Defining and predicting textbook outcomes in laparoscopic distal pancreatectomy

Laparoscopic distal pancreatectomy (LDP) has emerged as the preferred approach for both benign and malignant lesions located in the pancreatic body and tail. Nevertheless, a notable deficiency persists in the absence of a standardized, procedure-specific metric for evaluating and comparing surgical quality. A composite measure termed "textbook outcome (TO)", which encompasses key short-term endpoints, has been validated in laparoscopic pancreatoduodenectomy but has not yet been established in dedicated LDP cohorts. The definition and prediction of TO in this context could aid in facilitating cross-institutional benchmarking and fostering advancements in quality improvement.

To establish procedure-specific criteria for TO and identify independent predictors of TO failure in patients undergoing LDP.

Consecutive patients who underwent LDP at a single high-volume pancreatic center between January 2015 and August 2022 were retrospectively analyzed. TO was defined as the absence of clinically relevant postoperative pancreatic fistula (grade B/C), post-pancreatectomy hemorrhage (grade B/C), severe complications (Clavien-Dindo ≥ III), readmission within 30 days, and in-hospital or 30-day mortality. Multivariable logistic regression was employed to identify independent predictors of TO failure, and a nomogram was constructed and internally validated.

Among 405 eligible patients, 286 (70.6%) attained TO. Multivariable analysis revealed that female sex [odds ratio (OR) = 0.62, 95% confidence interval (CI): 0.39-0.99] conferred a protective effect, while preoperative endoscopic ultrasound-guided fine-needle aspiration (OR = 2.66, 95%CI: 1.05-6.73), pancreatic portal hypertension (OR = 2.81, 95%CI: 1.06-7.45), and cystic-solid (OR = 2.51, 95%CI: 1.34-4.69) or solid lesions (OR = 1.91, 95%CI: 1.06-3.44) were independently associated with TO failure (all P < 0.05). The derived nomogram exhibited modest discrimination and calibration when assessed in both the training and validation datasets.

The proposed LDP-specific definition of TO is feasible and discriminative, and the developed nomogram provides an objective tool for individualized risk assessment.