Age Does Not Affect Textbook Outcome After Liver Surgery Within an Enhanced Recovery Pathway

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BACKGROUND: Textbook outcome in liver surgery (TOLS) is a novel comprehensive quality metric reflecting an ideal postoperative course. Data on TOLS in older adult patients remain limited. This study aimed to compare TOLS achievement between older adults and younger patients and to identify TOLS predictors. METHODS: A retrospective cohort study including all consecutive patients undergoing elective liver surgery within an enhanced recovery (ERAS) program (2013-2023) was conducted. Older adult patients were defined as ≥ 70 years. TOLS achievement was based on international consensus criteria. TOLS predictors were assessed using multivariable logistic regression. RESULTS: A total of 618 patients were included, of whom 179 (29%) were ≥ 70 years. Overall, 354 patients (57%) achieved TOLS. TOLS rates were similar in older adults and younger patients (56% vs. 58%, p = 0.78). TOLS predictors were higher ERAS compliance (OR 1.1, p < 0.01), minor hepatectomy (OR 2.0, p < 0.01), absence of biliary anastomosis (OR 0.4, p < 0.01), preoperative biliary stenting (OR 0.2, p < 0.01), and absence of intraoperative blood transfusion (OR 0.2, p < 0.01). Age was not associated with TOLS (OR 1.0, p = 0.10). CONCLUSION: TOLS rates were comparable in older adults and younger patients. Within an ERAS pathway, age alone does not compromise the likelihood of achieving an optimal postoperative course. Surgical complexity and perioperative factors appear to be more critical determinants of TOLS.