Patient-Level Comparison of Surgical TOGS Components and DUCA-Based Textbook Outcome After Open D2 Total Gastrectomy
4 affiliations
- 1Department of Surgical Oncology, Faculty of Medicine, Çukurova University, 01330 Adana, Turkey; (S.G.); (C.K.P.)
- 2Department of General Surgery, Islahiye State Hospital, 27800 Gaziantep, Turkey;
- 3Department of Gastroenterological Surgery, Adana City Training and Research Hospital, University of Health Sciences, 01370 Adana, Turkey;
- 4Department of General Surgery, Faculty of Medicine, Çukurova University, 01330 Adana, Turkey; (M.H.A.); (İ.A.); (A.G.S.); (O.Y.)
Abstract
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.
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BibTeX
@article{topal2026patientlevel,
title = {{Patient-Level Comparison of Surgical TOGS Components and DUCA-Based Textbook Outcome After Open D2 Total Gastrectomy}},
author = {Uğur Topal and Burak Aydoğan and Yunus Kaycı and Mevlüt Harun Ağca and İshak Aydın and Serdar Gümüş and Ahmet Gökhan Sarıtaş and Orçun Yalav and Cem Kaan Parsak},
journal = {Medicina (Kaunas, Lithuania)},
year = {2026},
month = sep,
doi = {10.3390/medicina62101854},
url = {https://europepmc.org/article/PMC/PMC13707275},
note = {CC BY},
}
RIS
TY - JOUR
TI - Patient-Level Comparison of Surgical TOGS Components and DUCA-Based Textbook Outcome After Open D2 Total Gastrectomy
AU - Uğur Topal
AU - Burak Aydoğan
AU - Yunus Kaycı
AU - Mevlüt Harun Ağca
AU - İshak Aydın
AU - Serdar Gümüş
AU - Ahmet Gökhan Sarıtaş
AU - Orçun Yalav
AU - Cem Kaan Parsak
PY - 2026
DA - 2026/09/01
JO - Medicina (Kaunas, Lithuania)
DO - 10.3390/medicina62101854
UR - https://europepmc.org/article/PMC/PMC13707275
AB - 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.
SN - 1010-660X
SN - 1648-9144
ER -