An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS)

• Authors: Burak Görgec, Poliambulanza Foundation Hospital, Brescia, Italy; Andrea Benedetti Cacciaguerra, Poliambulanza Foundation Hospital, Brescia, Italy; Timothy M Pawlik, Ohio State University; Luca A Aldrighetti, IRCCS San Raffaele Hospital; Adnan A Alseidi, University of California San Francisco; Umberto Cillo, Padova University Hospital; Norihiro Kokudo, National Center for Global Health and Medicine, Tokyo, Japan; David A Geller, University of Pittsburgh; Go Wakabayashi, Ageo Central General Hospital, Saitama, Japan; Horacio J Asbun, Miami Cancer Institute; Marc G Besselink, University of Amsterdam; Daniel Cherqui, Paul Brousse University Hospital; Tan To Cheung, University of Hong Kong; Pierre-Alain Clavien, University Hospital Zurich; Claudius Conrad, Tufts University; Mathieu D'Hondt, Groeninge Hospital, Kortrijk, Belgium; Ibrahim Dagher, Antoine Béclère Hospital; Christos Dervenis, Konstantopouleio General Hospital; John Devar, University of Witwatersrand; Elijah Dixon, University of Calgary; Bjørn Edwin, Oslo University Hospital; Mikhail Efanov, Moscow Clinical Research Centre; Giuseppe M Ettore, San Camillo Hospital, Rome, Italy; Alessandro Ferrero, Umberto I Mauriziano Hosp; Constantino Fondevilla, Hospital Universitario La Paz; David Fuks, Université Paris Descartes, Paris, France; Felice Giuliante, Univ Cattolica Sacro Cuore; Ho-Seong Han, Seoul National University; Goro Honda, Tokyo Women’s Medical University; Oscar Imventarza, Hospital Argerich, Buenos Aires, Argentina; David Kooby, Emory University; Peter Lodge, St James’s University Hospital; Santiago Lopez-Ben, Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain; Marcel A Machado, University of São Paulo; Hugo P Marques, Curry Cabral Hospital, Lisbon, Portugal; Nick O'Rourke, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia; Juan Pekolj, Hospital Italiano de Buenos Aires; Antonio D Pinna, Cleveland Clinic Florida; Nazario Portolani, University of Brescia; John Primrose, Univ Hosp Southampton NHS Fdn Trust; Fernando Rotellar, Clinica Universidad de Navarra; Andrea Ruzzenente, University of Verona; Erik Schadde, University of Zurich; Ajith K Siriwardena, Manchester University NHS FT; Sameer Smadi, King Hussein Medical Center; Olivier Soubrane, Beaujon Hospital, Clichy, France; Kenneth K Tanabe, Harvard Medical School; Catheerine SC Teh, St Luke’s Medical Center; Guido Torzilli, Humanitas University; Thomas M Van Gulik, University of Amsterdam; Marco Vivarelli, Polytechnic University of Marche, Ancona, Italy; Stephen J Wigmore, The University of Edinburgh Clinical Surgery; Mohammad Abu Hilal, Poliambulanza Fdn Hosp
• Journal Title: ANNALS OF SURGERY
• Volume: Volume 277, Number 5
• Publisher: LIPPINCOTT WILLIAMS & WILKINS | 2023-05-01, Pages 821-828
• Type of Work: Article | Final Publisher PDF
• Publisher DOI: http://doi.org/10.1097/SLA.0000000000005668
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, Oncology
• Keywords: Science & Technology; Life Sciences & Biomedicine; Surgery; composite measure; laparoscopic liver surgery; liver surgery; minimally invasive liver surgery; patient outcome; quality of care; robotic liver surgery; textbook outcome; COMPOSITE MEASURES; QUALITY; MORTALITY; RESECTION; METASTASES; CARE; COMPLICATIONS; 30-DAY

Abstract

Objective: To reach global expert consensus on the definition of TOLS in minimally invasive and open liver resection among renowned international expert liver surgeons using a modified Delphi method. Background: Textbook outcome is a novel composite measure combining the most desirable postoperative outcomes into one single measure and representing the ideal postoperative course. Despite a recently developed international definition of Textbook Outcome in Liver Surgery (TOLS), a standardized and expert consensus-based definition is lacking. Methods: This international, consensus-based, qualitative study used a Delphi process to achieve consensus on the definition of TOLS. The survey comprised 6 surgical domains with a total of 26 questions on individual surgical outcome variables. The process included 4 rounds of online questionnaires. Consensus was achieved when a threshold of at least 80% agreement was reached. The results from the Delphi rounds were used to establish an international definition of TOLS. Results: In total, 44 expert liver surgeons from 22 countries and all 3 major international hepato-pancreato-biliary associations completed round 1. Forty-two (96%), 41 (98%), and 41 (98%) of the experts participated in round 2, 3, and 4, respectively. The TOLS definition derived from the consensus process included the absence of intraoperative grade ≥2 incidents, postoperative bile leakage grade B/C, postoperative liver failure grade B/C, 90-day major postoperative complications, 90-day readmission due to surgery-related major complications, 90-day/in-hospital mortality, and the presence of R0 resection margin. Conclusions: This is the first study providing an international expert consensus-based definition of TOLS for minimally invasive and open liver resections by the use of a formal Delphi consensus approach. TOLS may be useful in assessing patient-level hospital performance and carrying out international comparisons between centers with different clinical practices to further improve patient outcomes.