Impact of Textbook Outcome (TO) and Textbook Oncological Outcome (TOO) on Survival Following Surgery for Esophagogastric Cancer: A Systematic Review and Meta-analysis

Abstract

Abstract Background Textbook outcome (TO) and textbook oncological outcome (TOO) are increasingly used as composite measures of surgical success but are limited by heterogeneity in their definitions. This systematic review and meta-analysis aims to synthesize the association between composite outcome measures (TO/TOO) and survival in both gastric and esophageal cancer. Materials and Methods A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Six databases were searched for comparative studies meeting the inclusion criteria. Primary outcomes included overall survival (OS) and disease-free survival (DFS). Random-effects meta-analyses were performed for gastrectomy and esophagectomy using pooled hazard ratios (HRs) with 95% confidence intervals (CIs). Results A total of 46 retrospective cohort studies including 159,320 patients were analyzed (28 gastrectomy, 14 esophagectomy, 4 both). Definitions of TO/TOO varied substantially. Median achievement rates were 51.5% (IQR 34.3–60.5%) for gastrectomy and 35.1% (IQR 30.7–50.8%) for esophagectomy. Achievement of TO/TOO was associated with improved OS following gastrectomy (HR 0.60; 95% CI 0.54–0.67) and esophagectomy (HR 0.69; 95% CI 0.63–0.76). DFS was improved in patients achieving TO/TOO following gastrectomy (HR 0.54; 95% CI 0.42–0.70) and esophagectomy (HR 0.69; 95% CI 0.61 to 0.79). Heterogeneity was almost eliminated when pooling studies using a standardized TO definition (OS in gastrectomy: I 2 : 1%, P = 0.41; OS in esophagectomy: I 2 : 0%, P = 0.28). Median 1-, 3-, and 5-year OS and DFS rates were consistently higher in patients achieving TO/TOO. Conclusions Achievement of TO/TOO is associated with significantly improved OS and DFS in esophagogastric cancer surgery. These findings support the role of composite outcome measures as indicators of long-term oncological outcomes and highlight the need for standardization.