Background: Surgical treatment for biliary tract cancer (BTC) is typically complex and is associated with poor short-term postoperative outcomes. Recently, the concept of textbook outcome (TO) has been proposed as a composite measure to evaluate postoperative results, quality of care, and institutional performance. This PRISMA-compliant meta-analysis aimed to examine the association between TO and overall survival (OS) in BTC patients undergoing hepatic resection and to identify clinicopathologic predictors of TO achievement.
Materials and methods: A systematic search of PubMed, MEDLINE, Embase, and Cochrane Library (up to 1 July 2025) identified studies reporting TO-associated factors and OS stratified by TO status. Data synthesis was performed using fixed-effects or random-effects models based on the heterogeneity, with outcomes expressed as odds ratios (ORs) or hazard ratios (HRs) and 95% confidence intervals (CIs).
Results: Fourteen studies involving 11,787 patients with BTC, including intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma, and gallbladder cancer, were included in this analysis.TO achievement was significantly associated with improved OS in BTC (HR 0.69, 95% CI 0.58-0.82). Seventeen clinicopathologic factors were evaluated, of which thirteen were identified as predictors of TO achievement, including younger age (OR 1.61, 95% CI 1.27-2.03), lower ASA score (OR 1.83, 95% CI 1.30-2.58), reduced preoperative CA19-9 (OR 1.59, 95% CI 1.04-2.43,) and total bilirubin levels (OR 2.98, 95%CI 1.87-4.77), absence of neoadjuvant therapy (OR 2.30, 95%CI 1.70-3.11), laparoscopic surgery (OR 2.65, 95% CI 1.66-4.24), lymph node negativity (OR 1.84, 95% CI 1.53-2.23), early T stage (OR 1.90, 95% CI 1.47-2.46), smaller tumor size (OR 1.08, 95% CI 1.00-1.15), absence of macrovascular (OR 2.98, 95% CI 1.22-7.28) or microvascular invasion (OR 1.52, 95%CI 1.30-1.84), moderate/well differentiation (OR 2.15, 95% CI 1.72-2.69), and receipt of adjuvant therapy (OR 1.35, 95% CI 1.11-1.63).
Conclusions: This study demonstrated that achieving TO significantly improves OS in BTC and identifies thirteen predictive factors encompassing patient characteristic, biochemical markers, treatment parameter, and pathologic features. These findings may facilitate early identification of high-risk surgical candidates and support the preoperative optimization of modifiable factors to enhance the likelihood of achieving TO and improve patient prognosis.
Keywords: biliary tract cancer; liver surgery; meta-analysis; predictor; textbook outcome.
Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc.