Defining and predicting textbook outcomes for perihilar cholangiocarcinoma: analysis of factors improving of achievement of desired post-operative outcomes. retrospective cohort study

Abstract

Background: Definition of Textbook Outcome (TO), defined as a single indicator combining the most advantageous short-term outcomes, is still lacking for Perihilar Cholangiocarcinoma (PHC). The primary endpoint of the present study is to analyse the rate of achievement of a disease-specific textbook outcome for peri-hilar cholangiocarcinoma within a high volume tertiary referral center. Secondary endpoints are to identify predictive factors of TO achievement and to analyze the impact of achieving textbook outcome on long-term results. Methods: Between 2010 and 2022, a total of 237 patients undergoing combined liver and biliary resection for PHC at tertiary referral center were included. Disease-specific TO were defined as: no 90-days mortality, no postoperative complications, no readmission, no intraoperative transfusions and R0 margins. A logistic regression model was developed to identify predictors associated with TO achievement. Kaplan-Meier curves were designed to determine TO’s impact on survival. Results: TO was achieved in 60 (25.3%) patients. At multivariate logistic regression, preoperative biliary drainage (OR 2.90 (1.13 – 3.40), P=0.026), high prognostic nutritional index (OR 7.11 (6.71 – 9.43), P=0.007) and minimally-invasive approach (OR 3.57 (2.31 – 3.62), P=0.013) were identified as independent predictors of TO. High ASA score (OR 0.38 (0.17 – 0.82), P=0.013) decreased the odds of TO. A significant improvement in both overall survival and disease-free survival was associated to TO fulfilment. Conclusion: Since the achievement of textbook outcome correlates with better disease-free and overall survival, every effort should be made to ameliorate modifiable aspects prior to surery: management within referral centers with dedicated experience in biliary tract cancer and preoperative optimization protocol may positively contribute to improve postoperative outcomes, increasing the chance to obtain TO. Moreover, the implementation of advanced minimally invasive programs plays as well.