Assessment of Textbook Outcome in Laparoscopic and Open Liver Surgery

Burak Görgec; Andrea Benedetti Cacciaguerra; Jacopo Lanari; Nadia Russolillo; Federica Cipriani; Davit Aghayan; Giuseppe Zimmitti; Mikhail Efanov; Adnan Alseidi; Federico Mocchegiani; Felice Giuliante; Andrea Ruzzenente; Fernando Rotellar; David Fuks; Mathieu D’Hondt; Marco Vivarelli; Bjørn Edwin; Luca A Aldrighetti; Alessandro Ferrero; Umberto Cillo; Marc G Besselink; Mohammed Abu Hilal

doi:10.1001/jamasurg.2021.2064

. 2021 Jun 2;156(8):e212064. doi: 10.1001/jamasurg.2021.2064

Assessment of Textbook Outcome in Laparoscopic and Open Liver Surgery

Burak Görgec ^1,^2,³, Andrea Benedetti Cacciaguerra ^1,², Jacopo Lanari ⁴, Nadia Russolillo ⁵, Federica Cipriani ⁶, Davit Aghayan ^7,^8,⁹, Giuseppe Zimmitti ¹, Mikhail Efanov ¹⁰, Adnan Alseidi ^11,¹², Federico Mocchegiani ¹³, Felice Giuliante ¹⁴, Andrea Ruzzenente ¹⁵, Fernando Rotellar ¹⁶, David Fuks ¹⁷, Mathieu D’Hondt ¹⁸, Marco Vivarelli ¹³, Bjørn Edwin ^7,⁸, Luca A Aldrighetti ⁶, Alessandro Ferrero ⁵, Umberto Cillo ⁴, Marc G Besselink ³, Mohammed Abu Hilal ^1,^2,^✉

¹Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy

²Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom

³Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands

⁴Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy

⁵Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Turin, Italy

⁶Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy

⁷Department of Hepato-Pancreato-Biliary Surgery and The Intervention Center, Oslo University Hospital, Oslo, Norway

⁸Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway

⁹Department of Surgery N1, Yerevan State Medical University, Yerevan, Armenia

¹⁰Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia

¹¹Department of Surgery, Virginia Mason Medical Center, Seattle, Washington

¹²Department of Surgery, University of California, San Francisco

¹³Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy

¹⁴Chirurgia Epatobiliare, Università Cattolica del Sacro Cuore-IRCCS, Rome, Italy

¹⁵Department of Surgery, University of Verona, Verona, Italy

¹⁶Department of General and Digestive Surgery, Clinica Universidad de Navarra, Pamplona, Spain

¹⁷Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France

¹⁸Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium

Accepted for Publication: February 26, 2021.

Published Online: June 2, 2021. doi:10.1001/jamasurg.2021.2064

^✉

Corresponding Author: Mohammed Abu Hilal, MD, PhD, DocEur, Department of Surgery, Poliambulanza Foundation Hospital Brescia, Via Bissolati, 57, 25124 Brescia, Italy (abuhilal9@gmail.com).

Author Contributions: Dr Abu Hilal had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Görgec, Benedetti Cacciaguerra, Alseidi, Edwin, Ferrero, Abu Hilal.

Acquisition, analysis, or interpretation of data: Görgec, Benedetti Cacciaguerra, Lanari, Russolillo, Cipriani, Aghayan, Zimmitti, Efanov, Alseidi, Mocchegiani, Giuliante, Ruzzenente, Rotellar, Fuks, D'Hondt, Vivarelli, Aldrighetti, Cillo, Besselink, Abu Hilal.

Drafting of the manuscript: Görgec, Benedetti Cacciaguerra, Abu Hilal.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Görgec, Benedetti Cacciaguerra, Aghayan, Zimmitti.

Administrative, technical, or material support: Görgec, Aghayan, Alseidi, Rotellar.

Supervision: Russolillo, Alseidi, Mocchegiani, Giuliante, Rotellar, D'Hondt, Vivarelli, Aldrighetti, Cillo, Besselink, Abu Hilal.

Other: Cipriani.

Conflict of Interest Disclosures: Dr Rotellar reported personal fees from Sirtex Medical Lectures, personal fees from Olympus Lectures, personal fees from Baxter Lectures, personal fees from Integra Lectures, and personal fees from Medtronic Lectures outside the submitted work. No other disclosures were reported.

Additional Contributions: We would like to acknowledge the following individuals who responded to the international survey: Victor H. Torres Cueva (G. Almenra National Hospital Essalud, Lima, Peru), Fadi F. Attiyeh (The Mount Sinai Hospital, New York City, New York, USA), Michael House (Indiana University, Bloomington, Indiana, USA), Mohamed Bekheit (Aberdeen Royal Infirmary, Aberdeen, United Kingdom), Mario Serradilla Martín (Miguel Servet University Hospital, Zaragoza, Spain),Pablo Granero-Castro (Hospital Universitario Central de Asturias, Asturias, Spain), Arjen M. Rijken (Amphia Hospital, Breda, the Netherlands), Antonella Tudisco (Azienda Ospedaliera Università Pisana – Cisanello, Pisa, Italy), Ahmet Ayav (University Hospital Nancy, Nancy, France), David Badrudin (Université de Montréal, Montréal, Canada), Tzimas George (Hygeia Hospital, Durrës, Albania), Mark S. Talamonti (NorthShore University HealthSystem, Evanston, Illinois), Roberto Taruselli (Clinic Hospital, Medical School, Montevideo, Uruguay), Ajith Siriwardena (Manchester Royal Infirmary, Manchester, United Kingdom), Ajit Abraham (Barts Health NHS Trust, London, United Kingdom), Paolo Muiesan (Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom and Careggi University Hospital, Florence, Italy), Mert Erkan (Koç University School of Medicine, Istanbul, Turkey), Magnus Rizell (Sahlgrenska Transplant Institute, Goteborg, Sweden), Alfredo Escartín (Hospital Universitario Arnau de Vilanova, Lérida, Spain), Tihomir Georgiev Hristov (Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain), Arpad Ivanecz (University Medical Center Maribor, Maribor, Slovenia), Traian Dumitrascu (Fundeni Clinical Institute, Bucharest, Romania), Kees H.C. Dejong (Maastricht University Medical Centre, Maastrich, the Netherlands), Bert A. Bonsing (Leiden University Medical Center, Leiden, the Netherlands), Paul Gobardhan (Amphia Hospital, Breda, the Netherlands), Jose-Luis Beristain-Hernandez (Hospital de Especialidades Centro Médico Nacional La Raza, Mexico City, Mexico), Giedrius Barauskas (Hospital of the Lithuanian University of Health Sciences, Kaunas, Lithuania), Francesco Fleres (IRCCS Candiol, Turin, Italy), Abed Khalaileh (Hadassah Hebrew University Medical Center, Jerusalem, Israel), Erik Prabowo (Dr Kariadi General Hospital/Diponegoro University, Semarang, Indonesia), Jaime Krüger (Hospital das Clínicas University of Sao Paulo, Sao Paulo, Brazil), Nezor Houli (Western Health, Melbourne, Australia), Christo Kloppers (Groote Schuur Hospital, Cape Town, South Africa), Jordan Cloyd (Ohio State University, Columbus, Ohio, USA), Dimitri Dorcaratto (Hospital Clínico Universitario de Valencia/INCLIVA, Valencia, Spain), Henrique Alexandrino (Coimbra University Hospital Center, Coimbra, Portugal), Pål-Dag Line (Oslo University Hospital, Oslo, Norway), Marielle Coolren (Maastricht University Medical Centre, Maastricht, the Netherlands), Ugo Boggi (University of Pisa, Pisa, Italy), Anders R. Knudsen (Aarhus University Hospital, Aarhus, Denmark), Olivier Detry (CHU de Liège, Liège, Belgium), Fernando Alvarez (Clínica Universitaria Reina Fabiola, Catholic University of Córdoba, Córdoba, Argentina), James Kurtz (Phoenixville Hospital, Phoenixville, Pennsylvania), Juan Sanabria (Case Western/Marshall Universities, Cleveland, Ohio), Laurence Webber (Royal Brisbane and Women’s Hospital, Herston, Australia), Kursat Serin (Istanbul Faculty of Medicine, Istanbul, Turkey), Andrea Wirsching (University Hospital Zürich, Zurich, Switzerland), Javier Salinas (Hospital Universitario La Paz, Madrid, Spain), Alejandro Rossano (Grupo Médico Rossano, Mexico City, Mexico), Antonio Frena (Central Hospital of Bolzano, Bolzano, Italy), Federica Cipriani (Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy), Vimalraj Velayutham (Miot Hospital, Chennai, India), Perivoliotis Konstantinos (University Hospital of Larissa, Larissa, Greece), Thilo Hackert (Dept. of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany), Célia Turco (Centre Hospitalier Régional Universitaire De Besançon, Besançon, France), Piardi (University of Reims-HPB Unit-CHU Reims/CHTroyes), Paulo Herman (University of São Paulo Medical School, São Paulo, Brazil), Ilka Boin (Hospital das Clínicas da Unicamp, Unicamp, Brazil), Nuru Bayramov (Azerbaijan Medical University, Baku, Azerbaijan), Javier C. Lendoire (General Hospital Dr Cosme Argerich Treble, Buenos Aires, Argentina), Nelson Arellano (Hospital de Clinicas, Asunción, Paraguay), Marcel den Dulk (Maastricht University Medical Centre, Maastricht, the Netherlands), Carlijn Buis (University Medical Center Groningen, Groningen, the Netherlands), Yoichi Miyata (National Defense Medical College, Saitama, Japan), Marco Vito Marino (Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy), Paolo Ubiali (Azienda Sanitaria Friuli Occidentale, Pordenone, Italy), Dimitrios Magouliotis (Department of Surgery, University of Thessaly, Volos, Greece), Thomas Gruenberger (Kaiser Franz Josef Hospital, Community Medical Center South, Vienna, Austria), Athanasios Petrou (Nicosia Teaching Hospital, Strovolos, Cyprus), Hui Liang (Second Affiliated Hospital of Nanchang University, Nanchang, China), Frederik Berrevoet (University Hospital Ghent, Ghent, Belgium), Bobby Dasari (University Hospitals of Birmingham, Birmingham, United Kingdom), Olivier Soubrane (Beaujon Hospital, Clichy, France), Tommaso Campagnaro (General and Hepatobiliary Surgery, Verona University Hospital, Verona, Italy), Daniel Czarnevicz (Servicio Médico Integral, Montevideo, Uruguay), Natalie Coburn (University of Toronto, Toronto, Canada), Alejandro Serrablo (Miguel Servet University Hospital, Zaragoza, Spain), Robert Martin (University of Louisville, Louisville, Kentucky), Benjamin Darnis (Clinique de la Sauvegarde, Lyon, France), Mikel Prieto Calvo (Cruces University Hospital, Barakaldo, Spain), Nicolas Demartines (Lausanne University Hospital, Lausanne, Switzerland), Loannis Passas (Metropolitan Hospital, Athens, Greece), Kees Verhoef (Erasmus MC Cancer Institute, Rotterdam, the Netherlands), Patrick J. Worth (Oregon Health & Science University, Portland, Oregon), Louis A. DiFronzo (Kaiser Permanente Los Angeles, Los Angeles, California), Choon H. David Kwon (Cleveland Clinic, Cleveland, Ohio), Asma Sultana (East Lancashire Teaching Hospitals, Burnley, United Kingdom), Robert Sutcliffe (University Hospital Birmingham, Birmingham, United Kingdom), Ambareen Kausar (Royal Blackburn Hospital, Blackburn, England), Mikel Gastaca (Hospital Universitario Cruces, Barakaldo, Spain), Blaž Trotovšek (University Medical Centre, Ljubljana, Slovenia), Negoi Ionut (Emergency Hospital of Bucharest, Bucharest, Romania), Piotr Kalinowski (Department of General Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland), Kjetil Soreide (Stavanger University Hospital, Stavanger, Norway), Vincent E. de Meijer (University of Groningen and University Medical Center Groningen, Groningen, the Netherlands), Amine Benkabbou (National Institute of Oncology, Rabat, Morocco), Yoo-Seok Yoon (Seoul National Bundang Hospital, Seongnam, South Korea), Marco Massani (Ospedale Regionale Treviso, Treviso, Italy), Giuseppe Zimmitti (Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy), Mario Interiano (Instituto Salvadoreño del Seguro Social, San Salvador, El Salvador), Iakovidis Charalampos (Saint Luke’s Hospital, Panorama, Greece), Jun Li (Department of General, Visceral and Thorax Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany), Stefan Heinrich (University Hospital of Mainz, Mainz, Germany), Kaya Saribeyoglu (Carl Thiem Klinikum Cottbus, Germany), Mohammad Rahbari (Department of Surgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany), Gregor A. Stavrou (Saarbrücken General Hospital, Saarbrücken, Germany), Edoardo Rosso (Policlinique Sud Le Mans, Le Mans, France), Oscar Guevara (Universidad Nacional de Colombia/ Instituto Nacional de Cancerologia, Bogota, Colombia), Silvio M.P. Balzan (University of Santa Cruz do Sul, Santa Cruz do Sul, Brazil), Rafael Garcia (Santa Casa do Pará, Belém, Brazil), Valerio Lucidi (Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium), Sébastien Strypstein (Delta Hospital Roeselare, Roeselare, Belgium), Robert Jones (Austin Hospital, Melbourne, Australia).

^✉

Corresponding author.

PMCID: PMC8173471 PMID: 34076671

Key Points

Question

What is the survey consensus–based definition of textbook outcome in laparoscopic and open liver surgery (TOLS) and what is the rate of TOLS?

Findings

In this cohort study of 8188 patients who underwent liver surgery, TOLS was realized in 69.1% of patients, including 74.8% of patients after laparoscopic liver resection and 61.9% of patients after open liver resection.

Meaning

Findings of this study suggest that TOLS is an important tool to assess patient-level hospital performance and may have utility in optimizing patient outcomes after laparoscopic and open liver resection.

Abstract

Importance

Textbook outcome (TO) is a composite measure that captures the most desirable surgical outcomes as a single indicator, yet to date TO has not been defined and assessed in the field of laparoscopic liver resection (LLR) and open liver resection (OLR).

Objective

To obtain international agreement on the definition of TO in liver surgery (TOLS) and to assess the incidence of TO in LLR and OLR in a large international multicenter database using a propensity-score matched analysis.

Design, Setting, and Participants

Patients undergoing LLR or OLR for all liver diseases between January 2011 and October 2019 were analyzed using a large international multicenter liver surgical database. An international survey was conducted among all members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA) to reach agreement on the definition of TOLS. The rate of TOLS was assessed for LLR and OLR before and after propensity-score matching. Factors associated with achieving TOLS were investigated.

Main Outcomes and Measures

Textbook outcome, with TOLS defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leak grade B or C, severe postoperative complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin.

Results

A total of 8188 patients (4559 LLR; median age, 65 years [interquartile range, 55-73 years]; 2529 were male [55.8%] and 3629 OLR; median age, 64 years [interquartile range, 56-71 years]; 2204 were male [60.7%]) were included in the analysis of whom 69.1% achieved TOLS; 74.8% for LLR and 61.9% for OLR (P < .001). On multivariable analysis, American Society of Anesthesiologists grade III, previous abdominal surgery, histological diagnosis of colorectal liver metastases (odds ratio [OR], 0.656 [95% CI, 0.457-0.940]; P = .02), cholangiocarcinoma, non-CRLM, a tumor size of 30 mm or more, minor resection of posterior/superior segments (OR, 0.716 [95% CI, 0.577-0.887]; P = .002), anatomically major resection (OR, 0.579 [95% CI, 0.418-0.803]; P = .001), and nonanatomical resection (OR, 0.612 [95% CI, 0.476-0.788]; P < .001) were associated with a worse TOLS rate after LLR. For OLR, only histological diagnosis of cholangiocarcinoma (OR, 0.360 [95% CI, 0.214-0.607]; P < .001) and a tumor size of 30 mm or more (30-50 mm = OR, 0.718 [95% CI, 0.565-0.911]; P = .01; 50.1-100 mm = OR, 0.729 [95% CI, 0.554-0.960]; P = .02; >10 cm = OR, 0.550 [95% CI, 0.366-0.826]; P = .004) were associated with a worse TOLS rate.

Conclusions and Relevance

In this multicenter study, TOLS was found to be a useful tool for assessing patient-level hospital performance and may have utility in optimizing patient outcomes after LLR and OLR.

This cohort study assesses the achievement rate of textbook outcome in patients receiving laparoscopic liver resection and open liver resection procedures in a large international multicenter database using a propensity-score matched analysis.

Introduction

Traditional quality measurement for liver surgery has mainly relied on assessing individual surgical outcome parameters, such as morbidity, mortality, length of hospital stay (LOS), and readmission rates.^1,2,3 Although each outcome parameter may provide knowledge on a patient’s outcome, a single parameter does not reflect the multidimensional aspect of the whole surgical process.^4,5 Moreover, outcome parameters such as morbidity and mortality often have a low event rate, which may limit a thorough assessment of possible variations and may compromise improvement and excellence.^5,6,7 Composite measures have been proposed as a valid means to strengthen the current knowledge by combining multiple dimensions into a single summary measure.^{8,9,10,11,12,13,14}

Textbook outcome (TO) is such a composite measure that captures the most desirable surgical outcomes as a single indicator.⁵ Textbook outcome has been assessed in different surgical fields, showing TO to be a feasible and useful parameter for evaluating quality of surgical care and detecting interhospital variation.^{5,15,16,17,18}

Liver resection is performed for a number of liver and biliary diseases. Moreover, minimally invasive liver surgery is considered the reference approach for a variety of liver resections, while a wholistic precise consistent measure for more accurate and reliable conclusions has not yet been defined.^{1,2,19,20,21,22,23,24,25,26,27,28} To our knowledge, TO has not yet been defined and assessed in the field of laparoscopic liver resection (LLR) and open liver resection (OLR).

The aim of this study is to assess the achievement rate of TO in LLR and OLR in a large international multicenter database using a propensity-score matched analysis. The parameters to define TO in liver surgery (TOLS) were set after gathering opinions from international liver surgical experts through a web-based survey endorsed by the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA). In addition, we herein aim to assess factors associated with achieving TO in LLR and OLR.

Methods

Data Source and Patient Selection

Patient data were extracted from an international multicenter database including 14 high-volume tertiary hepatobiliary centers. Consecutive patients who underwent LLR or OLR for all liver diseases between January 2011 and October 2019 were included. Definitions, surgical technique and the complete statistical analysis are reported in the eMethods in the Supplement. Patients were excluded when hand-assisted laparoscopy was used, no formal resection was performed (ie, in the case of cyst fenestration or deroofing, biopsies, or diagnostic laparoscopy) or when emergency hepatic surgery was performed. Patients with missing information on 1 or more of the requirements for TO were excluded. Data were collected and registered anonymously; hence written informed consent or ethical approval was not required by the institutional review boards. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies.

International Survey on the Definition of TOLS

A survey was developed using an online survey tool (Google Forms Survey; Google) by 3 of us (B.G., A.B.C., and M.A.H.) and was subsequently submitted to the research committees of the E-AHPBA and IHPBA. After approval and endorsement, the survey was disseminated by email to all members of both associations. The survey included 19 individual surgical outcome parameters, each separated for LLR and OLR. Respondents were asked to indicate whether the particular parameter should be a requirement for achieving TO. An agreement rate of greater than 70% per parameter was considered as consensus and resulted in the parameter being included in the definition of TOLS for LLR and OLR separately. All responses were handled anonymously.

Statistical Analysis

Data analysis was performed using IBM SPSS, version 25.0 (SPSS Inc). Continuous, not normally distributed variables were expressed as median with interquartile range (IQR). Variables with normal distribution were reported as mean with SD. A Mann-Whitney U test was used to compare continuous, not normally distributed variables between groups. Normally distributed, continuous variables were compared using an independent-samples t test or a one-way analysis of variance, as appropriate. Categorical variables were reported as frequencies and proportions and compared between groups using a χ² test. Statistical significance was set at 2-sided P < .05.

Results

Definition of TOLS

A total of 116 liver surgeons responded to the survey. Most of the respondents (66.4%) were based in Europe, followed by North America (12.9%), South America (10.3%), Asia (6.0%), Australia (1.7%), and Africa (1.7%). Overall, 7 of 19 individual surgical outcome parameters for LLR and 7 of the 19 parameters for OLR had an agreement rate of greater than 70% and were selected as desirable outcome parameters representing the optimal patient outcome after liver surgery. The 7 surgical parameters in LLR were similar to the 7 parameters in OLR.

The TOLS was defined as the absence of intraoperative incidents of grade 2 or higher (defined according to the Oslo classification),²⁹ postoperative bile leak of grade B or C (according to the severity grading of the International Study Group of Liver Surgery),³⁰ severe complications (Clavien–Dindo grade III or higher),³¹ postoperative reintervention (ie, surgical, endoscopic, or radiologic), readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin (ie, 1 mm or more tumor-free margin). Because the item severe complications also covers the item postoperative reintervention, both items were combined. The item intraoperative incidents is mainly described in LLR and data on intraoperative incidents are rarely collected in OLR. Therefore, intraoperative incidents has been excluded from the definition of TOLS for OLR for the performance of reliable analyses in the present study. The survey results are presented in eTable 1 and eTable 2 in the Supplement.

Baseline Characteristics

A total of 8188 patients were included, consisting of 4559 LLR (median age, 65 years [interquartile range (IQR), 55-73 years]; 2529 were male [55.8%]) and 3629 OLR (median age, 64 years [IQR, 56-71 years]; 2204 were male [60.7%]). Baseline characteristics are shown in Table 1. Except for the presence of cirrhosis and previous extrahepatic abdominal surgery, all patient, tumor, and procedure characteristics between LLR and OLR differ significantly.

Table 1. Baseline Characteristics of Patients Undergoing Laparoscopic and Open Liver Resection Before and After Propensity-Score Matching.

Characteristic	Before PSM, No. (%)			After PSM, No. (%)
Characteristic	Laparoscopic (n = 4559)	Open (n = 3629)	P value	Laparoscopic (n = 2482)	Open (n = 2482)	P value	SMD
Patient characteristics
Age, median (IQR), y	65.0 (55.0-73.0)	64.0 (56.0-71.0)	.04	65.0 (56.0-72.0)	64.0 (56.0-71.0)	.049	0.0328
Sex
Male	2529 (55.8)	2204 (60.7)	<.001	1488 (60.0)	1480 (59.6)	.79	0.0202
Female	2030 (44.2)	1425 (39.3)		994 (40.0)	1002 (40.4)
BMI, median (IQR)	25.9 (22.6-28.3)	25.2 (22.6-28.3)	<.001	25.7 (23.4-28.0)	25.4 (23.4-27.8)	.41	0.0103
ASA grade, No. (%)
ASA I	325 (7.8)	280 (9.6)	<.001	195 (7.9)	207 (8.3)	.86	0.0124
ASA II	2589 (62.1)	1579 (54.3)		1428 (57.6)	1423(57.3)
ASA III	1221 (29.3)	1002 (34.5)		823 (33.2)	823 (33.2)
ASA IV	36 (0.9)	46 (1.6)		34 (1.4)	29 (1.2)
Cirrhosis, No. (%)	860 (20.1)	626 (20.0)	.92	427 (18.6)	495 (19.9)	<.001	0.033
Neoadjuvant chemotherapy, No. (%)	1396 (31.4)	1424 (40.8)	<.001	960 (38.7)	948 (38.2)	.70	0.0103
Previous extrahepatic abdominal surgery, No. (%)	1598 (36.9)	1110 (35.5)	.23	905 (36.5)	897 (36.1)	.79	0.0091
Previous liver surgery, No. (%)	421 (11.2)	491 (17.0)	<.001	318 (12.8)	314 (12.7)	.87	0.003
Tumor characteristics
Histologic diagnosis, No. (%)
CRLM	1960 (43.3)	1588 (44.0)	<.001	1137 (45.8)	1124 (45.3)	.93	0.0003
HCC	1024 (22.6)	688 (19.1)		530 (21.4)	556 (22.4)
Cholangiocarcinoma	237 (5.2)	610 (16.9)		227 (9.2)	219 (8.8)
Gall bladder carcinoma	56 (1.2)	93 (2.6)		51 (2.1)	49 (2.0)
Non-CRLM	400 (8.8)	223 (6.2)		177 (7.1)	185 (7.5)
Other malignant neoplasm	86 (1.9)	80 (2.2)		67 (2.7)	57 (2.3)
Benign	768 (16.9)	326 (9.0)		291 (11.7)	292 (11.8)
Lesions, No. (%)
0	60 (1.8)	21 (0.8)	<.001	123 (5.0)	135 (5.4)	.64	0.0303
1	2330 (68.4)	1524 (56.0)		1579 (63.6)	1528 (61.6)
2	536 (15.7)	410 (15.1)		340 (13.7)	348 (14.0)
3	240 (7.1)	267 (9.8)		202 (8.1)	215 (8.7)
≥4	238 (7.0)	499 (18.3)		238 (9.6)	256 (10.3)
Size of largest lesion, median (IQR), mm	28.0 (17.0-45.0)	35.0 (20.0-60.0)	<.001	35.0 (21.0-53.2)	36.0 (20.0-58.1)	.03	0.0203
Distribution of lesions, No. (%)
Unilobar	3674 (83.2)	2204 (63.3)	<.001	1870 (75.4)	1869 (75.3)	.93	0.0023
Bilobar	742 (16.8)	1279 (36.7)	<.001	610 (24.6)	613 (24.7)	.93	0.0023
Procedure characteristics
Type of resection, No. (%)
Anatomical	2108 (46.2)	1988 (54.8)	<.001	1206 (48.6)	1213 (48.9)	.96	0.0024
Nonanatomical	2088 (45.8)	1204 (33.2)		1013 (40.8)	1005 (40.5)
Combined nonanatomical/anatomical	363 (8.0)	437 (12.0)		261 (10.5)	264 (10.6)
Extent of resection, No. (%)
Anterior/left lateral segments (2,3,4b,5,6)			<.001			.99	0.0026
Wedge	1247 (27.9)	562 (15.5)		510 (20.6)	514 (20.7)
Segmentectomy	482 (10.6)	220 (6.1)		191 (7.7)	201 (8.1)
Bisegmentectomy	662 (14.5)	260 (7.2)		246 (9.9)	236 (9.5)
Posterior/superior segments (4a,7,8,1)
Wedge	814 (17.9)	642 (17.7)		503 (20.3)	491 (19.8)
Segmentectomy	253 (5.5)	222 (6.1)		174 (7.0)	180 (7.3)
Bisegmentectomy	237 (5.2)	217 (6.0)		166 (6.7)	165 (6.6)
Anatomically major
Trisegmentectomy	75 (1.6)	133 (3.7)		66 (2.7)	68 (2.7)
Hemihepatectomy	679 (14.9)	832 (22.9)		541 (21.8)	533 (21.5)
Extended hemihepatectomy	67 (1.5)	481 (13.3)		67 (2.7)	72 (2.9)
Other major hepatectomy	16 (0.4)	60 (1.7)		16 (0.6)	22 (0.9)

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Abbreviations: ASA, American Society of Anesthesiology; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CRLM, colorectal liver metastasis; HCC, hepatocellular carcinoma; IQR, interquartile range; SMD, standardized mean difference.

Although the primary aim of this study was not to compare the outcomes of LLR and OLR, a subanalysis using propensity-score matching (PSM) was performed to achieve an adequate balance between both groups for verification purposes on the TOLS rates in both approaches. After PSM, a total of 2482 LLR procedures were matched with 2482 OLR procedures (Table 1).

Textbook Outcome

Among the 8188 patients included before PSM, TOLS was realized in 69.1% of patients, including 74.8% of patients after LLR and 61.9% of patients after OLR (P < .001). After PSM, TOLS was realized in 68.7% of patients, including 70.7% after LLR and 66.8% after OLR (P < .001). Achievement of each TOLS item was calculated separately with cumulative percentages to identify which indicator was the main limiting factor for accomplishing TOLS (eFigure in the Supplement). In both approaches, the rate of R0 resection margin (87.4% in LLR and 78.1% in OLR) had the lowest incidence compared with the other items. Similarly, in both approaches, the rate of R0 resection margin was the most limiting parameter in achieving TOLS. After PSM, among the different parameters of TOLS, the rate of R0 resection margin remained the most limiting parameter in achieving TOLS for LLR and OLR (Figure).

The achievement of TOLS varied considerably between hospitals, with a range of 53.6% to 81.5% for OLR and 60.6% to 90.9% for LLR. There was no evident correlation between procedure volume and TOLS rates at different centers for LLR (β coefficient = 0.001; P = .46) as well as for OLR (β coefficient = 0.002; P = .34). Stratification of centers into low, medium, and high TOLS rates showed that for LLR, patients in the centers with a low TOLS rate had a higher American Society of Anesthesiologists (ASA) grade (ASA grade III = 37.7% vs 27.3%; P < .001), more previous abdominal surgery including previous liver surgery (15.7% vs 10.0%; P < .001), more malignant lesions (85.8% vs 82.5%; P = .001), more bilobar distribution of lesions (17.1% vs 11.2%; P = .004) and more non-anatomical resections (66.8% vs 29.9%; P < .001) as compared to the centers with a high TOLS rate (eTable 3 in the Supplement). In addition, for OLR, patients in the centers with a low TOLS rate had the same criteria as for LLR except fewer malignant lesions (89.7% vs 94.2%; P < .001) but also more cirrhosis (22.1% vs 6.8%; P < .001), greater number of lesions (3 lesions = 9.3% vs 5.5%; P < .001) and bigger size of largest lesion (40.0 mm [IQR, 22.0-62.8 mm] vs 33.0 mm [IQR, 20.0-60.0 mm]; P = .001) (eTable 4 in the Supplement).

Comparing patients with colorectal liver metastases (CRLM) and hepatocellular carcinoma showed that patients with CRLM achieved significantly less TOLS compared with patients with hepatocellular carcinoma, even after PSM (67.4% vs 72.2%; P < .001) (eTable 5 in the Supplement).

Factors Associated With TOLS

Results of univariable and multivariable analysis for all LLR and OLR are shown in Table 2, Table 3, and Table 4. On multivariable analysis, previous liver surgery (odds ratio [OR], 0.780 [95% CI, 0.652-0.932]; P = .01), histologic diagnosis of CRLM (OR, 0.631 [95% CI, 0.475-0.839]; P = .002), cholangiocarcinoma (OR, 0.283 [95% CI, 0.204-0.392]; P < .001), gallbladder carcinoma (OR, 0.558 [95% CI, 0.323-0.965]; P = .04), non-CRLM (OR, 0.489 [95% CI, 0.354-0.676]; P < .001), a tumor size of 30 mm or more (30-50 mm = OR, 0.679 [95% CI, 0.584-0.791]; P < .001; 50.1-100 mm = OR, 0.685 [95% CI, 0.567-0.827]; P < .001; >100 mm = OR, 0.477 [95% CI, 0.347-0.656]; P < .001), minor resection of posterior/superior segments (OR, 0.776 [95% CI, 0.665-0.904]; P = .001), anatomically major resection (OR, 0.687 [95% CI, 0.557-0.846]; P < .001), and nonanatomical resection (OR, 0.760 [95% CI, 0.638-0.906]; P = .002) were associated with a worse TOLS rate after all liver surgery. On multivariable analysis for LLR only, all those factors were confirmed with ASA grade III (OR, 0.597 [95% CI, 0.375-0.950]; P = .03) and previous extrahepatic abdominal surgery (OR, 0.771 [95% CI, 0.623-0.954]; P = .02) being revealed as additional factors associated with a reduced TOLS rate. In the OLR group, only histological diagnosis of cholangiocarcinoma (OR, 0.360 [95% CI, 0.214-0.607]; P < .001) and a tumor size of 30 mm or more (30-50 mm = OR, 0.718 [95% CI, 0.565-0.911]; P = .01; 50.1-100 mm = OR, 0.729 [95% CI, 0.554-0.960]; P = .02; >100 mm = OR, 0.550 [95% CI, 0.366-0.826]; P = .004) were associated with a reduced TOLS rate.

Table 2. Univariable and Multivariable Analysis of Parameters Associated With TO After Laparoscopic and Open Liver Surgery.

Variable	Univariable		Multivariable
Variable	OR (95% CI)	P value	OR (95% CI)	P value
Patient characteristics
Age	0.996 (0.992-1.000)	.05	NA	NA
Sex			NA	NA
Female	1 [Reference]		NA	NA
Male	0.915 (0.832-1.007)	.07	NA	NA
BMI	1.012 (0.999-1.024)	.06	NA	NA
ASA-classification			NA	NA
ASA I	1 [Reference]		NA	NA
ASA II	0.881 (0.726-1.068)	.19	NA	NA
ASA III	0.653 (0.0.534-0.798)	<.001	NA	NA
ASA IV	0.503 (0.313-0.809)	.01	NA	NA
Neoadjuvant chemotherapy
No	1 [Reference]		1 [Reference]
Yes	0.881 (0.798-0.972)	.01	0.938 (0.795-1.107)	.45
Cirrhosis
No	1 [Reference]		1 [Reference]
Yes	1.286 (1.133-1.461)	<.001	0.992 (0.764-1.288)	.95
Previous extrahepatic abdominal surgery
No	1 [Reference]		1 [Reference]
Yes	0.835 (0.754-0.925)	<.001	0.982 (0.848-1.136)	.81
Previous liver surgery
No	1 [Reference]		1 [Reference]
Yes	0.758 (0.654-0.878)	<.001	0.780 (0.652-0.932)	.01
Tumor characteristics
Histological diagnosis
CRLM (%)	0.602 (0.513-0.706)	<.001	0.631 (0.475-0.839)	.002
HCC (%)	0.805 (0.673-0.963)	.02	0.804 (0.579-1.115)	.19
Cholangiocarcinoma (%)	0.300 (0.246-0.365)	<.001	0.283 (0.204-0.392)	<.001
Gallbladder carcinoma (%)	0.556 (0.385-0.805)	.002	0.558 (0.323-0.965)	.04
Non-CRLM (%)	0.545 (0.438-0.678)	<.001	0.489 (0.354-0.676)	<.001
Other malignancy (%)	0.885 (0.603-1.299)	.53	0.840 (0.403-1.752)	.64
Benign (%)	1 [Reference]		1 [Reference]
No. of lesions
0	1 [Reference]		1 [Reference]
1	0.580 (0.338-0.994)	.05	0.837 (0.358-1.955)	.68
2	0.566 (0.326-0.984)	.04	0.799 (0.337-1.893)	.62
3	0.418 (0.238-0.735)	.002	0.604 (0.252-1.450)	.26
≥4	0.328 (0.188-0.570)	<.001	0.539 (0.226-1.286)	.16
Size of largest lesion	0.995 (0.993-0.996	<.001
<30 mm			1 [Reference]
30-50 mm	NA	NA	0.679 (0.584-0.791)	<.001
51-100 mm	NA	NA	0.685 (0.567-0.827)	<.001
>100 mm	NA	NA	0.477 (0.347-0.656)	<.001
Distribution of lesions
Unilobar	1 [Reference]		1 [Reference]
Bilobar	0.601 (0.541-0.668)	<.001	0.874 (0.745-1.026)	.10
Procedure characteristics
Surgical approach
Open	1 [Reference]		1 [Reference]
Laparoscopic	1.827 (1.662-2.009)	<.001	1.116 (0.968-1.288)	.13
Extent of resection
Minor resection of anterior/left lateral segments (2,3,4b,5,6)	1 [Reference]		1 [Reference]
Minor resection of posterior/superior segments (4a,7,8,1)	0.649 (0.578-0.729)	<.001	0.776 (0.665-0.904)	.001
Anatomically major resection	0.456 (0.407-0.511)	<.001	0.687 (0.557-0.846)	<.001
Type of resection
Anatomical	1 [Reference]		1 [Reference]
Nonanatomical	1.074 (0.972-1.187)	.16	0.760 (0.638-0.906)	.002
Combined nonanatomical/anatomical	0.795 (0.678-0.931)	.01	0.961 (0.756-1.222)	.75

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Abbreviations: ASA, American Society of Anesthesiology; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CRLM, colorectal liver metastasis; HCC, hepatocellular carcinoma; NA, not applicable; OR, odds ratio; TO, textbook outcome.

Table 3. Univariable and Multivariable Analysis of Parameters Associated With TO After Laparoscopic Liver Surgery.

Variable	Univariable		Multivariable
Variable	OR (95% CI)	P value	OR (95% CI)	P value
Patient characteristics
Age, y	0.994 (0.988-0.999)	.02	NA	NA
≤75	NA	NA	1 [Reference]	NA
>75	NA	NA	1.056 (0.825-1.350)	.67
Sex
Female	1 [Reference]	NA	NA	NA
Male	1.019 (0.890-1.166)	.79	NA	NA
BMI	1.003 (0.986-1.020)	.72	NA	NA
ASA-classification
ASA I	1 [Reference]		1 [Reference]	NA
ASA II	0.746 (0.557-1.000)	.05	0.791 (0.508-1.232)	.30
ASA III	0.538 0.0.397-0.729)	<.001	0.597 (.0.375-0.950)	.03
ASA IV	0.525 (0.245-1.125)	.10	0.375 (0.103-1.360)	.14
Neoadjuvant chemotherapy
No	1 [Reference]	NA	NA	NA
Yes	0.898 (0.778-1.038)	.15	NA	NA
Cirrhosis
No	1 [Reference]	NA	1 [Reference]	NA
Yes	1.198 (1.003-1.431)	.046	1.084 (0.716-1.640)	.70
Previous extrahepatic abdominal surgery
No	1 [Reference]	NA	1 [Reference]	NA
Yes	0.664 (0.576-0.764)	<.001	0.771 (0.623-0.954)	.02
Previous liver surgery
No	1 [Reference]	NA	1 [Reference]	NA
Yes	0.708 (0.567-0.885)	.002	0.752 (0.570-0.992)	.04
Tumor characteristics
Histological diagnosis
CRLM (%)	0.587 (0.477-0.722)	<.001	0.656 (0.457-0.940)	.02
HCC (%)	0.739 (0.585-0.933)	.01	0.701 (0.437-1.123)	.15
Cholangiocarcinoma (%)	0.548 (0.392-0.765)	<.001	0.472 (0.263-0.847)	.01
Gallbladder carcinoma (%)	0.562 (0.306-1.032)	.06	0.636 (0.248-1.634)	.35
Non-CRLM (%)	0.478 (0.362-0.631)	<.001	0.456 (0.298-0.696)	<.001
Other malignancy (%)	1.709 (0.862-3.388)	.13	0.213 (0.045-1.014)	.05
Benign (%)	1 [Reference]	NA	1 [Reference]	NA
No. of lesions
0	1 [Reference]	NA	1 [Reference]	NA
1	0.683 (0.361-1.295)	.24	1.203 (0.498-2.905)	.68
2	0.609 (0.315-1.178)	.14	1.083 (0.437-2.687)	.86
3	0.402 (0.203-0.797)	.01	0.807 (0.314-2.073)	.66
≥4	0.411 (0.207-0.815)	.01	0.893 (0.342-2.331)	.82
Size of largest lesion	0.992 (0.990-0.995)	<.001	NA	NA
<30 mm	NA	NA	1 [Reference]	NA
30-50 mm	NA	NA	0.601 (0.481-0.751)	<.001
51-100 mm	NA	NA	0.494 (0.369-0.661)	<.001
>100 mm	NA	NA	0.359 (0.202-0.639)	<.001
Distribution of lesions
Unilobar	1 [Reference]	NA	1 [Reference]	NA
Bilobar	0.641 (0.540-0.760)	<.001	0.802 (0.623-1.033)	.09
Procedure characteristics
Extent of resection
Minor resection of anterior/left lateral segments (2,3,4b,5,6)	1 [Reference]	NA	1 [Reference]	NA
Minor resection of posterior/superior segments (4a,7,8,1)	0.584 (0.501-0.682)	<.001	0.716 (0.577-0.887)	.002
Anatomically major resection	0.562 (0.407-0.671)	<.001	0.579 (0.418-0.803)	.001
Type of resection
Anatomical	1 [Reference]	NA	1 [Reference]	NA
Nonanatomical	0.811 (0.705-0.933)	.003	0.612 (0.476-0.788)	<.001
Combined nonanatomical/anatomical	0.709 (0.554-0.908)	.01	1.060 (0.703-1.599)	.78

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Abbreviations: ASA, American Society of Anesthesiology; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CRLM, colorectal liver metastasis; HCC, hepatocellular carcinoma; NA, not applicable; OR, odds ratio; TO, textbook outcome.

Table 4. Univariable and Multivariable Analysis of Parameters Associated With TO After Open Liver Surgery.

Variable	Univariate		Multivariable
Variable	OR (95% CI)	P value	OR (95% CI)	P value
Patient characteristics
Age	0.998 (0.993-1.004)	.54	NA	NA
Sex
Female	1 [Reference]		1 [Reference]	NA
Male	0.868 (0.757-0.997)	.045	0.853 (0.694-1.049)	.13
BMI	1.016 (0.998-1.035)	.09	NA	NA
ASA-classification
ASA I	1 [Reference]		1 [Reference]
ASA II	0.905 (0.0.694-1.181)	.46	0.882 (0.0.694-1.181)	.54
ASA III	0.752 (0.0.571-0.991)	.04	0.819 (0.0.571-0.991)	.35
ASA IV	0.538 (0.287-1.009)	.05	0.465 (0.287-1.009)	.08
Neoadjuvant chemotherapy
No	1 [Reference]		NA	NA
Yes	0.969 (0.844-1.113)	.66	NA	NA
Cirrhosis
No	1 [Reference]	NA	1 [Reference]	NA
Yes	1.400(1.163-1.686)	<.001	1.170 (0.725-1.886)	.52
Previous extrahepatic abdominal surgery
No	1 [Reference]	NA	NA	NA
Yes	1.058 (0.909-1.232)	.47	NA	NA
Previous liver surgery
No	1 [Reference]	NA	NA	NA
Yes	0.908 (0.744-0.1.107)	.34	NA	NA
Tumor characteristics
Histologic diagnosis
CRLM (%)	0.746 (0.577-0.964)	.03	0.888 (0.551-1.433)	.63
HCC (%)	1.035 (0.776-1.379)	.82	1.049 (0.561-1.964)	.88
Cholangiocarcinoma (%)	0.344 (0.259-0.458)	<.001	0.360 (0.214-0.607)	<.001
Gallbladder carcinoma (%)	0.757 (0.467-1.227)	.26	0.686 (0.330-1.427)	.31
Non-CRLM (%)	0.722 (0.504-1.034)	.08	0.927 (0.503-1.708)	.81
Other malignant neoplasm (%)	0.727 (0.436-1.211)	.22	0.939 (0.410-2.149)	.88
Benign (%)	1 [Reference]	NA	1 [Reference]	NA
No. of lesions
0	1 [Reference]	NA	1 [Reference]	NA
1	0.499 (0.182-1.369)	.18	1.100 (0.191-6.324)	.92
2	0.565 (0.203-1.574)	.28	1.098 (0.189-6.395)	.92
3	0.482 (0.171-1.356)	.17	0.993 (0.168-5.860)	.99
≥4	0.337 (0.122-0.935)	.04	0.569 (0.098-3.312)	.53
Size of largest lesion	0.997 (0.996-0.999)	.003	NA	NA
<30 mm	NA	NA	1 [Reference]	NA
30-50 mm	NA	NA	0.718 (0.565-0.911)	.01
51-100 mm	NA	NA	0.729 (0.554-0.960)	.02
>100 mm	NA	NA	0.550 (0.366-0.826)	.004
Distribution of lesions
Unilobar	1 [Reference]	NA	1 [Reference]	NA
Bilobar	0.719 (0.625-0.828)	<.001	1.061 (0.845-1.334)	.61
Procedure characteristics
Extent of resection
Minor resection of anterior/left lateral segments (2,3,4b,5,6)	1 [Reference]	NA	1 [Reference]	NA
Minor resection of posterior/superior segments (4a,7,8,1)	0.861 (0.719-1.033)	.86	1.179 (0.903-1.540)	.23
Anatomically major resection	0.543 (0.460-0.640)	<.001	0.913 (0.661-1.263)	.58
Type of resection
Anatomical	1 [Reference]	NA	1 [Reference]	NA
Nonanatomical	1.262 (1.087-1.465)	.002	0.758 (0.559-1.029)	.08
Combined nonanatomical/anatomical	0.920 (0.746-1.135)	.44	0.769 (0.555-1.064)	.11

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An Extended Definition of TOLS

Because TO definitions in other surgical fields included prolonged LOS, an extended definition of TOLS for LLR and OLR has been created including prolonged LOS (TOLS+). The TOLS+ includes the same variables as TOLS but adds prolonged LOS. Based on the survey results, most respondents (agreement rate of 56.9% for LLR and 56.0% for OLR) defined prolonged LOS as more than 4 days for minor LLR, more than 7 days for major LLR, more than 5 days for minor OLR, and more than 9 days for major OLR. The achievement rate of TOLS+ was 56.0% for LLR and 36.1% for OLR. Using the TOLS+ definition, prolonged LOS was the most limiting parameter in achieving TO for LLR and OLR.

Discussion

To date, this is the first study to deliver a survey-consensus-based definition of TOLS in both the laparoscopic and open approaches. The TOLS for LLR and OLR was defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leakage of grade B or C, severe complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin. The international multicenter analyses showed an achievement of TOLS of 69.1% in all patients undergoing liver surgery, including 74.8% after LLR and 61.9% after OLR. After PSM, the achievement rates of TOLS decreased to 70.7% of patients after LLR and increased to 66.8% of patients after OLR. On multivariable analysis, ASA grade III, previous abdominal surgery (including previous liver surgery), histological malignant diagnosis, a tumor size of 30 mm or more, minor resection of posterior or superior segments, anatomically major resection, and nonanatomical resection were associated with a worse TOLS rate after LLR. For OLR, only histological diagnosis of cholangiocarcinoma and a tumor size of 30 mm or more were associated with a reduced TOLS rate.

The TOLS definition in the current study was established by a survey, conducted among international expert liver surgeons. Of the 19 parameters, 6 were considered to reflect the ideal outcome after LLR and OLR. One of the remarkable findings was that 78.4% of the experts agreed on including the absence of intraoperative incidents of grade 2 or higher in the TOLS definition in both approaches. Intraoperative incidents are defined as surgical errors that are reported as “near misses” or adverse events with consequences.²⁹ It is a novel concept introduced by Satava et al³² and refined by Kazaryan et al²⁹ forming the Oslo Classification. In the current literature, intraoperative incidents are only assessed in the field of LLR and not in OLR or in the definition of TO for complex surgical procedures.^33,34 Nevertheless, this survey showed that intraoperative incidents are considered as important as postoperative outcome parameters in defining the ideal outcome after liver surgery. These findings indicate that intraoperative incidents may reflect the chosen surgical strategy and technique.

Notably, prolonged LOS had an agreement rate less than 70% for both approaches and therefore was not included in the main TOLS definition for LLR and OLR. Length of stay is an important parameter in the assessment of the quality of liver surgery and has been shown by many to be an important surrogate of surgical outcomes, closely associated with intraoperative and postoperative complications. However, unlike the current study, previously reported TO definitions for complex surgery such as colorectal, esophagogastric, liver transplant surgery, and resection for sarcoma all included LOS in their definition.^{5,16,35,36,37} An international multicenter study³⁸ investigated TO among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma. Results showed that the incidence of prolonged LOS was substantially different among Eastern hospitals (74.3%) and Western hospitals (33.3%). Hospital LOS might be affected by cultural and organizational differences between health care systems in different countries. Furthermore, economic interests or disincentives associated with funding mechanisms may play a role in discharge criteria and thereby affect LOS. We proposed the TOLS+ definition, and it remains to be determined whether LOS should be included as a parameter, leaving the TOLS+ definition to guide international practices or excluded as a parameter, leaving social and different surgical practices to influence the standardization of outcome measurement. However, if we were to use the TOLS+ definition, the achievement rates would decrease from 74.8% to 56.0% for LLR and from 61.9 to 36.1% for OLR.

The agreed TOLS definition for LLR and OLR in the current study contains oncologic as well as perioperative quality parameters. This definition is in line with the definition of TO in several complex surgical procedures and reflects the importance of both type of parameters. Oncologic parameters, such as resection margin, for malignant indications have implications for long-term patient outcomes, including recurrence and survival, whereas perioperative quality parameters are associated with short term outcomes and affect long-term prognosis.^39,40,41,42 Of note, it has been proposed that in selected patients with CRLM, R1 resection should not be considered directly as a technical error, especially in case of R1 vascular resection because studies showed that R1 vascular resection has equivalent long-term outcomes as R0 resection.^43,44 However, studies regarding this concept are limited and R0 resection continues to be the standard of care in liver surgery for CRLM.

Several recent studies have proposed a TO definition in a specific field of liver surgery.^13,38,45,46 Although the TOLS definition is mainly consistent with the prior literature, definitions of TO in these studies lack liver-specific items, such as postoperative bile leakage. Of note, most of these definitions are opinion based on a single expert or a scientific committee, increasing the possibility of individual bias, and are not stratified for LLR and OLR. Moreover, our study tests the real rate of achievement in a large multicenter database and explores risk factors associated with not achieving TO after both LLR and OLR.

The 69.1% rate TOLS is similar to an international multicenter study which reported 62% in patients following liver resection for primary liver malignant neoplasms.⁴⁶ Similarly, another retrospective multicenter study⁴⁵ investigated TO among patients who underwent liver resection for hepatocellular carcinoma only and reported an overall TO rate of 62.3%. On a hospital level, the current study showed that the percentage of patients who achieved TOLS ranged from 53.6% to 81.5% for OLR and 60.6% to 90.9% for LLR, which was consistent with the previous data on TO rates.^45,46 These studies did not stratify TO for OLR and LLR. The main reason for not achieving TOLS in the current study was no R0 resection margin for both OLR and LLR. These results differed from previous studies on TO for complex surgical procedures, in which prolonged LOS was the major obstacle to achieving TO.^5,13,16,38 Notably, using the TOLS+ definition for OLR and LLR shifted the main limiting item from no R0 resection margin to prolonged LOS.

Several factors were associated with the chance of achieving TOLS after LLR and OLR. The presence of cirrhosis was not negatively associated with achieving TOLS after both approaches. Of note, previous retrospective studies showed that resection of lesions of 30 mm or more, repeated liver resection and resection of lesions in the posterior or superior segments are all safe and feasible, but are considered technically difficult procedures.^{20,47,48,49,50,51} For these procedures, increased operative time, blood loss, and postoperative complications have been acknowledged.^{20,47,48,49,50,51}Although many factors are identified for LLR, only 2 factors are associated with achieving TOLS after OLR in the current study. This finding highlights the complexity and technical difficulty of LLR procedures and the need to emphasize selecting the right patients for LLR. Limited studies have been developed to determine which perioperative parameters were the risk factors associated with morbidity and oncologic outcomes of liver resection. A recent study analyzed risk factors for R1 resection in OLR and LLR separately and reported that, like the current study, nonanatomical resection was one of the risk factors in both approaches.⁵² Furthermore, a tumor size of 30 mm or more in LLR and 40.5 mm or more in OLR were considered as risk factors for R1 resection.⁵² The identified factors in the current study may help identify patients at risk for not achieving TOLS to finetune the surgical strategy and target specific interventions.

Results of this study highlight that even in major pioneering liver surgical centers the achievement of TOLS is far from guaranteed. The results would disappoint us further if we were to consider LOS into the TOLS definition (TOLS+). LOS is an important factor and consensus on its inclusion is still to be defined. While it may not be fair to use TOLS+ in international comparisons, it appears that TOLS+ may have utility on a national level or for centers using the same standards.

Results of this study confirm that continuous improvements in patient selection, surgical technique, and quality monitoring to help increase patients outcomes and experience are warranted. The risk factors highlighted may be taken into consideration during surgical planning and specific strategies should be put in place to prevent problems, especially in selecting the most suitable patients for LLR.

Limitations

This study has several limitations. First, the retrospective design introduces the risk of selection bias. In the current multicenter database, not all parameters are recorded, including some TOLS items. However, this multicenter database contains patient data from 14 expert liver surgical centers and, to our knowledge, is the most extended liver surgical database to date. Second, although the multicenter nature of the cohort was a strength, more than 50% of all patients underwent LLR, representing a very selected group of liver surgical centers, thus, requiring cautious interpretation of these results. Furthermore, there may be some variation in patient selection and preoperative and postoperative management strategies at the individual centers. Information about these variables is currently missing and may be valuable to gain more insight in TOLS. Third, the current TOLS definition is based on the opinion of expert liver surgeons only, while a multidisciplinary perspective might help to produce a TOLS definition which is more widely accepted and applicable. However, the concept of TO is still in the early phase and this is a postoperative TO, mainly related to the surgical procedure, and being an early definition of TOLS.

Conclusions

To our knowledge, this multicenter study provides the first international consensus-based definition of TOLS for LLR and OLR. Data from the current study show that TOLS may reflect the multidimensional aspect of the whole surgical process and be a useful tool for assessing patient-level hospital performance. Results also suggest that liver surgical centers still need to further improve their clinical practice to optimize the overall outcomes of patients after LLR and OLR. Further consensus-based studies may be warranted to confirm and strengthen the proposed TOLS definition.

Supplement.

eMethods. Definitions, Surgical Technique and Complete Statistical Analysis

eTable 1. Survey Results With Agreement Rates for All Individual Surgical Parameters for Laparoscopic Liver Surgery.

eTable 2. Survey Results With Agreement Rates for All Individual Surgical Parameters for Open Liver Surgery

eTable 3. Baseline Characteristics of Patients After Laparoscopic Liver Resection, Stratified for Centers With a Low, Medium and High Textbook Outcome Rate

eTable 4. Baseline Characteristics of Patients After Open Liver Resection, Stratified for Centers With a Low, Medium and High Textbook Outcome Rate

eTable 5. Textbook Outcome Rates After Laparoscopic and Open Liver Resection, Stratified for Histological Diagnosis, Before and After Propensity Score Matching

eFigure. Textbook Outcome Distribution by Its Definition, Before PSM

eReferences

Click here for additional data file.^{(366.4KB, pdf)}

References

1.Ciria R, Gomez-Luque I, Ocaña S, et al. A systematic review and meta-analysis comparing the short- and long-term outcomes for laparoscopic and open liver resections for hepatocellular carcinoma: updated results from the European Guidelines Meeting on Laparoscopic Liver Surgery, Southampton, UK, 2017. Ann Surg Oncol. 2019;26(1):252-263. doi: 10.1245/s10434-018-6926-3 [DOI] [PubMed] [Google Scholar]
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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eMethods. Definitions, Surgical Technique and Complete Statistical Analysis

eTable 1. Survey Results With Agreement Rates for All Individual Surgical Parameters for Laparoscopic Liver Surgery.

eTable 2. Survey Results With Agreement Rates for All Individual Surgical Parameters for Open Liver Surgery

eTable 3. Baseline Characteristics of Patients After Laparoscopic Liver Resection, Stratified for Centers With a Low, Medium and High Textbook Outcome Rate

eTable 4. Baseline Characteristics of Patients After Open Liver Resection, Stratified for Centers With a Low, Medium and High Textbook Outcome Rate

eTable 5. Textbook Outcome Rates After Laparoscopic and Open Liver Resection, Stratified for Histological Diagnosis, Before and After Propensity Score Matching

eFigure. Textbook Outcome Distribution by Its Definition, Before PSM

eReferences

Click here for additional data file.^{(366.4KB, pdf)}

[soi210036r1] 1.Ciria R, Gomez-Luque I, Ocaña S, et al. A systematic review and meta-analysis comparing the short- and long-term outcomes for laparoscopic and open liver resections for hepatocellular carcinoma: updated results from the European Guidelines Meeting on Laparoscopic Liver Surgery, Southampton, UK, 2017. Ann Surg Oncol. 2019;26(1):252-263. doi: 10.1245/s10434-018-6926-3 [DOI] [PubMed] [Google Scholar]

[soi210036r2] 2.Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804 patients. Ann Surg. 2009;250(5):831-841. doi: 10.1097/SLA.0b013e3181b0c4df [DOI] [PubMed] [Google Scholar]

[soi210036r3] 3.Cipriani F, Rawashdeh M, Stanton L, et al. Propensity score-based analysis of outcomes of laparoscopic versus open liver resection for colorectal metastases. Br J Surg. 2016;103(11):1504-1512. doi: 10.1002/bjs.10211 [DOI] [PubMed] [Google Scholar]

[soi210036r4] 4.Halls MC, Alseidi A, Berardi G, et al. A comparison of the learning curves of laparoscopic liver surgeons in differing stages of the IDEAL paradigm of surgical innovation: standing on the shoulders of pioneers. Ann Surg. 2019;269(2):221-228. doi: 10.1097/SLA.0000000000002996 [DOI] [PubMed] [Google Scholar]

[soi210036r5] 5.Kolfschoten NE, Kievit J, Gooiker GA, et al. Focusing on desired outcomes of care after colon cancer resections; hospital variations in ‘textbook outcome’. Eur J Surg Oncol. 2013;39(2):156-163. doi: 10.1016/j.ejso.2012.10.007 [DOI] [PubMed] [Google Scholar]

[soi210036r6] 6.Goutte N, Bendersky N, Barbier L, Falissard B, Farges O. Laparoscopic left lateral sectionectomy: a population-based study. HPB (Oxford). 2017;19(2):118-125. doi: 10.1016/j.hpb.2016.11.004 [DOI] [PubMed] [Google Scholar]

[soi210036r7] 7.He J, Amini N, Spolverato G, et al. National trends with a laparoscopic liver resection: results from a population-based analysis. HPB (Oxford). 2015;17(10):919-926. doi: 10.1111/hpb.12469 [DOI] [PMC free article] [PubMed] [Google Scholar]

[soi210036r8] 8.Sharahi S, Abedian M.. Performance measurement. In: Contributions to Management Science. Washington, D.C.: National Academies Press; 2009:21-42. doi: 10.1007/978-3-7908-2156-7_2 [DOI] [Google Scholar]

[soi210036r9] 9.Dimick JB, Staiger DO, Baser O, Birkmeyer JD. Composite measures for predicting surgical mortality in the hospital. Health Aff (Millwood). 2009;28(4):1189-1198. doi: 10.1377/hlthaff.28.4.1189 [DOI] [PubMed] [Google Scholar]

[soi210036r10] 10.Dimick JB, Birkmeyer NJ, Finks JF, et al. Composite measures for profiling hospitals on bariatric surgery performance. JAMA Surg. 2014;149(1):10-16. doi: 10.1001/jamasurg.2013.4109 [DOI] [PMC free article] [PubMed] [Google Scholar]

[soi210036r11] 11.Dimick JB, Staiger DO, Osborne NH, Nicholas LH, Birkmeyer JD. Composite measures for rating hospital quality with major surgery. Health Serv Res. 2012;47(5):1861-1879. doi: 10.1111/j.1475-6773.2012.01407.x [DOI] [PMC free article] [PubMed] [Google Scholar]

[soi210036r12] 12.Nolan T, Berwick DM. All-or-none measurement raises the bar on performance. JAMA. 2006;295(10):1168-1170. doi: 10.1001/jama.295.10.1168 [DOI] [PubMed] [Google Scholar]

[soi210036r13] 13.Merath K, Chen Q, Bagante F, et al. Textbook outcomes among Medicare patients undergoing hepatopancreatic surgery. Ann Surg. 2020;271(6):1116-1123. doi: 10.1097/SLA.0000000000003105 [DOI] [PubMed] [Google Scholar]

[soi210036r14] 14.Merkow RP, Hall BL, Cohen ME, et al. Validity and feasibility of the American college of surgeons colectomy composite outcome quality measure. Ann Surg. 2013;257(3):483-489. doi: 10.1097/SLA.0b013e318273bf17 [DOI] [PubMed] [Google Scholar]

[soi210036r15] 15.Karthaus EG, Lijftogt N, Busweiler LAD, et al. ; Dutch Society of Vascular Surgery; the Steering Committee of the Dutch Surgical Aneurysm Audit; the Dutch Institute for Clinical Auditing . Textbook outcome: a composite measure for quality of elective aneurysm surgery. Ann Surg. 2017;266(5):898-904. doi: 10.1097/SLA.0000000000002388 [DOI] [PubMed] [Google Scholar]

[soi210036r16] 16.Busweiler LAD, Schouwenburg MG, van Berge Henegouwen MI, et al. ; Dutch Upper Gastrointestinal Cancer Audit (DUCA) Group . Textbook outcome as a composite measure in oesophagogastric cancer surgery. Br J Surg. 2017;104(6):742-750. doi: 10.1002/bjs.10486 [DOI] [PubMed] [Google Scholar]

[soi210036r17] 17.van Roessel S, Mackay TM, van Dieren S, et al. Textbook outcome: nationwide analysis of a novel quality measure in pancreatic surgery. Ann Surg. 2019;1(July). doi: 10.1016/j.hpb.2019.03.036 [DOI] [PubMed] [Google Scholar]

[soi210036r18] 18.Poelemeijer YQM, Marang-van de Mheen PJ, Wouters MWJM, Nienhuijs SW, Liem RSL. Textbook outcome: an ordered composite measure for quality of bariatric surgery. Obes Surg. 2019;29(4):1287-1294. doi: 10.1007/s11695-018-03642-1 [DOI] [PubMed] [Google Scholar]

[soi210036r19] 19.Wakabayashi G, Cherqui D, Geller DA, et al. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg. 2015;261(4):619-629. doi: 10.1097/SLA.0000000000001184 [DOI] [PubMed] [Google Scholar]

[soi210036r20] 20.Cipriani F, Shelat VG, Rawashdeh M, et al. Laparoscopic parenchymal-sparing resections for nonperipheral liver lesions, the diamond technique: technical aspects, clinical outcomes, and oncologic efficiency. J Am Coll Surg. 2015;221(2):265-272. doi: 10.1016/j.jamcollsurg.2015.03.029 [DOI] [PubMed] [Google Scholar]

[soi210036r21] 21.Abu Hilal M, Aldrighetti L, Dagher I, et al. The Southampton consensus guidelines for laparoscopic liver surgery: from indication to implementation. Ann Surg. 2018;268(1):11-18. doi: 10.1097/SLA.0000000000002524 [DOI] [PubMed] [Google Scholar]

[soi210036r22] 22.Martínez-Cecilia D, Cipriani F, Shelat V, et al. Laparoscopic versus open liver resection for colorectal metastases in elderly and octogenarian patients: a multicenter propensity score based analysis of short- and long-term outcomes. Ann Surg. 2017;265(6):1192-1200. doi: 10.1097/SLA.0000000000002147 [DOI] [PubMed] [Google Scholar]

[soi210036r23] 23.Ciria R, Cherqui D, Geller DA, Briceno J, Wakabayashi G. Comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing. Ann Surg. 2016;263(4):761-777. doi: 10.1097/SLA.0000000000001413 [DOI] [PubMed] [Google Scholar]

[soi210036r24] 24.Kasai M, Cipriani F, Gayet B, et al. Laparoscopic versus open major hepatectomy: a systematic review and meta-analysis of individual patient data. Surgery. 2018;163(5):985-995. doi: 10.1016/j.surg.2018.01.020 [DOI] [PubMed] [Google Scholar]

[soi210036r25] 25.Fretland ÅA, Dagenborg VJ, Bjørnelv GMW, et al. Laparoscopic versus open resection for colorectal liver metastases: The OSLO-COMET randomized controlled trial. Ann Surg. 2018;267(2):199-207. doi: 10.1097/SLA.0000000000002353 [DOI] [PubMed] [Google Scholar]

[soi210036r26] 26.Buell JF, Cherqui D, Geller DA, et al. ; World Consensus Conference on Laparoscopic Surgery . The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg. 2009;250(5):825-830. doi: 10.1097/SLA.0b013e3181b3b2d8 [DOI] [PubMed] [Google Scholar]

[soi210036r27] 27.Görgec B, Suhool A, Al-Jarrah R, et al. Surgical technique and clinical results of one- or two-stage laparoscopic right hemihepatectomy after portal vein embolization in patients with initially unresectable colorectal liver metastases: a case series. Int J Surg. 2020;77:69-75. doi: 10.1016/j.ijsu.2020.03.005 [DOI] [PubMed] [Google Scholar]

[soi210036r28] 28.Di Fabio F, Samim M, Di Gioia P, Godeseth R, Pearce NW, Abu Hilal M. Laparoscopic major hepatectomies: clinical outcomes and classification. World J Surg. 2014;38(12):3169-3174. doi: 10.1007/s00268-014-2724-7 [DOI] [PubMed] [Google Scholar]

[soi210036r29] 29.Kazaryan AM, Røsok BI, Edwin B. Morbidity assessment in surgery: refinement proposal based on a concept of perioperative adverse events. ISRN Surg. 2013;2013:625093. doi: 10.1155/2013/625093 [DOI] [PMC free article] [PubMed] [Google Scholar]

[soi210036r30] 30.Koch M, Garden OJ, Padbury R, et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery. 2011;149(5):680-688. doi: 10.1016/j.surg.2010.12.002 [DOI] [PubMed] [Google Scholar]

[soi210036r31] 31.Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187-196. doi: 10.1097/SLA.0b013e3181b13ca2 [DOI] [PubMed] [Google Scholar]

[soi210036r32] 32.Satava RM. Identification and reduction of surgical error using simulation. Minim Invasive Ther Allied Technol. 2005;14(4):257-261. doi: 10.1080/13645700500274112 [DOI] [PubMed] [Google Scholar]

[soi210036r33] 33.Halls MC, Berardi G, Cipriani F, et al. Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection. Br J Surg. 2018;105(9):1182-1191. doi: 10.1002/bjs.10821 [DOI] [PubMed] [Google Scholar]

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PERMALINK

Assessment of Textbook Outcome in Laparoscopic and Open Liver Surgery

Burak Görgec, MD

Andrea Benedetti Cacciaguerra, MD

Jacopo Lanari, MD

Nadia Russolillo, MD, PhD

Federica Cipriani, MD

Davit Aghayan, MD

Giuseppe Zimmitti, MD, PhD

Mikhail Efanov, MD, PhD

Adnan Alseidi, MD, PhD

Federico Mocchegiani, MD

Felice Giuliante, MD, PhD

Andrea Ruzzenente, MD, PhD

Fernando Rotellar, MD, PhD

David Fuks, MD, PhD

Mathieu D’Hondt, MD, PhD

Marco Vivarelli, MD, PhD

Bjørn Edwin, MD, PhD

Luca A Aldrighetti, MD, PhD

Alessandro Ferrero, MD, PhD

Umberto Cillo, MD, PhD

Marc G Besselink, MD, PhD, Msc

Mohammed Abu Hilal, MD, PhD, DocEur

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Data Source and Patient Selection

International Survey on the Definition of TOLS

Statistical Analysis

Results

Definition of TOLS

Baseline Characteristics

Table 1. Baseline Characteristics of Patients Undergoing Laparoscopic and Open Liver Resection Before and After Propensity-Score Matching.

Textbook Outcome

Figure. Textbook Outcome Distribution by Its Definition After Propensity-Score Matching.

Factors Associated With TOLS

Table 2. Univariable and Multivariable Analysis of Parameters Associated With TO After Laparoscopic and Open Liver Surgery.

Table 3. Univariable and Multivariable Analysis of Parameters Associated With TO After Laparoscopic Liver Surgery.

Table 4. Univariable and Multivariable Analysis of Parameters Associated With TO After Open Liver Surgery.

An Extended Definition of TOLS

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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Links to NCBI Databases