Ann Surg Treat Res.  2021 Sep;101(3):151-159. 10.4174/astr.2021.101.3.151.

The role of laparoscopic management in perforated gastric cancer

• Kim CH
• Kim DJ
• Kim W

• KMID: 2519845
• DOI: http://doi.org/10.4174/astr.2021.101.3.151

Abstract

Purpose
Perforated gastric cancer is an extremely rare condition and usually presents in advanced stage with poor prognosis. Surgical strategies are still controversial regarding the extent to which complete resection or primary repair is performed and the application of laparoscopic techniques. We aim to determine the role of laparoscopic 2-stage approach in perforated gastric cancer.
Methods
Among 2,318 gastric cancers in Yeouido St. Mary’s Hospital from January 1990 to December 2017, 20 patients with perforated gastric cancer were enrolled, and 5 patients underwent 2-stage gastrectomy consisting of primary closure on perforation followed by curative gastrectomy. Clinicopathological features, surgical outcomes, and survival analysis were evaluated.
Results
Two-stage approach for perforated gastric cancer was all performed by laparoscopic approach except 1 patient who needed paraaortic lymph node dissection (LND). Those were first treated on peritonitis with laparoscopic primary closure with or without Foley gastrostomy. Compared to 1-stage gastrectomy, more D2 LND was performed (60.0% vs. 100.0%, P = 0.260) and retrieved lymph nodes were significantly higher (median [range]: 17.0 [12.0–27.0] vs. 33.0 [26.5–43.5], P = 0.019]. Two patients of stage II and 3 patients of stage III were included in the 2-stage gastrectomy group. During the 38 months of median follow-up period, there were 8 and 1 recurrence among 1-stage and 2-stage gastrectomies, respectively. Except for 1 patient, 4 other 2-stage patients survived around 5 years without recurrence (5-year disease-free survival, 80%).
Conclusion
Laparoscopic 2-stage surgery for perforated gastric cancer is safe and might increase the curability of gastrectomy with extended LND.

Keyword

Gastrectomy; Intestinal perforation; Laparoscopy; Stomach neoplasms

Figure

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  Fig. 1 First step surgery of laparoscopic primary closure with Foley catheter insertion as tube gastrostomy. (A, C) Large perforation site with suspicious serosal invasion of gastric cancer. (B, D) Tube gastrostomy with Foley catheter insertion through perforation site.

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  Fig. 2 Preoperative endoscopy after the first surgery. (A–C) Ulcerofungating lesion which is pathologically confirmed with gastric cancer. (D) Foley catheter tube gastrostomy insertion state.

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  Fig. 3 Intraoperative findings of the second surgery. (A, C) Severe adhesion between omentum, liver, and gastric perforation site. (B, D) Second-tier lymph node dissection area without severe adhesion.

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  Fig. 4 Kaplan-Meier survival curve of perforated gastric cancer with 1-stage and 2-stage gastrectomy. (A) Five-year overall survival. (B) Five-year disease-free survival.

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