ABSTRACT: TEXTBOOK OUTCOMES IN LIVER SURGERY: BREAKING THE MYTHS OF LOW-VOLUME CENTERS drrizwankhan@hotmail.com

 

ABSTRACT: TEXTBOOK OUTCOMES IN LIVER SURGERY: BREAKING THE MYTHS OF LOW-VOLUME CENTERS

2

 

 

 

 

Pakistan

Oral or Poster

Traditional quality assessment in liver surgery has focused on individual outcomes such as morbidity, mortality, hospital stay, and readmission. Textbook Outcomes in Liver Surgery (TOLS) is a novel composite measure that integrates multiple ideal surgical endpoints into a single indicator of success. While TOLS has been extensively studied in high-income countries, there is limited data from lower-middle income settings.

This study was conducted at a low-volume, tertiary care university hospital in Pakistan. We retrospectively analyzed 203 consecutive patients who underwent open liver surgery at Aga Khan University Hospital between January 2008 and December 2021. TOLS was assessed using a validated online calculator based on 7 parameters, including absence of: grade 2/3 intraoperative incidents, Clavien-Dindo grade III+ complications, 90-day readmission, grade B/C bile leak, grade B/C liver failure, in-hospital or 90-day mortality, and achievement of R0 resection.

The mean patient age was 54 years, with 56% being male. Cirrhosis was present in 33%, and 34% underwent major hepatic resections. TOLS was achieved in 76% of cases, including 73% of patients with hepatocellular carcinoma (HCC), 75% with biliary cancers, 82% with metastatic disease, and 79% with benign pathology. No case-mix adjustments were made. Multivariate analysis identified major resection, estimated blood loss >500 ml, and operative time >5 hours as predictors of failure to achieve TOLS. Age, gender, ASA class, and cirrhosis had no significant association.

TOLS is a meaningful, comprehensive quality metric. Our institution’s TOLS rates are comparable to global standards, despite being a low-volume center in a resource-limited setting.