Intraoperative Stress Burden, Adapted Textbook Outcome, and Overall Survival After Curative-Intent Gastrectomy for Gastric Adenocarcinoma: A Single-Center Retrospective Cohort Study

Background/Objectives: textbook outcome (TO) is an established surgical quality measure, but failure is recognized only after postoperative events. We evaluated whether intraoperative stress burden (blood loss, fluid administration, and transfusion) is associated with adapted TO attainment and overall survival (OS) after curative-intent gastrectomy. Methods: in 2352 patients with gastric adenocarcinoma (2010–2020), an intraoperative stress burden score summed three binary components (blood loss > 200 mL, fluid > 68 mL/kg, and any transfusion) and was categorized as low, intermediate, or high. Adapted TO required R0 resection, ≥15 retrieved nodes, no Clavien–Dindo ≥ III complication, no unplanned reoperation, no 30-day mortality, and length of stay ≤ 12 days. Multivariable logistic and Cox models, overlap weighting, and sensitivity analyses were applied. Results: the median age was 60 years; 66.9% were male, 67.7% had pT3–4 and 42.0% pN2–3 disease, and 30.1% underwent minimally invasive surgery. TO attainment declined with increasing burden (78.0%, 70.5%, and 65.2%; p < 0.001). Intermediate and high burden were associated with TO failure (adjusted odds ratios 1.50 and 1.68), though the high-burden association was attenuated after adjusting for operative time. High burden was associated with worse OS (adjusted hazard ratio 1.36; 95% CI 1.15–1.62; 1.44 after overlap weighting). Risk was time-varying—strongest in the first postoperative year (HR 2.03), persisting at 12–60 months (HR 1.54), and absent beyond 60 months. Conclusions: higher intraoperative stress burden identified patients with lower adapted TO attainment and increased early mortality after gastrectomy. External validation is needed.