Department of Gastrointestinal and Hepatobiliary Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India.
Department of Biostatistics, The Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India.
Ann Surg Oncol. 2024 Nov;31(12):7870-7881. doi: 10.1245/s10434-024-15983-6. Epub 2024 Aug 5.
'Textbook Outcome' (TO) represents an effort to define a standardized, composite quality benchmark based on intraoperative and postoperative endpoints. This study aimed to assess the applicability of TO as an outcome measure following liver resection for hepatic neoplasms from a low- to middle-income economy and determine its impact on long-term survival. Based on identified perioperative predictors, we developed and validated a nomogram-based scoring and risk stratification system.
We retrospectively analyzed patients undergoing curative resections for hepatic neoplasms between 2012 and 2023. Rates of TO were assessed over time and factors associated with achieving a TO were evaluated. Using stepwise regression, a prediction nomogram for achieving TO was established based on perioperative risk factors.
Of the 1018 consecutive patients who underwent liver resections, a TO was achieved in 64.9% (661/1018). The factor most responsible for not achieving TO was significant post-hepatectomy liver failure (22%). Realization of TO was independently associated with improved overall and disease-free survival. On logistic regression, American Society of Anesthesiologists score of 2 (p = 0.0002), perihilar cholangiocarcinoma (p = 0.011), major hepatectomy (p = 0.0006), blood loss >1500 mL (p = 0.007), and presence of lymphovascular emboli on pathology (p = 0.026) were associated with the non-realization of TO. These independent risk factors were integrated into a nomogram prediction model with the predictive efficiency for TO (area under the curve 75.21%, 95% confidence interval 70.69-79.72%).
TO is a realizable outcome measure and should be adopted. We recommend the use of the nomogram proposed as a convenient tool for patient selection and prognosticating outcomes following hepatectomy.
“教科书结局”（Textbook Outcome，TO）旨在基于术中及术后终点定义标准化的综合质量基准。本研究旨在评估 TO 在中低收入经济体肝肿瘤切除术后作为结局指标的适用性，并确定其对长期生存的影响。基于已确定的围手术期预测因素，我们开发并验证了基于列线图的评分和风险分层系统。
我们回顾性分析了 2012 年至 2023 年间接受肝肿瘤根治性切除术的患者。评估了 TO 的发生率，并评估了实现 TO 的相关因素。使用逐步回归，基于围手术期危险因素建立了实现 TO 的预测列线图。
在 1018 例连续接受肝切除术的患者中，64.9%（661/1018）实现了 TO。未能实现 TO 的主要原因是肝切除术后肝功能衰竭（22%）。实现 TO 与改善总生存和无病生存独立相关。在逻辑回归中，美国麻醉医师协会评分 2 分（p=0.0002）、肝门部胆管癌（p=0.011）、广泛肝切除术（p=0.0006）、出血量>1500mL（p=0.007）和病理学上存在血管淋巴管侵犯（p=0.026）与未能实现 TO 相关。这些独立的危险因素被整合到一个列线图预测模型中，用于预测 TO 的效率（曲线下面积 75.21%，95%置信区间 70.69%-79.72%）。
TO 是一个可实现的结局指标，应予以采用。我们建议使用所提出的列线图作为患者选择和预测肝切除术后结局的便利工具。
