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

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: I2: 1%, P = 0.41; OS in esophagectomy: I2: 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.