TEXTBOOK OUTCOME can be achieved in more than one-third of patients undergoing highly complex liver surgery with vascular reconstruction, according to an international multi-centre analysis from 22 expert hepatobiliary centres. The findings suggest favourable perioperative outcomes are achievable even in technically demanding resections performed in specialised units.
Liver resection with vascular reconstruction involves surgery on major vessels including the portal vein, hepatic veins, hepatic artery and inferior vena cava. These procedures are among the most technically demanding operations in hepatobiliary surgery because they combine extensive tumour resection with complex vascular repair or reconstruction.
Textbook Outcome Rates Highlight Surgical Feasibility
Textbook Outcome is a composite measure increasingly used to evaluate surgical quality. It was defined as the absence of intraoperative or major postoperative complications such as bile leak, post-hepatectomy liver failure, 90-day mortality, or unplanned readmission.
Among 426 adults included in the retrospective cohort, 155 patients (36.4%) achieved a Textbook Outcome. In the subgroup of 277 patients requiring vascular grafts, the rate was 32.5%.
Patients achieving a Textbook Outcome generally had lower tumour burden and less advanced disease features. They were less likely to have intrahepatic cholangiocarcinoma, hepatic vein involvement, or the need for extracorporeal bypass. They also more frequently underwent in-situ resections.
Operative Complexity Linked to Poorer Outcomes
The analysis identified several operative factors linked with failure to achieve a Textbook Outcome. Blood transfusion, lymphadenectomy, and use of synthetic vascular grafts were all associated with lower odds of success on multivariable analysis.
By contrast, use of the Pringle manoeuvre – temporary clamping of hepatic inflow to reduce blood loss during resection – was linked with a greater likelihood of achieving Textbook Outcome. Shorter vascular occlusion times also appeared beneficial, supporting the idea that limiting operative invasiveness may improve perioperative recovery.
The Textbook Outcome group also experienced significantly shorter operative times, lower blood loss, and fewer transfusions.
Findings May Inform Patient Selection and Benchmarking
It is important to note that patients who achieved optimal outcomes tended to have lower tumour burden and fewer advanced oncological features, suggesting that case selection remains a key determinant of success even in high-volume centres.
The authors concluded that integrating Textbook Outcome metrics into future hepatobiliary surgery protocols could help improve patient selection, operative planning, and quality benchmarking for advanced liver resections involving vascular reconstruction.
Reference
Lopez-Lopez V et al. Predictors of textbook outcomes in liver resection with vascular reconstruction: an international multicenter study. Hepatobiliary Surg Nutr. 2026;DOI:0.21037/hbsn-2026-1-0080.
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