Perforated Gastric Cancer: Epidemiology, Diagnosis, and Surgical Management Strategies

Gastric cancer complicated by free perforation is a rare but life-threatening oncological emergency, accounting for 0.3% ~ 3.9% of all gastric cancer cases. This review summarizes current evidence on the epidemiology, diagnosis, surgical management, and prognostic determinants of perforated gastric cancer, with emphasis on stage-adapted treatment strategies. It should be noted, however, that the available evidence is derived exclusively from retrospective studies, and all recommendations should be interpreted in the context of this inherent limitation. Relevant studies addressing perforation patterns, perioperative outcomes, one-stage versus two-stage gastrectomy, repair-only approaches, and management of metastatic disease were reviewed. Perforation typically arises from tumors located on the anterior wall or greater curvature, where transmural invasion creates direct communication with the peritoneal cavity, resulting in diffuse peritonitis and substantial postoperative mortality. Available pooled evidence suggests that radical resection, when oncologically and physiologically feasible, is associated with better survival than repair-only strategies. Comparative retrospective data suggest that two-stage gastrectomy may be associated with higher R0 resection rates and lower in-hospital mortality compared with emergency one-stage resection, without compromising long-term survival when curative resection is ultimately achieved; however, these findings should be interpreted with caution given the exclusively retrospective evidence base and the inherent patient selection bias in all published comparisons. In patients with stage IV disease or confirmed distant metastases, stomach-preserving source control followed by systemic chemotherapy may be a rational alternative. Prognosis is primarily determined by TNM stage and R0 resection status, similar to non-perforated gastric cancer. Individualized treatment based on tumor stage, resectability, peritoneal contamination, and physiological reserve is essential.