Neoadjuvant Treatment Versus Upfront Surgery in Gastric Cancer Patients: Early Postoperative and Pathological...

Background/Objectives: Gastric cancer remains one of the most frequent abdominal malignancies, being the 5th in incidence, and it is often diagnosed at advanced stages. Perioperative chemotherapy has been introduced to improve oncological outcomes, although concerns persist regarding increased postoperative complications after radical gastrectomy following neoadjuvant treatment (NAT). Methods: We performed a retrospective study on a continuous series of gastric cancer patients who underwent radical gastrectomy between January 2016 and December 2025. Patients were divided into two groups: those receiving NAT and those undergoing upfront surgery (US). Demographic data, clinical characteristics, operative variables, postoperative complications, 30-day mortality, and pathological findings were compared. Results: There were 383 patients included in the study; NAT was performed in 105 (27.4%) cases and US in 278 (72.6%) cases, with a mean age of 64.99 (63.09-66.88) vs. 67.83 (66.44-68.91) years. Baseline characteristics (Charlson score 3.8 vs. 4.26, p = 0.131), hemoglobin, and albumin levels, were similar between groups. Tumors in the NAT group were more frequently located in the upper stomach 19 (18.1%) vs. 33 (11.9%) or at the gastro-esophageal junction (only Siewert III tumors were included) 17 (16.2%) vs. 23 (8.3%) p = 0.04. Tumor stage was most frequently stage IIIB for radical surgery 111 (28.9%) and for the NAT group 20 (19.1%) and surgery first group 91 (32.7%). The overall grade III and above complication rates were 26 (6.8%) esojejunal fistula, 19 (4.9%) duodenal stump fistula, seven (1.8%) hemorrhagic complications, 31 (8.1%) cases of sepsis, and 33 (8.6%) medical complications. Anastomotic fistulas were more frequent in the surgery-first group, with 23 cases (8.3%), compared with the neoadjuvant group, with 3 patients (2.9%)-the result were not statistically significant. The number of resected lymph nodes was similar (35.4 vs. 35.2; p = 0.96), while NAT group had significantly fewer positive lymph nodes (5.7 vs. 8.0; p < 0.001). Complete pathological response was achieved in 10 (9.5%) of NAT patients. Conclusions: Neoadjuvant treatment does not appear to increase the complications rate following radical gastrectomy. This study supports the surgical safety of the perioperative adjuvant treatment for advanced gastric cancer patients. Further studies are necessary to assess long-term outcomes.