{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T02:51:53Z","timestamp":1781751113957,"version":"3.54.5"},"reference-count":37,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T00:00:00Z","timestamp":1781740800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100012245","name":"Science and Technology Planning Project of Guangdong Province","doi-asserted-by":"publisher","award":["2021B1212040006"],"award-info":[{"award-number":["2021B1212040006"]}],"id":[{"id":"10.13039\/501100012245","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Shenzhen Science and Technology Program","award":["JCYJ20230807110718037"],"award-info":[{"award-number":["JCYJ20230807110718037"]}]},{"name":"Medical Scientific Research Foundation of Guangdong Province, China","award":["A2025131"],"award-info":[{"award-number":["A2025131"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>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\u20132020), an intraoperative stress burden score summed three binary components (blood loss &gt; 200 mL, fluid &gt; 68 mL\/kg, and any transfusion) and was categorized as low, intermediate, or high. Adapted TO required R0 resection, \u226515 retrieved nodes, no Clavien\u2013Dindo \u2265 III complication, no unplanned reoperation, no 30-day mortality, and length of stay \u2264 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\u20134 and 42.0% pN2\u20133 disease, and 30.1% underwent minimally invasive surgery. TO attainment declined with increasing burden (78.0%, 70.5%, and 65.2%; p &lt; 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\u20131.62; 1.44 after overlap weighting). Risk was time-varying\u2014strongest in the first postoperative year (HR 2.03), persisting at 12\u201360 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.<\/jats:p>","DOI":"10.3390\/cancers18121975","type":"journal-article","created":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T02:10:16Z","timestamp":1781748616000},"page":"1975","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Intraoperative Stress Burden, Adapted Textbook Outcome, and Overall Survival After Curative-Intent Gastrectomy for Gastric Adenocarcinoma: A Single-Center Retrospective Cohort Study"],"prefix":"10.3390","volume":"18","author":[{"given":"Jianfeng","family":"Li","sequence":"first","affiliation":[{"name":"Digestive Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Songyao","family":"Chen","sequence":"additional","affiliation":[{"name":"Digestive Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hui","family":"Ren","sequence":"additional","affiliation":[{"name":"Digestive Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jingyao","family":"Chen","sequence":"additional","affiliation":[{"name":"Digestive Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mingzhe","family":"Li","sequence":"additional","affiliation":[{"name":"Digestive Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wenhui","family":"Wu","sequence":"additional","affiliation":[{"name":"Digestive Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dongjie","family":"Yang","sequence":"additional","affiliation":[{"name":"Digestive Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Changhua","family":"Zhang","sequence":"additional","affiliation":[{"name":"Digestive Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yulong","family":"He","sequence":"additional","affiliation":[{"name":"Digestive Medicine Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"},{"name":"Guangdong Provincial Key Laboratory of Digestive Cancer Research, Digestive Diseases Center, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen 518107, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1016\/S0140-6736(20)31288-5","article-title":"Gastric cancer","volume":"396","author":"Smyth","year":"2020","journal-title":"Lancet"},{"key":"ref_2","unstructured":"GBD 2017 Stomach Cancer Collaborators (2020). The global, regional, and national burden of stomach cancer in 195 countries, 1990\u20132017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet Gastroenterol. Hepatol., 5, 42\u201354."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Japanese Gastric Cancer Association (2023). Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer, 26, 1\u201325.","DOI":"10.1007\/s10120-022-01331-8"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"742","DOI":"10.1002\/bjs.10486","article-title":"Textbook outcome as a composite measure in oesophagogastric cancer surgery","volume":"104","author":"Busweiler","year":"2017","journal-title":"Br. J. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1002\/bjs.10729","article-title":"Using textbook outcome as a measure of quality of care in oesophagogastric cancer surgery","volume":"105","author":"Voncken","year":"2018","journal-title":"Br. J. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1097\/SLA.0000000000003849","article-title":"Textbook Outcome and Survival in Patients with Gastric Cancer: An Analysis of the Population Registry of Esophageal and Stomach Tumours in Ontario (PRESTO)","volume":"275","author":"Levy","year":"2022","journal-title":"Ann. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1402","DOI":"10.1016\/j.surg.2024.07.022","article-title":"Association Between Textbook Outcome and Long-term Survival Among Patients Undergoing Curative-intent Resection of Gastric Cancer","volume":"176","author":"Lin","year":"2024","journal-title":"Surgery"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"768","DOI":"10.1016\/j.ejso.2021.10.025","article-title":"Textbook outcome and survival after gastric cancer resection with curative intent: A population-based analysis","volume":"48","author":"Grande","year":"2022","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"\u00c7etinkaya-Hosg\u00f6r, C., Seika, P., Raakow, J., Kr\u00f6ll, D., Dobrindt, E.M., Maurer, M.M., Martin, F., Ossami Saidy, R.R., Thuss-Patience, P., and Pratschke, J. (2023). Textbook Outcome After Gastrectomy for Gastric Cancer Is Associated with Improved Overall and Disease-Free Survival. J. Clin. Med., 12.","DOI":"10.3390\/jcm12165419"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2141","DOI":"10.1016\/j.ejso.2022.05.025","article-title":"Textbook Outcome, Chemotherapy Compliance, and Prognosis After Radical Gastrectomy for Gastric Cancer: A Large Sample Analysis","volume":"48","author":"Chen","year":"2022","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"823","DOI":"10.1097\/SLA.0000000000006054","article-title":"Textbook Oncological Outcome in European GASTRODATA","volume":"278","author":"Mlak","year":"2023","journal-title":"Ann. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"8239","DOI":"10.1245\/s10434-022-12388-1","article-title":"Impact of Textbook Oncologic Outcome Attainment on Survival After Gastrectomy: A Review of the National Cancer Database","volume":"29","author":"Cibulas","year":"2022","journal-title":"Ann. Surg. Oncol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1186\/s12957-023-03166-8","article-title":"Textbook outcome in oncological gastric surgery: A systematic review and call for an international consensus","volume":"21","author":"Yang","year":"2023","journal-title":"World J. Surg. Oncol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1033","DOI":"10.1007\/s10120-025-01659-x","article-title":"Textbook outcome in gastrectomy: Useful metric or moving target? A scoping review","volume":"28","author":"Salem","year":"2025","journal-title":"Gastric Cancer"},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Wang, W., Zhao, L., Niu, P., Zhang, X., Luan, X., Zhao, D., and Chen, Y. (2023). Effects of Perioperative Blood Transfusion in Gastric Cancer Patients Undergoing Gastrectomy: A Systematic Review and Meta-analysis. Front. Surg., 9.","DOI":"10.3389\/fsurg.2022.1011005"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"zrad075","DOI":"10.1093\/bjsopen\/zrad075","article-title":"Association of perioperative allogeneic blood transfusions and long-term outcomes following radical surgery for gastric and colorectal cancers: Systematic review and meta-analysis of propensity-adjusted observational studies","volume":"7","author":"Zhang","year":"2023","journal-title":"BJS Open"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Hsu, F.K., Chang, W.K., Lin, K.J., Liu, C.Y., Fang, W.L., and Chang, K.Y. (2021). The Associations Between Perioperative Blood Transfusion and Long-Term Outcomes After Stomach Cancer Surgery. Cancers, 13.","DOI":"10.3390\/cancers13215438"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1007\/s12094-019-02046-6","article-title":"Intraoperative Blood Loss Does Not Independently Affect the Survival Outcome of Gastric Cancer Patients Who Underwent Curative Resection","volume":"21","author":"Zhao","year":"2019","journal-title":"Clin. Transl. Oncol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1007\/s10120-021-01266-6","article-title":"Negative impact of intraoperative blood loss on long-term outcome after curative gastrectomy for advanced gastric cancer: Exploratory analysis of the JCOG1001 phase III trial","volume":"25","author":"Misawa","year":"2022","journal-title":"Gastric Cancer"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/j.ijsu.2016.07.006","article-title":"Ratio of Intra-operative Fluid to Anesthesia Time and Its Impact on Short-term Perioperative Outcomes Following Gastrectomy for Cancer: A Retrospective Cohort Study","volume":"33","author":"Enomoto","year":"2016","journal-title":"Int. J. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1209","DOI":"10.1002\/bjs.9582","article-title":"Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS\u00ae) Society recommendations","volume":"101","author":"Mortensen","year":"2014","journal-title":"Br. J. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1002\/ags3.12232","article-title":"Current status of the \u201cenhanced recovery after surgery\u201d program in gastric cancer surgery","volume":"3","author":"Yamagata","year":"2019","journal-title":"Ann. Gastroenterol. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1001\/jamasurg.2016.4952","article-title":"Enhanced Recovery After Surgery: A Review","volume":"152","author":"Ljungqvist","year":"2017","journal-title":"JAMA Surg."},{"key":"ref_24","first-page":"250","article-title":"Addressing Extreme Propensity Scores via the Overlap Weights","volume":"188","author":"Li","year":"2019","journal-title":"Am. J. Epidemiol."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., G\u00f8tzsche, P.C., Vandenbroucke, J.P. (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. PLoS Med., 4.","DOI":"10.1371\/journal.pmed.0040296"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1002\/bjs.10976","article-title":"Improving surgical outcomes through benchmarking","volume":"106","author":"Staiger","year":"2019","journal-title":"Br. J. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1097\/JS9.0000000000000212","article-title":"Benchmarking: A novel measuring tool for outcome comparisons in surgery","volume":"109","author":"Wu","year":"2023","journal-title":"Int. J. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1097\/01.sla.0000133083.54934.ae","article-title":"Classification of Surgical Complications: A New Proposal with Evaluation in a Cohort of 6336 Patients and Results of a Survey","volume":"240","author":"Dindo","year":"2004","journal-title":"Ann. Surg."},{"key":"ref_29","unstructured":"Amin, M.B., Edge, S.B., Greene, F.L., Byrd, D.R., Brookland, R.K., Washington, M.K., Gershenwald, J.E., Compton, C.C., Hess, K.R., and Sullivan, D.C. (2017). AJCC Cancer Staging Manual, Springer. [8th ed.]."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1007\/s10120-020-01102-3","article-title":"Impact of Postoperative Complications on Survival Outcomes in Patients with cT3\/4a Gastric Cancer: Exploratory Analysis of a Randomized Controlled JCOG1001 Trial","volume":"24","author":"Tokunaga","year":"2021","journal-title":"Gastric Cancer"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"10732748211011955","DOI":"10.1177\/10732748211011955","article-title":"Relationship Between Postoperative Complications and the Prognosis of Gastric Carcinoma Patients Who Underwent Surgical Resection: A Systematic Review and Meta-Analysis","volume":"28","author":"Chen","year":"2021","journal-title":"Cancer Control"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"584","DOI":"10.5230\/jgc.2023.23.e38","article-title":"The Impact of Different Types of Complications on Long-Term Survival After Total Gastrectomy for Gastric Cancer","volume":"23","author":"Jung","year":"2023","journal-title":"J. Gastric Cancer"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"452","DOI":"10.1007\/s10120-025-01710-x","article-title":"Textbook outcome in gastric cancer surgery: A multicenter cohort study and proposal for a new specific index (TOGS)","volume":"29","author":"Marrelli","year":"2026","journal-title":"Gastric Cancer"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"3304","DOI":"10.1200\/JCO.20.01210","article-title":"Long-Term Outcomes of Laparoscopic Distal Gastrectomy for Locally Advanced Gastric Cancer: The KLASS-02-RCT Randomized Clinical Trial","volume":"38","author":"Hyung","year":"2020","journal-title":"J. Clin. Oncol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"5265","DOI":"10.1245\/s10434-020-09476-5","article-title":"Impact of Enhanced Recovery After Surgery on Postoperative Outcomes for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy","volume":"28","author":"White","year":"2021","journal-title":"Ann. Surg. Oncol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"402","DOI":"10.1007\/s12029-023-00976-7","article-title":"The Clinical Impact of Change in the Neutrophil to Lymphocyte Ratio During the Perioperative Period in Gastric Cancer Patients Who Receive Curative Gastrectomy","volume":"55","author":"Aoyama","year":"2024","journal-title":"J. Gastrointest. Cancer"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"989","DOI":"10.21037\/jgo.2019.06.05","article-title":"Quality of Life as a Fundamental Outcome after Curative Intent Gastrectomy for Adenocarcinoma: Lessons Learned from Patients","volume":"10","author":"Pinheiro","year":"2019","journal-title":"J. Gastrointest. Oncol."}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/12\/1975\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T02:10:46Z","timestamp":1781748646000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/12\/1975"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,18]]},"references-count":37,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["cancers18121975"],"URL":"https:\/\/doi.org\/10.3390\/cancers18121975","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,18]]}}}