RAMB - JUNHO 2017

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2017; 63(6):484-487

only factor indicating suspected cancer is the patient’s

advanced age, which was not applicable to our case, di-

agnosed intraoperatively based on presentation suggestive

of cancer with perforated lesion.

Similarly to most studies in the literature, the re-

ported case presented an advanced tumor with severe

invasion and lymph node metastasis.

1,2

However, there

are no previous reports of a gastric perforation by adeno-

carcinoma progressing with splenic perforation. A litera-

ture search of the PubMed and Lilacs databases spanning

20 years with search words, gastric cancer, splenic perfo-

ration and perforated gastric cancer, found no case reports

similar to that outlined above.

The spleen has a close relation with the stomach. The

stomach floor, and the part proximal to its body, inter-

faces laterally with the spleen, increasing the likelihood

of an extended lesion.

However, the site of this patient’s

lesion, which was the gastric floor, is atypical according

to the literature that reports that 50 to 80% of gastric

perforations by cancer invade the distal third of the

stomach.

1-3,5

The optimal management of neoplastic lesions of the

stomach complicated by perforation is not yet well-defined.

The surgeon must be able to refrain the deleterious effects

of the perforation, such as diffuse peritonitis and bleed-

ing, and to provide curative correction or correction with

a good prognosis for the patient. Given that the diagno-

sis of cancer is typically confirmed at the postoperative

stage, full neoplastic resection is hampered. Moreover,

most of the cases of perforation occur in advanced cancers

with peritoneal dissemination.

The most debated issue

is whether the surgical treatment should comprise one or

two operations, i.e. full resection in a single operation,

or correction of the lesion in a first operation followed

by oncological resection in a second. The current trend

is to surgically manage these cases using two separate

operations.

1,2,5

In the present case, however, the patient

underwent radical resection in a single surgical procedure,

because neoplasia was suspected intraoperatively.

Another common debate regarding gastric cancers

revolves around lymph node resection. Various Western

and Japanese studies have sought to compare effectiveness

in terms of mortality and morbidity among patients sub-

mitted to D1 (neoplastic tumor of up to 3 cm) or D2 (up

to 6 cm) lymph node resection, the latter done without

splenectomy or pancreatectomy. The result of these stud-

ies favors D2 resection, with splenectomy and pancreatec-

tomy elected only in certain cases.

6-8

In our patient, in

addition to total gastrectomy and D2 lymph node resec-

tion, splenectomy was also carried out due to the organ’s

perforation. The patient presented N2 staging and the

operation seems to have been curative.

The prognosis of patients with gastric tumor perfora-

tion depends on several factors but outcomes are poor in

most cases. A study reviewing factors that contribute to

poor prognosis showed that mortality is linked to advanced

cancer stages.

In very advanced cases, however, the only

possible approach is that of simple suturing of the perfo-

ration, although patients undergoing this procedure have

a higher mortality than those submitted to gastrectomy.

There is no relation between perforation site and chanc-

es of survival. However, the study showed that preopera-

tive shock and time until resolution of perforation were

directly linked to mortality.

Patients with advanced can-

cer are less able to deal with the complications of gastric

perforation such as peritonitis and hemorrhage. Despite

presenting advanced neoplasia in addition to the asso-

ciation with a splenic lesion, which may have led to bleed-

ing and resultant shock, the patient progressed well, with

current survival at one year. According to the literature,

the 5-year survival rate is 40% for emergency cases treated

with total resection, which was the procedure performed

in our patient.

onclusion

Exclusive perforated gastric carcinoma is

per se

a rare con-

dition, and its association with splenic perforation has

not yet been reported in the literature. The stage of the

disease, presence of preoperative shock and time to surgi-

cal intervention are the main prognostic factors. Asso-

ciation with splenic lesion can aggravate bleeding, leading

to shock and a poor outcome. Optimal management of

this condition remains unclear and depends on surgeon

skill and experience for a successful outcome.

onflict

interest

The authors declare no conflict of interest.

esumo

Neoplasia gástrica perfurada com extensão da lesão para

o baço

A neoplasia gástrica perfurada é uma condição incomum

e de difícil diagnóstico pré-operatório, estando relacio-

nada a estágios avançados e com alta mortalidade, prin-

cipalmente na presença de choque pré-operatório. Poucos

estudos foram feitos quanto a sua forma de apresentação

e ao tratamento adequado. Além disso, não há nenhum

relato em literatura quanto à extensão da perfuração para