Aguiar MFF, Pereira MA, Dias AR, Ribeiro Jr U, Ramos MFKP. Surgical treatment of perforated gastric tumors. World J Gastrointest Surg 2025; 17(11): 110490 [DOI: 10.4240/wjgs.v17.i11.110490]
Corresponding Author of This Article
Marcus Fernando Kodama Pertille Ramos, MD, PhD, Department of Gastroenterology, Instituto do Cancer, Instituto do Cancer, Hospital das Clinicas, HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, Sao Paulo 01249000, Brazil. marcus.kodama@hc.fm.usp.br
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Surg. Nov 27, 2025; 17(11): 110490 Published online Nov 27, 2025. doi: 10.4240/wjgs.v17.i11.110490
Surgical treatment of perforated gastric tumors
Matheus Felipe Ferreira Aguiar, Marina Alessandra Pereira, Andre Roncon Dias, Ulysses Ribeiro Jr, Marcus Fernando Kodama Pertille Ramos
Matheus Felipe Ferreira Aguiar, Marina Alessandra Pereira, Andre Roncon Dias, Ulysses Ribeiro Jr, Marcus Fernando Kodama Pertille Ramos, Department of Gastroenterology, Instituto do Cancer, Instituto do Cancer, Hospital das Clinicas, HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 01249000, Brazil
Co-first authors: Matheus Felipe Ferreira Aguiar and Marina Alessandra Pereira.
Author contributions: Aguiar MFF and Pereira MA contribute equally to this study as co-first authors; Aguiar MFF collected the data, performed the critical analysis, and wrote the manuscript; Pereira MA collected the data, analyzed the data, performed the critical analysis and wrote the manuscript; Dias AR and Ribeiro Jr U performed the critical analysis and reviewed the manuscript; Ramos MFKP designed the research study, collected the data, performed the critical analysis, and wrote the manuscript.
Institutional review board statement: The study was approved by the hospital ethics committee and registered online (https://plataformabrasil.saude.gov.br; CAAE: 47012521.3.0000.0068).
Informed consent statement: Informed consent was waived by the local Ethics Committee because of the retrospective nature of the study.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest that might be relevant to the contents of this manuscript.
Data sharing statement: No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Marcus Fernando Kodama Pertille Ramos, MD, PhD, Department of Gastroenterology, Instituto do Cancer, Instituto do Cancer, Hospital das Clinicas, HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Arnaldo 251, Sao Paulo 01249000, Brazil. marcus.kodama@hc.fm.usp.br
Received: June 10, 2025 Revised: July 5, 2025 Accepted: September 11, 2025 Published online: November 27, 2025 Processing time: 171 Days and 4.1 Hours
Abstract
BACKGROUND
Perforated gastric cancer (GC) is a rare but life-threatening surgical emergency. Optimal surgical management remains controversial, and evidence from high-volume centers, especially in Western countries, is limited.
AIM
To evaluate surgical and survival outcomes of patients with perforated GC (PGC) according to the initial treatment strategy.
METHODS
A retrospective cohort study was conducted including all patients with pathologically confirmed perforated gastric adenocarcinoma treated at a single tertiary cancer center between January 2009 and March 2024. Surgical strategies were categorized as gastrectomy or primary perforation repair. Outcomes analyzed included 30- and 90-day mortality, postoperative major complications, and overall survival (OS).
RESULTS
Among 1586 GC patients undergoing surgical treatment, 36 (2.3%) presented with PGC. The mean age was 62.5 years, and 55% were male. American Society of Anesthesiologists (ASA) class III/IV was present in 58.3%, and 83% had stage IV disease, with distant metastasis in 50%. Perforation repair was performed in 26 patients (72.2%), while 10 (27.8%) underwent one-stage gastrectomy. ASA III/IV status (57.7% vs 30%, P = 0.260) and metastatic disease (57.7% vs 30%, P = 0.137) were more frequent in the Perforation Repair Group, though not statistically significant. This group also had a higher rate of diffuse-type and poorly differentiated tumors (P = 0.024 and P = 0.014, respectively). Thirty- and 90-day mortality were higher in the Perforation Repair Group (61.5% vs 30%, P = 0.139; and 65.4% vs 30%, P = 0.073), without significance. Three patients initially repaired were later referred for gastrectomy. OS was significantly better in the Gastrectomy Group (P = 0.002), with median survival of 8.8 months vs 0.5 months. On multivariable analysis, gastrectomy was independently associated with improved survival (P = 0.026).
CONCLUSION
When clinically feasible, gastrectomy—either immediate or delayed—provides superior survival compared to local perforation repair alone in patients with PGC.
Core Tip: This retrospective study evaluated the clinical characteristics and survival outcomes of patients with perforated gastric cancer (GC) according to the surgical treatment approach. We found that perforated GC (PGC) is a rare but severe complication of GC, associated with high hospital mortality. It occurred more frequently in patients with advanced-stage disease, particularly stages III and IV. Surgical management varied, including one-stage gastrectomy, primary perforation repair, or a two-stage strategy—initial closure followed by delayed gastrectomy. Among these, overall survival was significantly higher in patients who underwent gastrectomy. Therefore, when clinically feasible, gastrectomy—either immediate or staged—should be considered the preferred approach, as it confers a survival advantage over perforation repair alone in the context of PGC.
