05; 5-year incidence 34.2% versus 32.7%), whereas nonrelapse mortality doubled (sHR 2.11, p = 0.008) and postrecurrence survival was shorter (36-month RMST difference -5.5 months, p = 0.003). CONCLUSIONS: Age 70 years stratifies TO and survival at population level, but too weakly to guide individual decisions. Beyond it, TO failure reflects operative demand and conduct, and the survival disadvantage arises from competing mortality and shorter postrecurrence survival rather than more aggressive disease. These findings favor perioperative optimization over restricting curative surgery.