Textbook outcomes in liver surgery for gallbladder cancer patients treated with curative-intent resection: a multicenter observational study

Abstract

Background: Cholecystectomy, hepatectomy, and lymphadenectomy are recommended as the curative treatment for resectable gallbladder cancer (GBC). Textbook outcomes in liver surgery (TOLS) is a novel composite measure that has been defined by expert consensus to represent the optimal postoperative course after hepatectomy. This study aimed to determine the incidence of TOLS and the independent predictors associated with TOLS after curative-intent resection in GBC patients.

Methods: All consecutive GBC patients who underwent curative-intent resection between 2014 and 2020 were enrolled from a multicenter database from 11 hospitals as the training and the internal testing cohorts, and Southwest Hospital as the external testing cohort. TOLS was defined as no intraoperative grade greater than or equal to 2 incidents, no grade B/C postoperative bile leaks, no postoperative grade B/C liver failure, no 90-day postoperative major morbidity, no 90-day readmission, no 90-day mortality after hospital discharge, and R0 resection. Independent predictors of TOLS were identified using logistic regression and were used to construct the nomogram. The predictive performance was assessed using the area under the curve and calibration curves.

Results: TOLS was achieved in 168 patients (54.4%) and 74 patients (57.8%) from the training and internal testing cohorts, and the external testing cohort, respectively. On multivariate analyses, age less than or equal to 70 years, absence of preoperative jaundice (total bilirubin≤3 mg/dl), T1 stage, N0 stage, wedge hepatectomy, and no neoadjuvant therapy were independently associated with TOLS. The nomogram that incorporated these predictors demonstrated excellent calibration and good performance in both the training and external testing cohorts (area under the curve: 0.741 and 0.726).

Conclusions: TOLS was only achieved in approximately half of GBC patients treated with curative-intent resection, and the constructed nomogram predicted TOLS accurately.

Graphical abstract

Figure 1

Patient selection for GBC. GBC, gallbladder cancer; TOLS, Textbook outcomes in Liver Surgery.

Figure 2

Distribution of TOLS for GBC from the training cohort.

Figure 3

Nomogram for predicting TOLS in GBC treated with curative-intent resection patients. TB, total bilirubin; TOLS, Textbook outcome in liver surgery.

Figure 4

Applicability verified using calibration and ROC curve of the model in the training (A and C) and test (B and D) cohorts. AJCC, American Joint Committee on Cancer; AUC, area under the curve.

Figure 5

Model applicability compared with the 8th AJCC stage using receiver operating characteristic ROC curve and decision curve analysis in the training (A and C) and test (B and D) cohorts. AJCC, American Joint Committee on Cancer; AUC, area under the curve.