Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 May 1;277(5):821-828.
doi: 10.1097/SLA.0000000000005668. Epub 2022 Aug 10.

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

Burak Görgec  1   2   3   4 , Andrea Benedetti Cacciaguerra  1   4   5 , Timothy M Pawlik  6 , Luca A Aldrighetti  7 , Adnan A Alseidi  8 , Umberto Cillo  9 , Norihiro Kokudo  10 , David A Geller  11 , Go Wakabayashi  12 , Horacio J Asbun  13 , Marc G Besselink  2   3 , Daniel Cherqui  14 , Tan To Cheung  15 , Pierre-Alain Clavien  16 , Claudius Conrad  17 , Mathieu D'Hondt  18 , Ibrahim Dagher  19 , Christos Dervenis  20 , John Devar  21   22 , Elijah Dixon  23 , Bjørn Edwin  24   25 , Mikhail Efanov  26 , Giuseppe M Ettore  27 , Alessandro Ferrero  28 , Constantino Fondevilla  29 , David Fuks  30 , Felice Giuliante  31 , Ho-Seong Han  32 , Goro Honda  33 , Oscar Imventarza  34   35 , David A Kooby  36 , Peter Lodge  37 , Santiago Lopez-Ben  38 , Marcel A Machado  39 , Hugo P Marques  40 , Nick O'Rourke  41 , Juan Pekolj  42 , Antonio D Pinna  43 , Nazario Portolani  44 , John Primrose  4 , Fernando Rotellar  45 , Andrea Ruzzenente  46 , Erik Schadde  47   48   49 , Ajith K Siriwardena  50 , Sameer Smadi  51 , Olivier Soubrane  52 , Kenneth K Tanabe  53 , Catherine S C Teh  54 , Guido Torzilli  55 , Thomas M Van Gulik  2   3 , Marco Vivarelli  5 , Stephen J Wigmore  56 , Mohammad Abu Hilal  1   4
Affiliations

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

Burak Görgec et al. Ann Surg. .

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.

PubMed Disclaimer

Figures

FIGURE 1
FIGURE 1
Flowchart of the Delphi process.
See this image and copyright information in PMC

References

    1. Dijs-Elsinga J, Otten W, Versluijs MM, et al. . Choosing a hospital for surgery: the importance of information on quality of care. Med Decis Making. 2010;30:544–555. - PubMed
    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;26:252–263. - PubMed
    1. Di Fabio F, Samim M, Di Gioia P, et al. . Laparoscopic major hepatectomies: clinical outcomes and classification. World J Surg. 2014;38:3169–3174. - PubMed
    1. 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;103:1504–1512. - PubMed
    1. 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;269:221–228. - PubMed

Publication types

LinkOut - more resources