Two-Stage Gastrectomy Improves Outcomes in Perforated Gastric Cancer: A Single-Institution Retrospective Study.

Background: Perforated gastric cancer (PGC) is a rare but life-threatening surgical emergency. Due to its low reported incidence and significant challenges in the preoperative diagnosis of malignancy, there is no established consensus on optimal management. Recent evidence suggests that a two-stage surgical strategy, involving initial damage control followed by delayed curative resection, may reduce morbidity and mortality while improving oncological outcomes. Preoperative diagnosis of malignancy is uncommon, and the utility of routine intraoperative biopsy has been questioned, highlighting the importance of postoperative endoscopic biopsy for definitive diagnosis. This study aims to evaluate the safety and effectiveness of a two-stage surgical strategy for PGC, emphasizing its adaptability and outcomes based on a 27-year retrospective analysis at a single institution.

Methods: We retrospectively reviewed 62 cases of gastric perforation treated between 1998 and October 2023. Among them, nine cases were pathologically confirmed as PGC. Initial management involved conservative therapy or omental patch repair (via laparotomy or laparoscopy) aimed at stabilizing the patient's condition and managing peritonitis. Following malignancy confirmation (often by postoperative biopsy) and clinical stabilization, elective curative gastrectomy with appropriate lymphadenectomy was planned for eligible patients. Postoperative outcomes, including complications (graded by Clavien-Dindo), curative resection rates, and survival, were analyzed.

Results: Of the nine PGC patients (median age 74 years), none were diagnosed preoperatively. Initial management included conservative therapy (n=3), open omental patch repair (n=3), and laparoscopic omental patch repair (n=3). No Clavien-Dindo grade III or higher complications were observed following initial management. Eight patients subsequently underwent gastrectomy, with seven achieving R0 resection. One patient succumbed to cancer progression during hospitalization prior to the planned gastrectomy. For the seven patients who underwent R0 resection, the median follow-up was 24 months (range: 12-56 months). At the final data cut-off (April 2025), three of these seven R0 patients were alive and disease-free; one had died from cancer recurrence, and three were lost to follow-up while alive. Notably, one complex case with initial peritoneal dissemination (Case 6) successfully underwent delayed radical resection after chemotherapy, illustrating the strategy's adaptability. Conversely, Case 7 exemplified a straightforward and successful two-stage laparoscopic approach, resulting in long-term disease-free survival. This patient is one of the three currently alive.

Conclusion: This retrospective study suggests that a two-stage surgical strategy, involving initial stabilization followed by elective curative gastrectomy, is a safe and effective approach for managing PGC. It achieved high rates of R0 resection with low morbidity and demonstrated promising survival outcomes in this high-risk cohort. Further multicenter prospective studies are needed to establish standardized protocols and validate patient selection criteria.