An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS)
Burak Görgeç, Andrea Benedetti Cacciaguerra, Timothy M. Pawlik, Luca Aldrighetti, Adnan Alseidi, Umberto Cillo, Norihiro Kokudo, David A. Geller, Go Wakabayashi, Horacio J. Asbun, Marc G. Besselink, Daniel Cherqui, Tan To Cheung, Pierre‐Alain Clavien, Claudius Conrad, Mathieu D’Hondt, Ibrahim Dagher, Christos Dervenis, John Devar, Elijah Dixon, Bjørn Edwin, Михаил Ефанов, Giuseppe Ettore, Alessandro Ferrero, Constantino Fondevilla, David Fuks, Felice Giuliante, Ho‐Seong Han, Goro Honda, Oscar Imventarza, David A. Kooby, P. Lodge, Santiago López‐Ben, Marcel Autran C. Machado, Hugo P. Marques, Nick O’Rourke, Juan Pekolj, Antonio Daniele Pinna, Nazario Portolani, John Primrose, Fernando Rotellar, Andrea Ruzzenente, Erik Schadde, Ajith K. Siriwardena, Sameer Smadi, Olivier Soubrane, Kenneth K. Tanabe, Catherine Teh, Guido Torzilli, Thomas M. van Gulik, Marco Vivarelli, Stephen J. Wigmore, Mohammad Abu Hilal
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.