Defining textbook outcome for distal pancreatectomy by systematic review. Is it clinically relevant?

A textbook outcome is a composite score of individual metrics that report an ideal outcome for a given surgery. The objectives of this study were to develop and validate a textbook outcome definition for distal pancreatectomy.

PubMed, Embase, and Web of Science databases were searched until October 1, 2024 for this systematic review, and studies that evaluated textbook outcome for distal pancreatectomy were selected. Textbook outcome metrics were chosen by data strength and validated by reviewing our institution's distal pancreatectomy database from 1999 to 2024. Univariate and multivariate analyses evaluated the association of 180-day mortality with clinical factors, textbook outcome definition, and iterations of the definition. Cumulative incidence method estimated time to adjuvant therapy in patients with adenocarcinoma based on textbook outcome achievement.

The systematic review included 10 studies. A textbook outcome was defined as no readmission or death within 90 days, length of stay <75th percentile, no Clavien-Dindo complication grade ≥III, and a negative margin. In our institution's database, textbook outcome frequency was 46.3% (n = 157/339). A textbook outcome was not associated with 180-day mortality; a major complication parameter was associated with 180-day mortality in multivariate analysis (odds ratio 0.04, P = .009). In patients with adenocarcinoma, time to adjuvant therapy was significantly shorter in patients with a textbook outcome (mean 1.47 months vs. 2.56 months, P < .001).

We present a definition for textbook outcome for distal pancreatectomy based on systematic review; the only parameter affecting 180-day mortality was a major complication. All parameters affected time to adjuvant therapy in adenocarcinoma. The definition of textbook outcome is not universally applicable and should be evaluated based on disease type.