Highlights
• Robotic gastrectomy achieved the highest textbook outcome rate (68.6%) compared to laparoscopic (56.8%) and open surgery (31.4%).
• Minimally invasive approaches (robotic and laparoscopic) were associated with shorter hospital stays and better oncological resection quality.
• Textbook outcome achievement was independently linked to higher 1-year survival across all surgical approaches.
Background
Gastric cancer remains a significant global health burden, with surgery being the cornerstone of curative treatment. The evolution of surgical techniques from open gastrectomy (OG) to minimally invasive approaches like laparoscopic gastrectomy (LG) and robotic gastrectomy (RG) has aimed to reduce morbidity while maintaining oncological efficacy. This study evaluates these approaches using the textbook outcome (TO), a composite measure reflecting optimal perioperative results, and its impact on 1-year survival.
Study Design
This retrospective cohort study analyzed 200 patients with gastric or esophagogastric junction cancer who underwent curative gastrectomy between 2014 and 2023 at a tertiary center. Surgical approaches included OG (n=53), LG (n=103), and RG (n=44). The primary endpoint was TO achievement, defined by: R0 resection, ≥15 lymph nodes harvested, no severe complications, no reoperation, no readmission, and no mortality within 30 days. Secondary endpoints included hospital stay and 1-year mortality. Inverse probability weighting balanced baseline characteristics, and multivariable logistic regression with weighted Cox models assessed associations.
Key Findings
After adjustment, TO rates were significantly higher in minimally invasive groups: 31.4% (OG), 56.8% (LG), and 68.6% (RG) (p<0.001). RG excelled in R0 resection rates (95.5% vs. 90.3% LG, 84.9% OG) and lymphadenectomy adequacy (88.6% vs. 82.5% LG, 73.6% OG). Hospital stays were shorter for LG (7 days) and RG (6 days) versus OG (9 days) (p=0.002). Achieving TO was independently associated with 1-year survival (HR: 0.42, 95% CI: 0.24–0.73), regardless of surgical approach.
Expert Commentary
This study underscores the value of TO as a quality metric in gastric cancer surgery. While RG demonstrated superior outcomes, access and cost remain barriers. The findings align with the 2025 NCCN Guidelines’ emphasis on minimally invasive techniques for experienced centers. Limitations include the retrospective design and single-center data, warranting randomized trials to validate these results.
Conclusion
Robotic gastrectomy achieves the highest TO rates and improves 1-year survival, positioning it as a promising approach for gastric cancer. However, institutional expertise and patient selection remain critical. Future research should address cost-effectiveness and long-term oncologic outcomes.
Funding and Registration
This study received no external funding. Data were extracted from institutional records without clinical trial registration.
References
1. Garsot Savall E, et al. Surgery. 2026; PMID: 42002439. 2. NCCN Guidelines® Gastric Cancer, Version 2.2025.