Balancing emergency repair and oncological safety in gastric ulcer perforations

Abstract

Several issues should be considered before the surgical treatment of gastric ulcer perforations, including morbidity, mortality, and recurrence. However, an often-overlooked issue is determining the cause of the perforation. When the perforation is secondary to an underlying and undiagnosed malignancy, stomach resection inadequately treats the oncological disease and may increase postoperative morbidity and require re-surgery.

Key Words: Gastric ulcer; Perforation; Stomach ulcer; Peptic ulcer; Gastric cancer

Core Tip: Gastric ulcer perforations are not always benign. The possibility of malignancy should not be overlooked during emergency repair. Early endoscopy following simple closure can help avoid unnecessary radical surgery while allowing timely cancer diagnosis. Additional studies are needed to determine the earliest time that endoscopy can be performed safely following peptic ulcer perforation repair.

TO THE EDITOR

We read with great interest the article by Pang et al[1] titled “Retrospective comparative study of different surgical methods for gastric ulcer perforation: Efficacy and postoperative complications” published in the World Journal of Gastrointestinal Surgery. The authors presented a retrospective analysis of three surgical approaches for gastric ulcer perforation: Simple closure, omental patch repair, and partial gastrectomy. The reported success rates were high (92.5%-97.5%), and the complication rate of each procedure was similar (15.0%-20.0%) to the others.

Gastrectomy is recommended for patients with large perforations or suspected malignancy because it has the lowest ulcer recurrence rate at the 1-year follow-up (2.5%). Omental patch repair offers the most appropriate balance of effectiveness, safety, and postoperative recovery; it is the preferred method at our institution. This procedure is excellent for treating cases in which there is suspicion of undiagnosed malignancy causing the ulcer. Pang et al[1] did not report the number of excluded patients with malignancy nor the method used for diagnosing the cancer (e.g., diagnosed malignancy preoperatively, intraoperative frozen section, or postoperative cancer diagnosis).

Morbidity, mortality, and recurrence risk should be considered when determining the most effective surgical treatment of gastric ulcer perforations. However, the cause of the perforation should also be considered, particularly if the perforation is secondary to an underlying malignancy. Stomach resection in cases of undiagnosed cancer inadequately treats the oncological disease and may increase postoperative morbidity and require additional surgeries.

Intraoperative identification of malignancy secondary to gastric ulcer perforation is challenging, depending on the severity of peritonitis and inflammation. While frozen section histology is the standard for intraoperative diagnostics, it is not always possible in emergency conditions. Even if malignancy is suspected, radical gastrectomy of a septic abdomen is not recommended due to an increased surgical risk and impaired recovery. Unless there are clear intraoperative indications for radical gastrectomy, a more prudent strategy is a simple closure or omental patch repair with an upper gastrointestinal endoscopy 4-6 weeks after surgery[2,3]. This delayed approach enables the correct histological diagnosis under more controlled conditions to determine an effective and safe treatment plan[4]. The probability of cancer spreading during a routine protocol biopsy of a gastric ulcer perforation varies between 0%-1.6% in studies involving more than 100 cases[4,5]. In studies involving a limited number of patients, this rate increases to 12.1%[6].

Additional studies are needed to determine the earliest time that endoscopy can be performed safely following peptic ulcer perforation repair. From our experience, patients who underwent endoscopy before the suggested 4-6 weeks did not suffer any adverse effects. If future published reports show that endoscopy can be safely performed earlier, then intraoperative biopsy may almost never be necessary. If malignancy is confirmed during the follow-up endoscopy, radical gastrectomy is recommended following neoadjuvant therapy. In the absence of cancer, conservative medical treatment for peptic ulcer disease may eliminate the need for further surgical intervention. This stepwise strategy balances oncological awareness and patient safety in gastric ulcer perforations.