title: The best surgical approach for perforated gastric cancer: one-stage vs. two-stage gastrectomy.
abstract: BACKGROUND
  Surgery for perforated gastric cancer has a dual purpose: treating life-threatening peritonitis and curing gastric cancer. An emergent one-stage gastrectomy may place an undue burden on patients with a poor general status and could impair long-term survival even if the gastric malignancy is curable. A two-stage gastrectomy, in which the initial treatment of peritonitis is followed by elective gastrectomy, can accomplish both desired purposes.
  
  
  METHODS
  We retrospectively analyzed 514 Japanese cases of perforated gastric cancer. 376 patients underwent a one-stage gastrectomy and 54 patients underwent a two-stage gastrectomy. We evaluated patient characteristics, surgical outcomes, postoperative complications, and survival rates in both groups.
  
  
  RESULTS
  The two-stage gastrectomy group saw a 78.4% rate of curative R0 resection and 1.9% hospital mortality rate, while corresponding rates in the one-stage gastrectomy group were 50 and 11.4%, respectively. Among cases in which curative R0 resection was performed, there was no significant difference in overall survival between 136 one-stage gastrostomies and 40 two-stage gastrostomies. In a multivariate analysis, curative R0 resection [hazard ratio (HR) 2.937, p = 0.001] and depth of tumor invasion (HR 1.179, p = 0.016) were identified as independent prognostic factors.
  
  
  CONCLUSIONS
  Regardless of whether patients underwent a one-stage or two-stage gastrectomy, curative R0 resection improved survival in patients with perforated gastric cancer. When curative R0 resection cannot be performed in the initial treatment phase due to diffuse peritonitis, non-curative and palliative gastrectomy should be avoided, and a two-stage gastrectomy should be planned following peritonitis recovery and detailed examinations.
authors.affiliation: Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
authors.forename: Tatsuo
authors.initials: T
authors.lastname: Hata
authors.forename: Naoaki
authors.initials: N
authors.lastname: Sakata
authors.forename: Katsuyoshi
authors.initials: K
authors.lastname: Kudoh
authors.forename: Chikashi
authors.initials: C
authors.lastname: Shibata
authors.forename: Michiaki
authors.initials: M
authors.lastname: Unno
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D007564:Japan; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D015996:Survival Rate; D055815:Young Adult