Surgical treatment of perforated gastric tumors

Table 1 Clinical characteristics of patients with perforated gastric cancer according to initial surgical approach - primary perforation repair and one-stage gastrectomy groups

Variables	Primary perforation repair, n = 26	One-stage gastrectomy, n = 10	P value
Sex, n (%)			0.722
Female	11 (42.3)	5 (50)
Male	15 (57.7)	5 (50)
Age (years)	61 ± 13.4	66.5 ± 11.3	0.263
Body mass index (kg/m²)	21.1 ± 4.6	23.5 ± 3.0	0.145
Hemoglobin (g/dL)	10.5 ± 2.3	10.2 ± 2.4	0.736
< 11, n (%)	17 (65.4)	7 (70)	1.0
Albumin (g/dL), n (%)	3.0 (0.9)	3.2 (0.7)	0.492
< 3.5	16 (61.5)	6 (60)	1.000
Neutrophil-to-lymphocyte ratio	1.92 ± 1.15	2.56 ± 1.16	0.145
Charlson-Deyo comorbidity index, n (%)			0.688
0	19 (73.1)	6 (60)
≥ 1	7 (26.9)	4 (40)
American Society of Anesthesiologists, n (%)			0.260
I/II	9 (34.6)	6 (60)
III/IV	17 (65.4)	4 (40)
Tumor location, n (%)			0.709
Distal third	9 (34.6)	5 (50)
Middle third	4 (15.4)	1 (10)
Proximal third	9 (34.6)	4 (40)
Linite plastica	4 (15.4)	0 (0)
Lauren type, n (%)			0.024
Intestinal	12 (46.2)	9 (90)
Diffuse/mixed	14 (53.8)	1 (10)
Histological tumor grade, n (%)			0.014
Well/moderately differentiated	4 (15.4)	6 (60)
Poorly differentiated	22 (84.6)	4 (40)

Table 2 Clinical stage and surgical outcomes of patients with perforated gastric cancer according to initial surgical approach - primary perforation repair and one-stage gastrectomy groups, n (%)

Variables	Primary perforation repair, n = 26	One-stage gastrectomy, n = 10	P value
cT			1.0
< T4a	14 (53.8)	5 (50)
cT4b	12 (46.2)	5 (50)
cN			0.484
cN0	1 (3.8)	1 (10)
cN+	5 (96.2)	9 (90)
cM			0.137
cM0	11 (42.3)	7 (70)
cM1	15 (57.7)	3 (30)
cTNM			0.324
≤ III	4 (15.4)	2 (20)
IVA	7 (26.9)	5 (50)
IVB	15 (57.7)	3 (30)
Preoperative chemotherapy			0.397
No	19 (73.1)	9 (90)
Yes	7 (26.9)	1 (10)
Length of hospital stay (days)			0.185
Median (IQR)	11 (5-20)	13.5 (10-37)
Postoperative complication (Clavien-Dindo)			1.000
0-I-II	9 (34.6)	3 (30)
III-V	18 (69.2)	7 (70)
Clavien V			0.260
No	9 (35.6)	6 (60)
Yes	17 (65.4)	4 (40)
Mortality
30-day	16 (61.5)	3 (30)	0.139
90-day	17 (65.4)	3 (30)	0.073

Table 3 Surgical and pathological characteristics of perforated gastric cancer patients undergoing gastrectomy (one- and two-stage approach)

Variables	Gastrectomy, n = 13	%
Previous perforation repair
Yes	3	23.1
Lymphadenectomy
D0/D1	8	61.5
D2	5	38.5
Type of gastrectomy
Subtotal	5	38.5
Total	8	61.5
Tumor size (cm)	5.8 ± 3.7
Invasion
Lymphatic invasion	8	61.5
Venous invasion	8	61.5
Perineural invasion	6	46.2
pT
pT2	1	7.7
pT3	2	15.4
pT4	10	76.9
Number of dissected LN	23.1 ± 16.7
pN
pN0	5	38.5
pN+	8	61.5
pM
pM0	10	76.9
pM1	3	23.1
pTNM
> II	1	15.4
III	8	61.5
IV	3	23.1

LN: Lymph node.

Table 4 Patient data with two-stage approach: Local repair of perforation following gastrectomy

No	Sex	Age (year)	cTNM	Clavien (local repair)	Interval local repair vs gastrectomy (month)	Type of surgery	pTNM	DFS (month)	OS (month)	Status
1	Male	68.9	T4b N1 M0	4	6.4	TG D2	pT4 pN0 pM0	14	21.6	Death
2	Male	68.5	T4b N1 M0	2	3.4	TG D2	pT4 pN1 pM0	11.6	20.5	Death
3	Male	39.1	T1 N1 M0	2	3.5	SG D2	pT3 pN1 pM0	53.3	53.3	Alive

DFS: Disease-free survival; OS: Overall survival; TG: Total gastrectomy; SG: Subtotal gastrectomy.

Table 5 Univariable and multivariable analysis for overall survival

Overall survival, variables	Univariable			Multivariable
	HR	95%CI	P value	HR	95%CI	P value
Female (vs male)	1.47	0.70-3.07	0.306	-	-	-
Age > 65 years (vs < 65 years)	0.69	0.34-1.40	0.306	-	-	-
Charlson > 1 (vs CCI 0)	1.25	0.59-2.66	0.557	-	-	-
ASA III/IV (vs ASA I/II)	1.79	0.87-3.68	0.114	-	-	-
Hemoglobin < 11 g/dL (vs > 11 g/dL)	2.41	1.05-5.52	0.037	1.56	0.45-5.40	0.478
Albumin < 3.5 g/dL (vs > 3.5 g/dL)	2.35	1.09-5.07	0.029	1.44	0.42-4.91	0.561
cM1 (vs cM0)	3.25	1.41-7.52	0.006	1.43	0.50-4.09	0.509
Perforation repair exclusive (vs gastrectomy)	3.66	1.51-8.87	0.004	3.18	1.15-8.82	0.026

HR: Hazard ratio; 95%CI: 95% confidence interval; ASA: American Society of Anesthesiologists; CCI: Charlson–Deyo comorbidity index.