Textbook outcome in gastrectomy: useful metric or moving target? A scoping review

Composite metrics including Textbook Outcome (TO) and Textbook Oncological Outcome (TOO) are increasingly utilised to assess quality in gastric cancer surgical research. However, inconsistent and variable reporting limits their clinical application.

This scoping review aimed to catalogue definitions and criteria of TO and TOO in gastrectomy, report achievement rates and determinants, associations with survival outcomes, and identify methodological gaps.

A search was conducted in MEDLINE, Embase, Web of Science, and Scopus from inception to April 2025. Eligible studies reported TO or TOO for adults undergoing curative-intent gastrectomy for cancer. Reviewers screened studies and extracted data on characteristics, definitions, achievement rates, and survival outcomes. Owing to heterogeneity, findings were summarised narratively.

Forty-five studies (published 2017-2025; n = 139,972 patients) were included. Definitions varied, with 26 unique components identified. Common components were adequate lymphadenectomy (≥ 15 nodes), absence of postoperative complications (Clavien-Dindo grade ≥ II), and no 30-day readmission. Median TO and TOO achievement rates were 58.6% (IQR: 37.6-75.8) and 30.3% (IQR: 23.6-40.2). The primary barriers were inadequate lymphadenectomy and CD ≥ II complications. Twelve studies reported a significant association between TO/TOO and improved overall and disease-free survival. Influencing factors included age, comorbidity, tumour characteristics, surgeon volume, and surgical approach. Limitations included non-standardised definitions, limited patient-reported outcomes, and a lack of prospective validation.

TO and TOO are associated with improved survival in gastrectomy but are hampered by inconsistent definitions and limited prospective evidence. Standardisation, patient-reported outcomes, and prospective validation are needed to realise their potential as clinically useful quality metrics.