Determinants of Optimal Outcomes in Laparoscopic Liver Resection

Overview

This study validates the textbook outcome for laparoscopic liver surgery (TOLLS) in a Western tertiary center and identifies factors influencing its achievement. Analysis of 421 patients undergoing laparoscopic liver resection revealed key demographic, clinical, and operative determinants associated with optimal peri-operative outcomes.

Background

Laparoscopic liver surgery (LLS) has become a safe and feasible approach for treating benign and malignant liver diseases, offering advantages over open surgery such as reduced morbidity and shorter hospital stays. Surgical quality assessment in LLS is complex, as single outcome measures may not fully capture care quality. Composite measures like textbook outcome (TO) combine multiple peri-operative indicators to better reflect optimal surgical care, but a standardized TO definition for LLS has been lacking. This study applies a recently proposed TOLLS definition to a Western patient cohort to evaluate its validity and explore factors affecting its achievement.

Data Highlights

Key Findings

• Textbook outcome for laparoscopic liver surgery (TOLLS) was defined by absence of grade II/III intra-operative events, no severe post-operative complications (Clavien-Dindo ≥ III), no 30-day readmission, no in-hospital mortality, and R0 resection margins.
• An extended definition, TOLLS+, also includes length of hospital stay within the 75th percentile for the extent of resection.
• Factors analyzed included demographics, comorbidities, liver disease status, tumor characteristics, surgical complexity, and intra-operative parameters.
• Multivariate logistic regression identified significant predictors of achieving TOLLS and TOLLS+, highlighting the impact of patient selection and surgical factors on optimal outcomes.
• The study supports the use of TOLLS as a comprehensive quality indicator for laparoscopic liver surgery in Western tertiary centers.

Clinical Implications

The validated TOLLS definition provides a multidimensional quality metric that can guide clinical decision-making and benchmarking in laparoscopic liver surgery. Recognizing factors associated with achieving TOLLS may help optimize patient selection and peri-operative management to improve surgical outcomes. Incorporating length of hospital stay into outcome assessment (TOLLS+) further refines quality evaluation.

Conclusion

This study confirms the applicability of the TOLLS composite outcome measure in a Western tertiary center and identifies key determinants influencing optimal laparoscopic liver resection outcomes. TOLLS represents a valuable tool for quality assessment and improvement in hepatobiliary surgery.

References

1. Görcec et al. 2023 -- Definition and factors influencing textbook outcome in laparoscopic liver surgery
2. Oslo classification of intra-operative events
3. Clavien-Dindo classification of post-operative complications