An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS)

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; Mohammad Abu Hilal

doi:https://doi.org/10.1097/SLA.0000000000005668

An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS)

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 DixonBjørn 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, Mohammad Abu Hilal

Research output: Contribution to journal › Article › Academic › peer-review

18 Citations (Scopus)

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.

Original language	English
Pages (from-to)	821-828
Number of pages	8
Journal	Annals of surgery
Volume	277
Issue number	5
DOIs	https://doi.org/10.1097/SLA.0000000000005668
Publication status	Published - 1 May 2023

Keywords

composite measure
laparoscopic liver surgery
liver surgery
minimally invasive liver surgery
patient outcome
quality of care
robotic liver surgery
textbook outcome

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https://doi.org/10.1097/SLA.0000000000005668

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Görgec, B., Benedetti Cacciaguerra, A., Pawlik, T. M., Aldrighetti, L. A., Alseidi, A. A., Cillo, U., Kokudo, N., Geller, D. A., Wakabayashi, G., Asbun, H. J., Besselink, M. G., Cherqui, D., Cheung, T. T., Clavien, P. A., Conrad, C., D'Hondt, M., Dagher, I., Dervenis, C., Devar, J., ... Abu Hilal, M. (2023). An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS). Annals of surgery, 277(5), 821-828. https://doi.org/10.1097/SLA.0000000000005668

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title = "An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS)",

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.",

keywords = "composite measure, laparoscopic liver surgery, liver surgery, minimally invasive liver surgery, patient outcome, quality of care, robotic liver surgery, textbook outcome",

author = "Burak G{\"o}rgec and {Benedetti Cacciaguerra}, Andrea and Pawlik, {Timothy M.} and Aldrighetti, {Luca A.} and Alseidi, {Adnan A.} and Umberto Cillo and Norihiro Kokudo and Geller, {David A.} and Go Wakabayashi and Asbun, {Horacio J.} and Besselink, {Marc G.} and Daniel Cherqui and Cheung, {Tan To} and Clavien, {Pierre Alain} and Claudius Conrad and Mathieu D'Hondt and Ibrahim Dagher and Christos Dervenis and John Devar and Elijah Dixon and Bj{\o}rn Edwin and Mikhail Efanov and Ettore, {Giuseppe M.} and Alessandro Ferrero and Constantino Fondevilla and David Fuks and Felice Giuliante and Han, {Ho Seong} and Goro Honda and Oscar Imventarza and Kooby, {David A.} and Peter Lodge and Santiago Lopez-Ben and MacHado, {Marcel A.} and Marques, {Hugo P.} and Nick O'Rourke and Juan Pekolj and Pinna, {Antonio D.} and Nazario Portolani and John Primrose and Fernando Rotellar and Andrea Ruzzenente and Erik Schadde and Siriwardena, {Ajith K.} and Sameer Smadi and Olivier Soubrane and Tanabe, {Kenneth K.} and Teh, {Catherine S.C.} and Guido Torzilli and {Van Gulik}, {Thomas M.} and Marco Vivarelli and Wigmore, {Stephen J.} and {Abu Hilal}, Mohammad",

year = "2023",

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day = "1",

doi = "https://doi.org/10.1097/SLA.0000000000005668",

language = "English",

volume = "277",

pages = "821--828",

journal = "Annals of surgery",

issn = "0003-4932",

publisher = "Lippincott Williams and Wilkins",

number = "5",

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Görgec, B, Benedetti Cacciaguerra, A, Pawlik, TM, Aldrighetti, LA, Alseidi, AA, Cillo, U, Kokudo, N, Geller, DA, Wakabayashi, G, Asbun, HJ, Besselink, MG, Cherqui, D, Cheung, TT, Clavien, PA, Conrad, C, D'Hondt, M, Dagher, I, Dervenis, C, Devar, J, Dixon, E, Edwin, B, Efanov, M, Ettore, GM, Ferrero, A, Fondevilla, C, Fuks, D, Giuliante, F, Han, HS, Honda, G, Imventarza, O, Kooby, DA, Lodge, P, Lopez-Ben, S, MacHado, MA, Marques, HP, O'Rourke, N, Pekolj, J, Pinna, AD, Portolani, N, Primrose, J, Rotellar, F, Ruzzenente, A, Schadde, E, Siriwardena, AK, Smadi, S, Soubrane, O, Tanabe, KK, Teh, CSC, Torzilli, G, Van Gulik, TM, Vivarelli, M, Wigmore, SJ & Abu Hilal, M 2023, 'An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS)', Annals of surgery, vol. 277, no. 5, pp. 821-828. https://doi.org/10.1097/SLA.0000000000005668

TY - JOUR

T1 - An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS)

AU - Görgec, Burak

AU - Benedetti Cacciaguerra, Andrea

AU - Pawlik, Timothy M.

AU - Aldrighetti, Luca A.

AU - Alseidi, Adnan A.

AU - Cillo, Umberto

AU - Kokudo, Norihiro

AU - Geller, David A.

AU - Wakabayashi, Go

AU - Asbun, Horacio J.

AU - Besselink, Marc G.

AU - Cherqui, Daniel

AU - Cheung, Tan To

AU - Clavien, Pierre Alain

AU - Conrad, Claudius

AU - D'Hondt, Mathieu

AU - Dagher, Ibrahim

AU - Dervenis, Christos

AU - Devar, John

AU - Dixon, Elijah

AU - Edwin, Bjørn

AU - Efanov, Mikhail

AU - Ettore, Giuseppe M.

AU - Ferrero, Alessandro

AU - Fondevilla, Constantino

AU - Fuks, David

AU - Giuliante, Felice

AU - Han, Ho Seong

AU - Honda, Goro

AU - Imventarza, Oscar

AU - Kooby, David A.

AU - Lodge, Peter

AU - Lopez-Ben, Santiago

AU - MacHado, Marcel A.

AU - Marques, Hugo P.

AU - O'Rourke, Nick

AU - Pekolj, Juan

AU - Pinna, Antonio D.

AU - Portolani, Nazario

AU - Primrose, John

AU - Rotellar, Fernando

AU - Ruzzenente, Andrea

AU - Schadde, Erik

AU - Siriwardena, Ajith K.

AU - Smadi, Sameer

AU - Soubrane, Olivier

AU - Tanabe, Kenneth K.

AU - Teh, Catherine S.C.

AU - Torzilli, Guido

AU - Van Gulik, Thomas M.

AU - Vivarelli, Marco

AU - Wigmore, Stephen J.

AU - Abu Hilal, Mohammad

PY - 2023/5/1

Y1 - 2023/5/1

N2 - 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.

AB - 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.

KW - composite measure

KW - laparoscopic liver surgery

KW - liver surgery

KW - minimally invasive liver surgery

KW - patient outcome

KW - quality of care

KW - robotic liver surgery

KW - textbook outcome

UR - http://www.scopus.com/inward/record.url?scp=85141300072&partnerID=8YFLogxK

U2 - https://doi.org/10.1097/SLA.0000000000005668

DO - https://doi.org/10.1097/SLA.0000000000005668

M3 - Article

C2 - 35946822

SN - 0003-4932

VL - 277

SP - 821

EP - 828

JO - Annals of surgery

JF - Annals of surgery

IS - 5

ER -

An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS)

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