Patient-Level Comparison of Surgical TOGS Components and DUCA-Based Textbook Outcome After Open D2 Total Gastrectomy

Background and Objectives: Textbook outcome (TO) is increasingly used as a composite quality metric in gastric cancer surgery, but different TO frameworks can classify the same patient differently. This study compared surgical and perioperative components of the Textbook Outcome in Gastric Surgery (TOGS) framework with the Original Dutch Upper Gastrointestinal Cancer Audit textbook outcome (Original DUCA-TO) and a Modified DUCA-TO definition using Clavien-Dindo (CD) grade ≥III as the morbidity threshold, focusing on patient-level agreement and discordance. Methods: Patients undergoing curative-intent open D2 total gastrectomy for gastric adenocarcinoma at a single tertiary center (January 2015-January 2025) were retrospectively analyzed. TOGS was evaluated using the surgical and perioperative components of the TOGS framework, excluding the multimodality-treatment domain. Original DUCA-TO used CD grade ≥II morbidity as a failure criterion; Modified DUCA-TO used CD grade ≥III, with other components unchanged. Achievement rates, concordance, factors associated with TO achievement, and overall survival were assessed. Results: Among 133 patients, TOGS, Original DUCA-TO, and Modified DUCA-TO were achieved in 45.9%, 27.8%, and 52.6%, respectively. Agreement with TOGS improved after raising the DUCA morbidity threshold, with Cohen's kappa increasing from 0.563 to 0.686; this reclassified 24.8% of patients to achievement and reversed the discordance direction. Higher preoperative hemoglobin was independently associated with greater odds of TOGS and Original DUCA-TO achievement, with adjusted odds ratios (ORs) of 1.50 and 1.67, respectively. In separate exploratory adjusted models, each 50 mL increase in intraoperative blood loss was associated with lower odds of TOGS and Original DUCA-TO achievement (adjusted ORs, 0.13 and 0.11, respectively), as was each 1-unit increase in intraoperative erythrocyte transfusion (adjusted ORs, 0.14 and 0.13, respectively); postoperative erythrocyte transfusion was also associated with lower odds of TOGS achievement (adjusted OR, 0.26). TOGS and Modified DUCA-TO were associated with longer unadjusted survival, but no definition remained independently associated with overall survival after adjustment. Conclusions: The evaluated surgical/perioperative TOGS components and DUCA-based TO definitions are related but not interchangeable after open D2 total gastrectomy for gastric adenocarcinoma. The DUCA morbidity threshold substantially affects achievement rates, the direction of discordance, and the interpretation of associated factors, particularly the association with preoperative hemoglobin under a morbidity criterion that includes transfusion-related CD grade II events. Clear reporting of the TO framework, threshold, and failure patterns is essential for cross-cohort comparisons.