Use of Textbook Outcome as a Quality Metric in Hepatopancreaticobiliary Surgery: A Systematic Review and Meta-Analysis.

Abstract

Background: Textbook outcomes (TO) represent the optimal course following surgery. To date, no meta-analysis has assessed the pooled TO of patients undergoing hepato-pancreato-biliary (HPB) surgery and the impact of TO achievement on patient outcomes. We sought to conduct a systematic review and meta-analysis to assess TO achievement across different studies, as well as characterize the impact of the achievement of TO on patient related outcomes including the disease-free survival (DFS) and overall survival (OS) METHODS: PubMed, Embase, and Scopus databases were searched (1990-2024). The criteria used to define TO and the median overall TO in HPB surgery were obtained. Additionally, a random effect meta-analysis was conducted to assess the impact of TO achievement on 5-year OS and DFS.

Results: Seventy-two studies (517,304 patients) met inclusion criteria. The main criteria used to define TO included absence of re-admission and mortality within 30days after discharge; severe postoperative complications; prolonged hospital stay and negative surgical margin (R0). Of note, the main factors related with achievement of TO were younger patient age and lower American Society of Anesthesiologist score. Overall, median rate of TO achieved across procedures was hepatic-62.0% (IQR:48.0%-69.0%), biliary-54.0% (IQR: 41.0% - 68.0%), combined hepatopancreatic-46.0%(IQR:42.0%-46.5%), pancreatic- 45.0% (IQR:30.5% - 59.0%), liver transplantation-33.0% (IQR: 32.2%-34.0%) and combined hepatobiliary-19.5% (IQR: 16.8% - 22.3%). Achievement of TO was associated with improved odds of 5-year OS and DFS (OR: 1.22 (95% CI: 1.20-1.24) and 1.26 (95% CI: 1.16-1.37) respectively).

Conclusion: Overall, hepatic and biliary operations had the highest TO achievement followed by pancreatic procedures. In contrast, hepatobiliary surgery and liver transplantation had the lowest TO. There was significant discrepancy in TO definition across different studies highlighting the need for consensus on the definition of TO.