Use of textbook outcome as a quality metric in hepatopancreaticobiliary surgery: a systematic review and meta-analysis

Background: Textbook outcomes (TOs) represent the optimal course after surgery. To date, no meta- analysis has assessed the pooled TOs of patients undergoing hepatopancreatobiliary (HPB) surgery and the effect of TO achievement on patient outcomes. This systematic review and meta-analysis aimed to assess TO achievement across different studies and to characterize the effect of TO achievement on patient-related outcomes, including 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. In addition, a random-effects meta-analysis was conducted to assess the effect of TO achievement on 5-year OS and DFS. Results: A total of 27 studies involving 517,304 patients met inclusion criteria. The main criteria used to define TO included absence of readmission and mortality within 30 days after discharge, severe postoperative complications, prolonged hospital stay, and negative surgical margin (R0). Of note, the main factors related to TO achievement were younger patient age and lower American Society of Anesthesiologists score. Overall, the median rates of TOs achieved across procedures were 62.0% (IQR, 48.0%-69.0%) for hepatic procedure, 54.0% (IQR, 41.0%-68.0%) for biliary procedure, 46.0% (IQR, 42.0%-46.5%) for combined hepatopancreatic procedure, 45.0% (IQR, 30.5%-59.0%) for pancreatic procedure, 33.0% (IQR, 32.2%-34.0%) for liver transplantation, and 19.5% (IQR, 16.8%-22.3%) for combined hepatobiliary procedure. TO achievement was associated with improved odds of 5-year OS (odds ratio [OR], 1.22 [95% CI, 1.20-1.24]) and 5-year DFS (OR, 1.26 [95% CI, 1.16-1.37]). 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 a significant discrepancy in the definition of TO across different studies, highlighting the need for consensus on the definition of TO. (c) 2025 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.