Textbook outcome in hepato-pancreato-biliary surgery: systematic review

Abstract

Background: Textbook outcome (TO) is a multidimensional measure reflecting the ideal outcome after surgery. As a benchmarking tool, it provides an objective overview of quality of care. Uniform definitions of TO in hepato-pancreato-biliary (HPB) surgery are missing. This study aimed to provide a definition of TO in HPB surgery and identify obstacles and predictors for achieving it.

Methods: A systematic literature search was conducted using PubMed, Embase, and Cochrane Database according to PRISMA guidelines. Studies published between 1993 and 2021 were retrieved. After selection, two independent reviewers extracted descriptive statistics and derived summary estimates of the occurrence of TO criteria and obstacles for achieving TO using co-occurrence maps.

Results: Overall, 30 studies were included. TO rates ranged between 16-69 per cent. Commonly chosen co-occurring criteria to define TO included 'no prolonged length of stay (LOS)', 'no complications', 'no readmission', and 'no deaths'. Major obstacles for achieving TO in HPB surgery were prolonged LOS, complications, and readmission. On multivariable analysis, TO predicted better overall and disease-free survival in patients with cancer. Achievement of TO was more likely in dedicated centres and associated with procedural and structural indicators, including high case-mix index and surgical volume.

Conclusion: TO is a useful quality measure to benchmark surgical outcome. Future definitions of TO in HPB surgery should include 'no prolonged LOS', 'no complications', 'no readmission', and 'no deaths'.

Fig. 1

Flow chart of literature selection strategy

Fig. 2

Definition of textbook outcome Co-occurrence maps visualizing how many times each TO criterion was examined in the context of all other criteria across studies. TO criteria are shown along the x and y axis, with matrix values (and tile colours) indicating the amount of co-occurrence. a All HPB studies, similar TO criteria were grouped into summary variables: ‘no prolonged LOS’ (summarizing: no prolonged LOS in either the 50th or 75th percentile), ‘no readmission’ (30 days, 90 days, any), ‘no deaths’ (30 days, 90 days, in-hospital, any), ‘no complications’ (three or more, any), and ‘no bile leak’ (grade B/C, any), b All HPB studies, similar TO criteria are all shown individually, c Studies focusing on pancreatic cancer only. d Studies focusing on hepatobiliary malignancies only. HPB, hepato-pancreato-biliary; TO, textbook outcome; CTx, chemotherapy; LOS, length of stay; POPF, postoperative pancreatic fistula; PPH, post-pancreatectomy haemorrhage.

Fig. 2

Definition of textbook outcome Co-occurrence maps visualizing how many times each TO criterion was examined in the context of all other criteria across studies. TO criteria are shown along the x and y axis, with matrix values (and tile colours) indicating the amount of co-occurrence. a All HPB studies, similar TO criteria were grouped into summary variables: ‘no prolonged LOS’ (summarizing: no prolonged LOS in either the 50th or 75th percentile), ‘no readmission’ (30 days, 90 days, any), ‘no deaths’ (30 days, 90 days, in-hospital, any), ‘no complications’ (three or more, any), and ‘no bile leak’ (grade B/C, any), b All HPB studies, similar TO criteria are all shown individually, c Studies focusing on pancreatic cancer only. d Studies focusing on hepatobiliary malignancies only. HPB, hepato-pancreato-biliary; TO, textbook outcome; CTx, chemotherapy; LOS, length of stay; POPF, postoperative pancreatic fistula; PPH, post-pancreatectomy haemorrhage.

Fig. 3

Components of textbook outcome and percentages reached Overview of criteria chosen to define TO within each study with percentages of patients reaching each component (studies with missing data are not included). The colour gradient highlights that the major obstacles for achieving TO across all studies were ‘prolonged LOS’, ‘complications’, and ‘readmission’. LOS, length of stay; read, readmission; mort, deaths; comp, complication; transf, transfusion; LAE, lymphadenectomy; adj CTx, adjuvant chemotherapy; POPF, postoperative pancreatic fistula; PPH, post-pancreatectomy haemorrhage; TO, textbook outcome.

Fig. 4

Multivariate contributors to textbook outcome For ease of interpretation, negative (OR less than 1), indicated in blue, a and positive (OR higher than 1, indicated in red, b contributors are visualized using word clouds. The size of each word/term reflects the strength of its (negative/positive) contribution to TO. Specifically, weak and strong contributions are represented by small and large font. To indicate the relevance of each contributor to achieving TO in the context of a particular diagnosis, we added diagnostic labels in parentheses following terms (where applicable). L, hepatic surgery; HP, hepatobiliary surgery; PD, pancreatoduodenectomy; TO, textbook outcome; ALBI, albumin-bilirubin; ICC, intrahepatic cholangiocarcinoma; MELD, Model for End-Stage Liver Disease; CMI, case-mix index; SVI, social-vulnerability index; CTx, chemotherapy; BCLC, Barcelona Clinic Liver Cancer; PDAC, pancreatic ductal adenocarcinoma.