Textbook Outcomes and Minimally Invasive Techniques in Resectable Gallbladder Cancer: A Global Cohort Study

Introduction: Surgery for resectable gallbladder cancer (GbC) encompasses complex operative management, and evaluating surgical quality through textbook outcome (TO) is crucial. This study aimed to assess TO incidence and impact in a global cohort, identify independent predictors, and evaluate TO rates of minimally invasive (MI) techniques, including robotic (ROB) and laparoscopic (LPS). Materials and methods: This cohort study included patients undergoing curative-intent hepatectomy and lymphadenectomy for GbC (T1b–T3) from 2012 to 2023 in 41 hospitals. TO was defined as the absence of intraoperative transfusion, major complications, readmission, reoperation, or 90-day mortality, alongside negative margins and ≥6 retrieved lymph nodes. MI-TO additionally required no conversion. A 1:1 propensity score matching compared TO in open (OPEN) and MI approaches. Data were analyzed from July to November 2024. Results: Among 667 patients (MI, 361; OPEN, 306), TO was achieved in 205 (30.7 %), with no difference between OPEN and MI. ROB independently increased TO (odds ratio, 4.297; p = 0.002), achieving higher MI-TO (37.8 % vs. 23.2 %; p = 0.003), better lymphadenectomy (≥6 nodes: 55.3 % vs. 40.6 %; p = 0.009), and fewer OPEN conversions (1.2 % vs. 13.7 %; p < 0.001) than LPS. TO correlated with lower mortality (HR, 0.506; p = 0.001) and recurrence (HR, 0.682; p = 0.027). Conclusion: TO in resectable GbC is achieved in one-third of cases, with significant long-term benefits. MI is effective, with ROB outperforming LPS in MI-TO measures. These results establish a benchmark for centers to enhance outcomes.