Rate of 'Textbook Outcomes' in Curative-Intent Resection of Intrahepatic Cholangiocarcinoma


Key Points

  • Overall, 30-day mortality occurred in < 5% of patients.
  • Textbook outcomes were achieved in 26% of patients, with prolonged hospital stay having the greatest negative association with such outcome.

In a multi-institutional international analysis reported in JAMA Surgery, Merath et al found that a textbook outcome was achieved in a minority of patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma.

Study Details

The study involved data on 687 patients from 15 major hepatobiliary centers in North America, Europe, Australia, and Asia who underwent curative-intent resection of intrahepatic cholangiocarcinoma between 1993 and 2015. Textbook outcome was defined as negative margins, no perioperative transfusion, no postoperative surgical complications, no prolonged length of stay, no 30-day readmissions, and no 30-day mortality.

Textbook Outcomes

A textbook outcome was achieved in 175 patients (25.5%). On multivariate analysis, factors significantly associated with achieving a textbook outcome were: age ≤ 60 years (odds ratio [OR] = 1.61, P = .03); absence of preoperative jaundice (OR = 4.40, P = .02); no neoadjuvant chemotherapy (OR = 2.57, P = .04); T1a/T1b-stage disease (OR = 1.58, P = .049 vs T2-, T3-, or T4-stage); N0 status (OR = 3.89, P = .001); and no bile duct resection (OR = 2.46, P = .009).

For the components of textbook outcome, no 30-day mortality was achieved in 95.6% of patients, negative surgical margins in 85.0%, and no perioperative transfusions in 70.9%; whereas lower percentages of patients had no postoperative surgical complications (57.9%) and no prolonged length of hospital stay (51.8%). Prolonged length of stay had the greatest negative association with textbook outcome.

The investigators concluded, “In this study, while hepatic resection for intrahepatic cholangiocarcinoma was performed with less than 5% mortality in specialized centers, a textbook outcome was achieved in only approximately 26% of patients. A textbook outcome may be useful for the reporting of patient-level hospital performance and hospital variation, leading to quality improvement efforts after resection of intrahepatic cholangiocarcinoma.”

Timothy M. Pawlik, MD, MPH, PhD, of The Ohio State University Wexner Medical Center, is the corresponding author for the JAMA Surgery article.

Disclosure: For full disclosures of the study authors, visit

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.