Textbook outcome among patients undergoing enhanced recovery after liver transplantation stratified by risk. A single-center retrospective observational cohort study

Use of textbook outcome as a quality metric in hepatopancreaticobiliary surgery: a systematic review and meta-analysis

BACKGROUND

Textbook outcomes (TOs) represent the optimal course after surgery. To date, no meta-analysis has assessed the pooled TOs of patients undergoing hepatopancreatobiliary (HPB) surgery and the effect of TO achievement on patient outcomes. This systematic review and meta-analysis aimed to assess TO achievement across different studies and to characterize the effect of TO achievement on patient-related outcomes, including disease-free survival (DFS) and overall survival (OS).

METHODS

PubMed, Embase, and Scopus databases were searched (1990-2024). The criteria used to define TO and the median overall TO in HPB surgery were obtained. In addition, a random-effects meta-analysis was conducted to assess the effect of TO achievement on 5-year OS and DFS.

RESULTS

A total of 27 studies involving 517,304 patients met inclusion criteria. The main criteria used to define TO included absence of readmission and mortality within 30 days after discharge, severe postoperative complications, prolonged hospital stay, and negative surgical margin (R0). Of note, the main factors related to TO achievement were younger patient age and lower American Society of Anesthesiologists score. Overall, the median rates of TOs achieved across procedures were 62.0% (IQR, 48.0%-69.0%) for hepatic procedure, 54.0% (IQR, 41.0%-68.0%) for biliary procedure, 46.0% (IQR, 42.0%-46.5%) for combined hepatopancreatic procedure, 45.0% (IQR, 30.5%-59.0%) for pancreatic procedure, 33.0% (IQR, 32.2%-34.0%) for liver transplantation, and 19.5% (IQR, 16.8%-22.3%) for combined hepatobiliary procedure. TO achievement was associated with improved odds of 5-year OS (odds ratio [OR], 1.22 [95% CI, 1.20-1.24]) and 5-year DFS (OR, 1.26 [95% CI, 1.16-1.37]).

CONCLUSION

Overall, hepatic and biliary operations had the highest TO achievement, followed by pancreatic procedures. In contrast, hepatobiliary surgery and liver transplantation had the lowest TO. There was a significant discrepancy in the definition of TO across different studies, highlighting the need for consensus on the definition of TO.

Association of the Number of Concurrent Metabolic Syndrome Risk Factors with Textbook Outcomes Following Liver Resection for Patients with Hepatocellular Carcinoma: A Multicenter Study

BACKGROUND

There is little information regarding the impact of the number of concurrent metabolic syndrome (MetS) risk factors on the textbook outcomes (TO) in patients with hepatocellular carcinoma (HCC) following liver resection.

PATIENTS AND METHODS

Data from patients who underwent liver resection between 2015 and 2023 in a multicenter database were retrospectively reviewed (N = 3156). According to the guidelines, MetS risk factors include obesity, hypertension, diabetes, and dyslipidemia.

RESULTS

In this study, 2056 (65.1%) patients achieved TO. The incidence of TO was 63.1% in patients with ≥ 1 MetS risk factor, which was lower than that in patients without any MetS risk factors (67.5%, P = 0.011). As the number of MetS risk factors increased, the probability of not achieving TO gradually increased. The non-TO rates in patients with no, 1, 2, and ≥ 3 MetS risk factors were 32.5%, 35.9%, 37.6% and 40.2%, respectively (Ptrend = 0.005). Multivariate logistic regression confirmed that the number of MetS risk factors (0 as a reference; 1, OR 1.220, 95% CI 1.029-1.447, P = 0.022; 2, OR 1.397, 95% CI 1.113-1.755, P = 0.004; ≥ 3, OR 1.647, 95% CI 1.197-2.264, P = 0.002) independently contributed to non-TO in patients with HCC after liver resection. Both the 5-year recurrence-free survival (TO: 50.7% versus non-TO: 43.9%, P < 0.001) and overall survival rates (TO: 71.0% versus non-TO: 58.7%, P < 0.001) of TO patients were significantly better than those of non-TO patients.

CONCLUSIONS

Concurrent MetS risk factors can adversely impact TO achievement in patients with HCC after liver resection. The more risk factors patients have, the less likely they are to achieve TO.

Textbook Outcomes in Solid Transplantation: A Systematic Review

Background

The concept of TO is expanding across various surgical disciplines to establish a standardized, comprehensive quality benchmark. Traditional metrics such as 1-y patient and graft survival have been key for evaluating transplant program performance but are now deemed inadequate because of significant field advancements. This systematic review aims to provide a comprehensive understanding of the applicability and validity of textbook outcome (TO) in the setting of solid organ transplantation.

Methods

A structured search, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, was conducted across PubMed, Embase, and Scopus databases on March 10, 2024.

Results

Fourteen articles were identified for inclusion in this review. Of these, 2 studies addressed TO in heart transplantation, 3 in lung transplantation, 2 in kidney transplantation, and 7 in liver transplantation. A subgroup analysis was conducted to categorize the different definitions of TOs and identify the most common reasons for TO failure.

Conclusions

Our systematic review highlights the ongoing efforts in the field of solid organ transplantation to define TO and emphasizes the importance of developing a universally recognized set of TO criteria for each type of transplant. TO provides a valuable framework for transplant centers to benchmark their performance against similar institutions on a risk-adjusted basis and to pinpoint specific areas for enhancing patient outcomes. Even the most successful programs may discover aspects within the composite outcome with scope for improvement.

A critical analysis of surgical outcomes indicators in hepato-pancreato-biliary surgery: From crude mortality to composite outcomes

BACKGROUND

Indicators of surgical outcomes are designed to objectively evaluate surgical performance, enabling comparisons among surgeons and institutions. In recent years, there has been a surge in complex indicators of perioperative short-term and long-term outcomes. The aim of this narrative review is to provide an overview and a critical analysis of surgical outcomes indicators, with a special emphasis on hepato-pancreato-biliary (HPB) surgery.

METHODS

A narrative review of outcome measures was conducted using a combined text and MeSH search strategy to identify relevant articles focused on perioperative outcomes, specifically within HPB surgery.

RESULTS

The literature search yielded 624 records, and 94 studies were included in the analysis. Included papers were classified depending on whether they assessed intraoperative or postoperative specific or composite outcomes, and whether they assessed purely clinical or combined clinical and socio-economic indicators. Specific indicators included in composite outcomes were categorized into three main domains: intraoperative metrics, postoperative outcomes, and oncological outcomes. While postoperative mortality, complications, hospital stay and readmission were the indicators most frequently included in composite outcomes, oncological outcomes were rarely considered.

CONCLUSIONS

The evolution of surgical outcomes has shifted from the simplistic assessment of crude mortality rates to complex composite outcomes. Whether the recent explosion of publications on these topics has a clinical impact in real life is questionable. Outcomes from the patient perspective, integrating social and financial indicators, are not yet integrated into most of these composite analytical tools but should not be underestimated.

European validation of the classification for the anticipated difficulty of liver transplantation

BACKGROUND

Appropriate risk stratification for the difficulty of liver transplantation (LT) is essential to guide the selection and acceptance of grafts and avoid morbidity and mortality.

METHODS

Based on 987 LTs collected from 5 centers, perioperative outcomes were analyzed across the 3 difficulty levels. Each LT was retrospectively scored from 0 to 10. Scores of 0-2, 3-5 and 6-10 were then translated into respective difficulty levels: low, moderate and high. Complications were reported according to the comprehensive complication index (CCI).

RESULTS

The difficulty level of LT in 524 (53%), 323 (32%), and 140 (14%) patients was classified as low, moderate and high, respectively. The values of major intraoperative outcomes, such as cold ischemia time (p = 0.04) and operative time (p < 0.0001) increased gradually with statistically significant values among difficulty levels. There was a corresponding increase in CCI (p = 0.04), severe complication rates (p = 0.05) and length of ICU (p = 0.01) and hospital (p = 0.004) stays across the different difficulty levels.

CONCLUSION

The LT difficulty classification has been validated.

Patients' perceptions of the definition of a textbook outcome following liver transplantation

BACKGROUND

A textbook outcome (TO) describes the results of a successful liver transplantation (LT) in which all aspects of the LT and posttransplant courses were uneventful. We compared patient perceived experience of a TO with clinically defined TO.

METHODS

This was a single-institution cohort study with retrospective chart review including patients who underwent LT from 2019 to 2021. Patients were asked to complete the survey at a scheduled posttransplant visit. The survey was designed to assess their viewpoints on the definition of a TO. A clinically defined TO was defined as no mortality, no severe complications, no need for reintervention, no prolonged hospital and intensive care unit stays, and no readmission.

RESULTS

Of the 182 patients who were contacted, 132 (72.5%) completed the survey. Overall, 98 patients (74%) considered that they had experienced a TO. The clinically defined TO rate was 22.0%. Multivariate analysis showed that patients who did not experience severe complications were more likely to consider that they had a TO (P = 0.01; odds ratio: 3.2; 95% confidence interval: 1.3-7.9).

CONCLUSIONS

From patients' perspectives, survival and avoidance of complications were the major characteristics of a TO.

Post-Operative Care of the Cancer Patient: Emphasis on Functional Recovery, Rapid Rescue, and Survivorship

A cancer diagnosis and its subsequent treatments are life-changing events, impacting the patient and their family. Treatment options available for cancer care are developing at pace, with more patients now able to achieve a cancer cure. This is achieved through the development of novel cancer treatments, surgery, and modern imaging, but also as a result of better understanding treatment/surgical trauma, rescue after complications, perioperative care, and innovative interventions like pre-habilitation, enhanced recovery, and enhanced post-operative care. With more patients living with and beyond cancer, the role of survivorship and quality of life after cancer treatment is gaining importance. The impact cancer treatments can have on patients vary, and the "scars" treatments leave are not always visible. To adequately support patients through their cancer journeys, we need to look past the short-term interactions they have with medical professionals and encourage them to consider their lives after cancer, which often is not a reflection of life before a cancer diagnosis.

Classification of Adverse Events in Adult Surgery

Successful surgery combines quality (achievement of a positive outcome) with safety (avoidance of a negative outcome). Outcome assessment serves the purpose of quality improvement in health care by establishing performance indicators and allowing the identification of performance gaps. Novel surgical quality metric tools (benchmark cutoffs and textbook outcomes) provide procedure-specific ideal surgical outcomes in a subgroup of well-defined low-risk patients, with the aim of setting realistic and best achievable goals for surgeons and centers, as well as supporting unbiased comparison of surgical quality between centers and periods of time. Validated classification systems have been deployed to grade adverse events during the surgical journey: (1) the ClassIntra classification for the intraoperative period; (2) the Clavien-Dindo classification for the gravity of single adverse events; and the (3) Comprehensive Complication Index (CCI) for the sum of adverse events over a defined postoperative period. The failure to rescue rate refers to the death of a patient following one or more potentially treatable postoperative adverse event(s) and is a reliable proxy of the institutional safety culture and infrastructure. Complication assessment is undergoing digital transformation to decrease resource-intensity and provide surgeons with real-time pre- or intraoperative decision support. Standardized reporting of complications informs patients on their chances to realize favorable postoperative outcomes and assists surgical centers in the prioritization of quality improvement initiatives, multidisciplinary teamwork, surgical education, and ultimately, in the enhancement of clinical standards.

Textbook outcome in the surgical treatment of liver hydatid cyst

BACKGROUND

Textbook outcome is a composite measure used in surgery to define the ideal postoperative period and to assess the quality of care. The aim of this study was to analyze the incidence of textbook outcome and the factors independently associated with its achievement following surgical treatment of liver hydatid cysts.

METHODS

Retrospective cohort study of patients operated on for liver hydatid cysts between January 2006 and December 2021. Textbook outcome was achieved when all the following criteria were fulfilled: no mortality within 90 days, no major complications within 90 days, no hospital readmission within 90 days, and no prolonged hospital stay. Univariable and multivariable analyses were performed to identify factors associated with textbook outcome.

RESULTS

During the study period, 296 patients underwent surgery. Textbook outcome was recorded in 65.9% (195/296). Female gender (odds ratio 2.02; P = .010), noncomplicated cyst (odds ratio 3.97, P < .001), and radical surgery (odds ratio 2.26, P = .003) were the variables associated with a higher probability of achieving textbook outcome.

CONCLUSION

Textbook outcome may be a useful measure to assess the variations in surgical management between different centers, and to improve quality of care after liver hydatid cysts resection.