Textbook outcome in gastric cancer surgery: a multicenter cohort study and proposal for a new specific index (TOGS)

Background Textbook Outcome (TO) combines optimal surgical outcomes into a single measure. This study evaluates achievement of TO using a multicenter database, assessing hospital variation, its correlation with early and late results, and refining a tailored definition of Textbook Outcome in Gastric Surgery (TOGS). Methods Data from patients undergoing curative gastrectomy (2011-2020) in Italian centers affiliated to the Italian Gastric Cancer Research Group (GIRCG) were analyzed. TOGS was introduced at the 2024 GIRCG Annual Meeting in Siena (Italy). Results Among 1988 patients (median age 72 years, BMI 24.9 kg/m2), 1523 underwent surgery in higher-volume centers (>= 30 cases per year) and 465 in lower-volume centers (15-30 cases per year). TO was achieved in 54.6% of patients (55.2% in higher-volume vs. 52.7% in lower-volume centers, P = 0.350). Clavien-Dindo grade II or higher complications (34.8%) and re-interventions (11.5%) mostly affected the achievement of TO. Younger age (P < 0.001), early stages (P < 0.001), female gender (P = 0.005), open approach (P = 0.008) and absence of extensive surgery (P = 0.033) were independent predictors of TO. Patients achieving TO showed better survival (5-y 69.8% vs. 57.3%, HR 0.63 [95% CI, 0.54-0.75], P < 0.001), also when stratifying for tumor stages. The new TOGS definition, based on specific criteria for gastric surgery, reduced its achievement rate (50.2%) but shortened mean hospital stay (8.9 vs. 18 days) and increased the likelihood of long-term survival. Conclusions TO and TOGS are valuable metrics for assessing hospital performance and optimizing outcomes following gastrectomy for gastric cancer. Hospital volume did not impact TO and TOGS rates in GIRCG centers.