Association between the Achievement of Textbook Outcomes in Liver Surgery (TOLS) and Overall Survival in Perihilar Cholangiocarcinoma Patients Following Major Hepatectomy: A Multicenter Study

Introduction Major hepatectomy is the mainstay of curative-intent resection for perihilar cholangiocarcinoma (pCCA) patients. Textbook Outcomes in Liver Surgery (TOLS) are a new composite parameter for evaluating the short-term outcomes of surgery; however, their association with overall survival (OS) is unknown. Therefore, this study aimed to investigate the association between TOLS and OS in pCCA patients following major hepatectomy. Methods Consecutive pCCA patients who underwent major hepatectomy between 2014 and 2020 at 5 hospitals were included in this analysis. TOLS were defined as no intraoperative grade ≥ 2 incidents, no postoperative grade B/C bile leakage, no postoperative grade B/C liver failure, no postoperative major morbidity, no readmission within 90 days due to surgery-related major morbidity, no mortality within 90 days after hospital discharge, and R0 resection. The Kaplan‒Meier method was used to compare OS rates between patients who achieved TOLS and those who did not. Cox regression analysis was used to identify independent risk factors for poor OS. Results In total, 399 patients were included in this study, 214 (53.6%) of whom achieved TOLS. After excluding patients who died within 90 days, the 5-year OS rate of patients who achieved TOLS were significantly greater than that of patients who did not achieve TOLS (5-year OS rate: 26.2% vs. 17.3%, P=0.001). TOLS were independently associated with OS for pCCA patients following major hepatectomy. Conclusions TOLS were achieved in approximately half of the pCCA patients following major hepatectomy, and the patients who achieved TOLS had better survival.