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

Abstract

We read with great interest the article by Görgec et al.1 This is the first study to provide an international expert consensus-based definition of the textbook outcome in liver surgery (TOLS) for laparoscopic and open hepatectomy using a formal Delphi consensus approach. TOLS is considered a comprehensive patient-centered outcome that represented the optimal short-term outcome for patients treated with hepatectomy. In addition, TOLS is useful in evaluating patient-level surgical quality and hospital performance and in carrying out comparisons between institutions with different clinical practices to further improve patient-level outcomes. Despite inspiring and thought-provoking, we have the following comments. First, the initial survey comprised 6 surgical domains with a total of 19 questions on individual surgical outcome variables. However, there was no patient involvement in the process of defining TOLS. All the individual outcomes included in TOLS were developed and voted on by surgical specialists. We believe that TOLS is necessary to be defined and applied not only from the perspective of surgeons but also from patients. The lack of patient involvement in the formulation process may result in the new definition of TOLS failing to provide a comprehensive summary of the quality of patient-centered hospital care. In a previous study, which defined the core outcome set after hepatobiliary surgery, it was found that how patients felt after surgery matters.2 For example, the pain after surgery could make patients feel that the surgery did not achieve the minimum set of outcomes. Unfortunately, in the study by Görgec et al,1 patients were not given the opportunity to express their opinions and participate in the definition of TOLS. Second, the surgical outcomes included in the authors’ original questionnaire are not comprehensive enough. These outcomes focus only on the surgical field and do not differ much from the definitions of textbook outcome that were reported previously, such as the absence of postoperative complications, mortality, readmissions, and the presence of negative surgical margins.3,4 In my opinion, the humanistic needs of patients treated with hepatectomy also deserve equal attention, such as quality of life, satisfaction, etc. If the authors could enroll and deeply analyze all previously reported short-term outcomes of patients treated with hepatectomy at the beginning of designing the questionnaire, rather than just from the perspective of surgery, it may be possible to improve the comprehensiveness of TOLS. Finally, we are very appreciative of Görgec et al1 for the development of such a new comprehensive outcome, TOLS, for all patients treated with hepatectomy. Compared with the previous definitions of textbook outcome after hepatectomy, I believe that TOLS is more convincing and contributes to further improvement of patient outcomes.