Surgical Procedure and Postoperative S-1 Chemotherapy Deliverability in Symptomatic Stage IV Gastric Cancer

Symptomatic incurable stage IV gastric cancer (GC) may require palliative surgery for bleeding or obstruction before systemic therapy. We examined whether procedure type-distal gastrectomy (DG), total gastrectomy (TG), or gastrojejunostomy (GJ)-is associated with nutritional/inflammatory changes, S-1 deliverability, and overall survival (OS).

We retrospectively studied 49 patients who underwent palliative DG (n=13), TG (n=20), or GJ (n=16) and then received S-1 as first-line postoperative chemotherapy. Body weight, prognostic nutritional index (PNI), and neutrophil-to-lymphocyte ratio (NLR) were assessed preoperatively and before chemotherapy. Deliverability was evaluated by time to S-1 initiation, continuation beyond 3 months, and treatment modification within 3 months. OS was analyzed using Kaplan-Meier and Cox models.

Postoperative complications were more frequent after GJ (p=0.002); time to S-1 initiation was similar among groups (p=0.144). S-1 continuation beyond 3 months was achieved in 29/49 patients (59.2%; DG 76.9%, TG 55.0%, GJ 50.0%; p=0.302). Weight loss was significantly greater after TG than after DG or GJ, and GJ showed a postoperative decline in PNI and a significantly higher pre-chemotherapy NLR than DG and TG (p=0.015 and p=0.036, respectively). Median OS was 474 days (DG: 812, TG: 422, and GJ: 293 days) and was significantly longer after DG than after TG (p=0.042) or GJ (p=0.003). In multivariate Cox analysis, chemotherapy for ≥3 months (HR=0.46, 95% CI=0.22-0.95; p=0.036) and high PNI (HR=0.31, 95% CI=0.13-0.77; p=0.012) were independent prognostic factors.

In symptomatic incurable stage IV GC treated with palliative surgery followed by S-1, procedure type was associated with distinct perioperative profiles and OS. Maintaining chemotherapy and immuno-nutritional status may be clinically relevant in these patients.