Redefining success in gastric cancer surgery: validation of “optimal recovery” as a multidimensional, patient-centered composite endpoint

To define and validate “optimal recovery” (OR) as a multidimensional composite endpoint for gastric cancer surgery, identify its predictors, and evaluate its correlation with postoperative quality of life (QOL) compared to traditional indicators. In this single-center retrospective cohort study, 456 patients undergoing curative-intent gastrectomy were analyzed. Optimal recovery was defined as simultaneous achievement of five criteria: no major complications (Clavien-Dindo ≥ III), flatus by postoperative day (POD) 3, independent ambulation ≥ 30 min by POD 3, tolerance of semi-liquid diet without intravenous support by POD 6, and discharge by POD 7 without 30-day re-admission. Multivariable logistic regression identified OR predictors. Multiple linear regression compared OR, complications, and length of stay (LOS) in predicting 30-day QOL (EORTC QLQ-C30/STO22). Optimal recovery was achieved in 218 patients (47.8%). Independent predictors included: preoperative prognostic nutritional index (PNI) ≥ 45 (p < 0.001), modified Glasgow prognostic score (mGPS) 0 (p = 0.006), distal gastrectomy (p = 0.011), and operation time ≤ 180 min (p < 0.001). In predicting 30-day global health status, optimal recovery alone explained 28.3% of variance (adjusted r²=0.283), outperforming models with complications alone (r²=0.182), LOS alone (r²=0.152), or both (r²=0.201). OR patients reported significantly better QOL across physical, role, and symptom domains (all p < 0.001). Optimal recovery is a stringent, patient-centered endpoint that reflects high-quality convalescence. Its predictors are clinically modifiable, and it correlates more strongly with early QOL than traditional surgical metrics, supporting its use as a benchmark for surgical quality and a target for prehabilitation. Definition, predictors, and quality-of-life impact of Optimal Recovery (OR) after gastric cancer surgery. Left panel: OR is a composite endpoint requiring simultaneous achievement of five criteria: no major complications (Clavien–Dindo<III), flatus by postoperative day (POD) 3, independent ambulation ≥30 minutes by POD 3, tolerance of semi-liquid diet without intravenous support by POD 6, and discharge within 7 days without readmission. Center panel: OR was achieved in 47.8% (218/456) of patients. Independent predictors included preoperative prognostic nutritional index ≥45 (odds ratio [OR] 2.38), modified Glasgow prognostic score of 0 (OR 1.96), distal gastrectomy (OR 1.82), operation time ≤180 minutes (OR 2.63), and younger age (OR 0.96 per year). Right panel: Patients achieving OR reported significantly better 30‑day quality of life across multiple domains (EORTC QLQ-C30/STO22). The OR composite explained 28.3% of variance in global health status, substantially outperforming traditional metrics (complications alone: 18.2%; length of stay alone: 15.2%). All text in Times New Roman. POD, postoperative day; PNI, prognostic nutritional index; mGPS, modified Glasgow prognostic score; QOL, quality of life; LOS, length of stay We define "Optimal Recovery" as a novel composite endpoint for gastric cancer surgery requiring simultaneous achievement of five milestones: no major complications, flatus by day 3, independent ambulation by day 3, oral nutrition by day 6, and discharge within 7 days without readmission. Nearly half (47.8%) of patients achieved this stringent definition. Four independent predictors—PNI, mGPS, operation time, and distal gastrectomy—represent actionable targets for precision prehabilitation. Patients with poor nutritional or inflammatory status (PNI <45 or mGPS ≥1) have substantially lower odds of achieving optimal recovery and should receive targeted preoperative optimization. Optimal recovery strongly predicts 30-day quality of life and outperforms traditional surgical metrics. The composite endpoint explains 28.3% of variance in global health status--a 55% relative improvement over complication-based models--and captures patient experience dimensions that conventional indicators miss, particularly eating restrictions, physical function, and appetite loss.