Textbook case.

The first two years of medical education are spent buried in books. Here’s a creative look at how well reality holds up to textbook standards. This group of surgeons from 15 of the top hepatobiliary centers from around the world defined a “textbook outcome” after definitive resection of intrahepatic cholangiocarcinoma as one that achieved negative margins (≤1 mm) without requiring an unanticipated blood transfusion, a prolonged hospital stay, or a readmission within 30 days and without being associated with a peri-op complication or death within 30 days. Well, when it’s put that way, perhaps it shouldn’t be a surprise that only one-quarter of the 678 cases achieved the elusive textbook outcome, even among these prestigious centers. The authors produce a nomogram (figure 3) to help tease out which patients are and are not likely to achieve this ideal outcome, as they note the patient is typically more interested in patient risk and less about overall complication risk. TBL: Endpoints should be assessed on a patient, not outcome, level. | Merath, JAMA Surg 2019