Textbook outcome in esophagogastric oncological surgery and long-term survival - A systematic review and meta-analysis.

INTRODUCTION: Esophageal and gastric cancer surgeries are complex procedures with high morbidity and modest long-term survival. Previous studies have suggested that achieving Textbook Outcome (TO) a composite measure of surgical quality may be associated with improved survival, but these findings have not been systematically summarized for esophageal and gastric cancer. TO integrates multiple aspects of perioperative care into a single benchmark, enabling meaningful comparisons across institutions and serving as a clinically relevant measure of quality. This study represents the first systematic review and meta-analysis evaluating TO in esophageal and gastric oncological surgery. AIM: To systematically evaluate the association between TO and long-term survival in esophageal and gastric oncological surgery. METHODS: Following PRISMA 2020 and MOOSE guidelines, Medline, Embase, and Web of Science were searched. Screening, data extraction, and quality assessment were conducted independently. Meta-analysis was performed for studies reporting hazard ratios (HRs) for overall survival, with subgroup analyses for esophageal, gastric, and mixed cohorts. RESULTS: Thirty-eight studies, including 160,596 patients, were analyzed. TO achievement rates ranged from 21.8% to 84.2% (mean 49.4%, 95% CI 43.8-55.1%). Meta-analysis of 27 studies revealed a 38% reduction in mortality for patients achieving TO (pooled HR 0.62, 95% CI 0.58-0.67, p < 0.0001), with a median survival advantage of 32.5 months. Weighted survival differences were 17%, 6%, and 23.5% at 2-, 3-, and 5-year follow-up, respectively. Benefits were consistent across esophageal, gastric, and mixed cohorts. Seven studies reported on the HR for patients achieving TOO and demonstrated a 28% reduction in mortality (HR 0.72, 95% CI 0.66-0.78, p < 0.0001). CONCLUSION: In esophageal and gastric oncological surgery, achieving TO is strongly associated with improved long-term survival. TO represents a clinically meaningful quality benchmarking tool, highlighting both perioperative performance and prognosis. Standardization of TO definitions is essential to optimize its utility in guiding surgical quality improvement.