Textbook outcome in liver surgery after staged versus simultaneous resection for synchronous colorectal liver metastases

Background: We sought to define the likelihood of textbook outcome in liver surgery (TOLS) among patients undergoing simultaneous versus staged resection for sCRLM. Methods: Patients with sCRLM who underwent curative-intent resection between 2000-2022 were identified from an international multi-institutional database. TOLS was defined by the absence of intraoperative grade >= 2 events, R1 resection margin, post-hepatectomy liver failure, bile leakage, major postoperative complications, in-hospital/90-day mortality, and 90-day readmission. Multivariable regression was utilized to study associations between surgical approach and TOLS. Results: Among 897 patients with median age of 62 (IQR 55-69) years, 376 (41.9 %) patients underwent synchronous resection whereas 521 (58.1 %) patients had staged resection of sCRLM. 62.8 % of patients had TOLS following sCRLM resection and patients who underwent staged resection were more likely to have TOLS (staged: 65.8 % vs. simultaneous: 58.5 %, p = 0.025). Staged resection was associated with 37 % higher odds of TOLS (OR 1.37, 95 % CI 1.04-1.80) than simultaneous resection. Incidence of TOLS decreased with extensive resection (low-risk colectomy and minor hepatectomy: 69.6 % vs. high-risk colectomy and major hepatectomy: 2.8 %; p < 0.001). Conclusion: 62.8 % of patients had TOLS following sCRLM resection. Staged versus simultaneous resection was associated with 37 % higher odds of TOLS. Extent of resection should be considered when determining the optimal operative approach.