Impact of surgical approach on gastric cancer surgery based on textbook outcome: Open, laparoscopic, and robotic surgery-A retrospective cohort study

Elisenda Garsot Savall; Arantxa Clavell; Sebastià Videla; Natalia Pallarès; Cinta Hierro; Cristina Bugés; Sergio Alonso; Marta Viciano

doi:10.1016/j.surg.2026.110205

Impact of surgical approach on gastric cancer surgery based on textbook outcome: Open, laparoscopic, and robotic surgery-A retrospective cohort study

Surgery. 2026 Apr 18:110205. doi: 10.1016/j.surg.2026.110205. Online ahead of print.

Authors

Elisenda Garsot Savall¹, Arantxa Clavell², Sebastià Videla³, Natalia Pallarès⁴, Cinta Hierro⁵, Cristina Bugés⁵, Sergio Alonso⁶, Marta Viciano²

Affiliations

¹ Department of General and Digestive Surgery, Hospital Universitari Germans Trias i Pujol (HUGTIP), Barcelona, Spain; Faculty of Medicine, Department of Surgery, Universitat Autonoma de Barcelona, Barcelona, Spain. Electronic address: egarsot.germanstrias@gencat.cat.
² Department of General and Digestive Surgery, Hospital Universitari Germans Trias i Pujol (HUGTIP), Barcelona, Spain.
³ Department of Clinical Pharmacology and Research Support Unit, Institut Investigació Germans Trias i Pujol, Badalona(IGTP), Barcelona, Spain.
⁴ Biostatistics Support and Research Unit, Institut Investigació Germans Trias i Pujol(IGTP), Barcelona, Spain.
⁵ Deparment of Medical Oncology, Catalan Institute of Oncology (ICO)-Badalona, Barcelona, Spain; Deparment of General and Digestive Surgery, Upper Gastrointestinal Unit, Hospital Universitari Germans Trias i Pujol (HUGTIP), Barcelona, Spain.
⁶ Cancer Genetics and Epigenetics Group (CGE), Translational Program in Cancer Research (CARE), Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain.

PMID: 42002439
DOI: 10.1016/j.surg.2026.110205

Abstract

Background: Gastric cancer surgery is evolving toward minimally invasive techniques such as laparoscopic and robotic gastrectomy. This study assesses surgical quality through the textbook outcome, a composite measure reflecting optimal perioperative results. We compared textbook outcome achievement across open gastrectomy, laparoscopic gastrectomy, and robotic gastrectomy, and its association with 1-year mortality.

Methods: A retrospective cohort of patients with gastric or esophagogastric junction cancer undergoing curative gastrectomy between 2014 and 2023 at a tertiary center was analyzed. Surgical approaches included open gastrectomy, laparoscopic gastrectomy, and robotic gastrectomy. Textbook outcome was used to evaluate surgical quality. Inverse probability weighting balanced baseline characteristics across groups. Multivariable logistic regression and weighted Cox models explored associations between surgical approach, textbook outcome, and 1-year mortality.

Results: Two hundred patients were included: 53 open gastrectomy, 103 laparoscopic gastrectomy, and 44 robotic gastrectomy. After inverse probability weighting adjustment, minimally invasive approaches showed superior outcomes. Textbook outcome was achieved in 31.4% (95% confidence interval: 15.2%-53.9%) of open gastrectomy, 56.8% (95% confidence interval: 46.5%-66.6%) of laparoscopic gastrectomy, and 68.6% (95% confidence interval: 51.5%-81.8%) of robotic gastrectomy patients, mainly due to higher R0 resection rates and adequate lymphadenectomy (≥15 nodes). Hospital stay was shorter in laparoscopic gastrectomy and robotic gastrectomy. Achieving textbook outcome was independently associated with higher 1-year survival across all approaches.

Conclusion: This is the first Western study evaluating surgical quality using textbook outcome across gastrectomy approaches. Both laparoscopic gastrectomy and robotic gastrectomy achieved higher textbook outcome rates than open gastrectomy, with robotic gastrectomy showing the best outcomes, largely driven by improved oncological resection. Textbook outcome achievement correlated with significantly improved 1-year overall survival.