Textbook outcome after hepatoblastoma resection: Definition, failure modes, and risk-adjusted benchmarking in a tertiary European center.

BACKGROUND

Textbook Outcome (TO) has emerged as a composite quality metric for benchmarking perioperative performance in adult hepatobiliary surgery. Its role in pediatric oncologic liver surgery remains insufficiently explored and TO has never been defined for hepatoblastoma resection.

METHODS

Single-center cohort study including children undergoing curative-intent liver resection for hepatoblastoma. Textbook Outcome after hepatoblastoma resection (TO-HB) was defined as an all-or-none composite comprising: (i) no postoperative complications (CCI = 0), (ii) no prolonged length of stay (≤procedure-specific 75th-percentile), (iii) no reoperation within 90 days, (iv) no unplanned readmission within 90 days, and (v) no 90-day mortality. Case-mix adjustment was performed using ridge-penalized logistic regression with pre-specified covariates. Model performance was evaluated in terms of overall accuracy and calibration, including the Brier score and calibration-in-the-large, with bootstrap internal validation, to support risk-adjusted benchmarking analyses.

RESULTS

TO-HB was achieved in 60/108 patients (55.6%). Failure to achieve TO-HB was predominantly driven by postoperative complications (38/48; 79%) and prolonged length of stay (18/48; 38%). TO-HB rates decreased with increasing surgical complexity, including higher PRETEXT stage and more extensive hepatectomy types. Risk-adjusted predictions were narrowly distributed around the overall TO rate (mean predicted probability 0.556), with preserved population-level calibration. The observed-to-expected ratio for TO-HB was 1.00, corresponding to a risk-standardized TO-HB rate of 55.6% (95% CI 42.4-71.5%).

CONCLUSIONS

TO-HB is a feasible and stringent benchmark for perioperative quality in hepatoblastoma surgery. Failure to achieve TO-HB is predominantly driven by postoperative morbidity rather than mortality or reintervention, highlighting postoperative complications as target for quality improvement.