• Burak Görgec, Andrea Benedetti Cacciaguerra, Timothy M Pawlik, Luca A Aldrighetti, Adnan A 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, Mikhail Efanov, Giuseppe M Ettore, Alessandro Ferrero, Constantino Fondevilla, David Fuks, Felice Giuliante, Ho-Seong Han, Goro Honda, Oscar Imventarza, David A Kooby, Peter Lodge, Santiago Lopez-Ben, Marcel A Machado, Hugo P Marques, Nick O'Rourke, Juan Pekolj, Antonio D Pinna, Nazario Portolani, John Primrose, Fernando Rotellar, Andrea Ruzzenente, Erik Schadde, Ajith K Siriwardena, Sameer Smadi, Olivier Soubrane, Kenneth K Tanabe, Catherine S C Teh, Guido Torzilli, Thomas M Van Gulik, Marco Vivarelli, Stephen J Wigmore, and Mohammad Abu Hilal.
• Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy.
• Ann. Surg. 2023 May 1; 277 (5): 821828821-828.

ObjectiveTo 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.BackgroundTextbook 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.MethodsThis 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.ResultsIn 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.ConclusionsThis 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.Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.

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