Achieving “textbook outcome” after hepatectomy for hepatocellular carcinoma in the era of enhanced recovery: development and validation of a clinical nomogram

Background Traditional perioperative metrics such as complication rates and length of stay (LOS) are fragmented and fail to capture the “ideal” recovery trajectory. “Textbook outcome” (TO) has emerged as a composite quality metric representing optimal surgical results. However, validated tools for predicting TO specifically for patients with hepatocellular carcinoma (HCC) undergoing hepatectomy within an Enhanced Recovery After Surgery (ERAS) pathway remain scarce, particularly models integrating the albumin–bilirubin (ALBI) grade. Methods We conducted a single-center retrospective analysis of 685 consecutive patients who underwent curative hepatectomy for HCC between January 2021 and December 2025. TO was defined as the concurrent fulfillment of six criteria: no Clavien–Dindo grade ≥III complications, no prolonged LOS (>75th percentile), no readmission within 30 days, no 90-day mortality, R0 resection, and no clinically relevant bile leak. The cohort was randomly divided into a training set ( n = 480) and a validation set ( n = 205). Least absolute shrinkage and selection operator (LASSO) regression was utilized for variable selection. A nomogram was constructed based on multivariable logistic regression analysis. Model performance was assessed via the concordance index ( C -index), calibration plots, and decision curve analysis (DCA). Results The overall TO rate was 62.8% (430/685). In the training cohort, the multivariable analysis identified ALBI grade (OR = 0.45, 95%CI = 0.28–0.71), minimally invasive surgery (MIS) approach (OR = 2.15, 95%CI = 1.45–3.20), tumor size <5 cm (OR = 1.88, 95%CI = 1.22–2.90), and absence of microvascular invasion (OR = 1.65, 95%CI = 1.10–2.48) as independent predictors of achieving TO. The nomogram demonstrated good discrimination, with C -index values of 0.78 (95%CI = 0.73–0.83) in the training set and 0.76 (95%CI = 0.69–0.82) in the validation set. The calibration curves showed excellent agreement between the predicted and the observed probabilities. DCA confirmed the clinical utility of the nomogram across a wide range of threshold probabilities. Conclusion TO serves as a comprehensive standard for patient-centered care. Our preliminary nomogram, which incorporates the objective ALBI grade and the surgical approach, offers a practical tool to predict ideal recovery likelihood. However, external validation is required before widespread clinical implementation.