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
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.
Summary background data: 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. 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 three 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 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.