Impact of surgical approach on gastric cancer surgery based on textbook outcome: Open, laparoscopic, and robotic surgery-A retrospective cohort study.

BACKGROUND

Gastric cancer surgery is evolving toward minimally invasive techniques such as laparoscopic and robotic gastrectomy. This study assesses surgical quality through the textbook outcome, a composite measure reflecting optimal perioperative results. We compared textbook outcome achievement across open gastrectomy, laparoscopic gastrectomy, and robotic gastrectomy, and its association with 1-year mortality.

METHODS

A retrospective cohort of patients with gastric or esophagogastric junction cancer undergoing curative gastrectomy between 2014 and 2023 at a tertiary center was analyzed. Surgical approaches included open gastrectomy, laparoscopic gastrectomy, and robotic gastrectomy. Textbook outcome was used to evaluate surgical quality. Inverse probability weighting balanced baseline characteristics across groups. Multivariable logistic regression and weighted Cox models explored associations between surgical approach, textbook outcome, and 1-year mortality.

RESULTS

Two hundred patients were included: 53 open gastrectomy, 103 laparoscopic gastrectomy, and 44 robotic gastrectomy. After inverse probability weighting adjustment, minimally invasive approaches showed superior outcomes. Textbook outcome was achieved in 31.4% (95% confidence interval: 15.2%-53.9%) of open gastrectomy, 56.8% (95% confidence interval: 46.5%-66.6%) of laparoscopic gastrectomy, and 68.6% (95% confidence interval: 51.5%-81.8%) of robotic gastrectomy patients, mainly due to higher R0 resection rates and adequate lymphadenectomy (≥15 nodes). Hospital stay was shorter in laparoscopic gastrectomy and robotic gastrectomy. Achieving textbook outcome was independently associated with higher 1-year survival across all approaches.

CONCLUSION

This is the first Western study evaluating surgical quality using textbook outcome across gastrectomy approaches. Both laparoscopic gastrectomy and robotic gastrectomy achieved higher textbook outcome rates than open gastrectomy, with robotic gastrectomy showing the best outcomes, largely driven by improved oncological resection. Textbook outcome achievement correlated with significantly improved 1-year overall survival.