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Görgec B, Benedetti Cacciaguerra A, Pawlik TM, Aldrighetti LA, Alseidi AA, Cillo U, Kokudo N, Geller DA, Wakabayashi G, Asbun HJ, Besselink MG, Cherqui D, Cheung TT, Clavien PA, Conrad C, D’Hondt M, Dagher I, Dervenis C, Devar J, Dixon E, Edwin B, Efanov M, Ettore GM, Ferrero A, Fondevilla C, Fuks D, Giuliante F, Han HS, Honda G, Imventarza O, Kooby DA, Lodge P, Lopez-Ben S, Machado MA, Marques HP, O’Rourke N, Pekolj J, Pinna AD, Portolani N, Primrose J, Rotellar F, Ruzzenente A, Schadde E, Siriwardena AK, Smadi S, Soubrane O, Tanabe KK, Teh CS, Torzilli G, Van Gulik TM, Vivarelli M, Wigmore SJ, Abu Hilal M. An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS). Ann Surg 2023; 277:821-828. [PMID: 35946822 PMCID: PMC10082050 DOI: 10.1097/sla.0000000000005668] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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.
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Affiliation(s)
- Burak Görgec
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, AmsterdamUMC, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andrea Benedetti Cacciaguerra
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | | | - Adnan A. Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplantation Unit, Padova University Hospital, Padova, Italy
| | - Norihiro Kokudo
- Department of Surgery, Hepatobiliary Pancreatic Surgery Division, National Center for Global Health and Medicine, Tokyo, Japan
| | - David A. Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan
| | - Horacio J. Asbun
- Hepato-Biliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL
| | - Marc G. Besselink
- Department of Surgery, AmsterdamUMC, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Daniel Cherqui
- Department of Hepatobiliary Surgery, Paul Brousse University Hospital, Villejuif, France
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Pierre-Alain Clavien
- Department of surgery and transplantation, University Hospital Zurich, Switzerland
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, MA
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Ibrahim Dagher
- Department of Minimally Invasive Digestive Surgery, Antoine Béclère Hospital, Clamart, France
| | - Christos Dervenis
- Department of Surgery, Konstantopouleio General Hospital, Nea Ionia, Athens, Greece
| | - John Devar
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Hepato-Pancreatico-Biliary Unit, Department of General Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Bjørn Edwin
- Department of Hepato-Pancreato-Biliary Surgery and The Intervention Center, Oslo University Hospital Oslo, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
| | - Giuseppe M. Ettore
- General Surgery and Transplantation Unit, San Camillo Hospital, Rome, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Turin, Italy
| | | | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Felice Giuliante
- Chirurgia Epatobiliare, Università Cattolica del Sacro Cuore-IRCCS, Rome, Italy
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Goro Honda
- Department of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Oscar Imventarza
- Department of surgery, Hospital Argerich, Buenos Aires, Argentina
- Department of surgery, Hospital Garrahan, Buenos Aires, Argentina
| | - David A. Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA
| | - Peter Lodge
- HPB and Transplant Unit, St James’s University Hospital, Leeds, UK
| | - Santiago Lopez-Ben
- Department of General and Digestive Surgery, HPB Unit, Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain
| | | | - Hugo P. Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Nick O’Rourke
- Department of HPB Surgery, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Juan Pekolj
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Antonio D. Pinna
- Abdominal Transplant and HPB Center, Cleveland Clinic Florida, Weston, Florida
| | - Nazario Portolani
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Italy
| | - John Primrose
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Fernando Rotellar
- Department of General and Digestive Surgery, Clinica Universidad de Navarra, Pamplona, Spain
| | | | - Erik Schadde
- Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
- Division of Transplant Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Ajith K. Siriwardena
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, UK
| | - Sameer Smadi
- Department of Surgery, King Hussein Medical Center, Amman, Jordan
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Kenneth K. Tanabe
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Catherine S.C. Teh
- Section of Hepatobiliary Pancreatic Surgery, Surgical Oncology, and Minimally Invasive Surgery, St Luke’s Medical Center, Quezon City, Philippines
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, Italy
| | - Thomas M. Van Gulik
- Department of Surgery, AmsterdamUMC, University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Stephen J. Wigmore
- Department of Hepato-Pancreato-Biliary (HPB)/Transplant Surgery, The University of Edinburgh Clinical Surgery, Edinburgh, UK
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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