Two-stage radical gastrectomy for perforated gastric cancer

Introduction: Perforation represents a severe complication of gastric cancer. Because it is rare, only few data are available regarding treatment and prognosis. Methods: Patients with perforated gastric cancer were identified from two prospective registers of gastric cancer and of gastroduodenal ulcer. Results: Between February 1982 and June 1999 23 patients with perforated gastric cancer were treated surgically. This corresponds to only 1.8% of 1273 patients presenting with gastric cancer, but to 140/a of 161 patients presenting with gastric perforation during this time period. Overall, post-operative mortality was 13% (3/23). Initially, 21 patients had palliative operations. Two patients had a potentially curative procedure at the emergency operation and one of the two died post-operatively. Another six patients had potentially curative gastrectomy at a second stage and no patient died post-operatively. The 5-year overall survival was estimated at 50% for all eight curatively-treated patients. Median survival of palliatively treated patients was 6 months. Conclusions: Perforation of the stomach should raise suspicion of malignancy particularly in elderly patients. At the time of perforation radical gastrectomy with lymphadenectomy is mostly not advised, either because a diagnosis of gastric cancer is not confirmed or because the patient's condition does not allow extended surgery. In this situation it is suggested to consider a two-stage procedure and direct the primary operation at the treatment of perforation and peritonitis. Tumour staging can be completed when the patient has recovered and a radical operation with curative intent can be planned without compromising long-term prognosis. Our observations and a review of the literature confirm that perforation of gastric cancer does not preclude long-term survival per se in a substantial number of patients. (C) 2000 Harcourt Publishers Ltd.