Perforated gastric cancer treated with staged surgery, HIPEC and chemotherapy

What happened, in summary

A 65-year-old man was admitted with fever, shortness of breath and upper-left abdominal pain after treatment for presumed pneumonia. CT instead showed a large subdiaphragmatic and perisplenic abscess. Endoscopy found a deep ulcer in the gastric fundus, and peritoneal cytology contained carcinoma cells. Biopsy confirmed moderately differentiated intestinal-type gastric adenocarcinoma.

Emergency laparoscopy was used first to drain the abscesses and control the sepsis. Ten days later, after his condition improved, he underwent laparoscopic total gastrectomy. The resection margins were negative and 48 lymph nodes were free of cancer. The tumor extended through the stomach wall, while the initial peritoneal cytology had been positive despite no visible peritoneal metastases.

Because of the perforation and concern about peritoneal recurrence, hyperthermic intraperitoneal chemotherapy was given during surgery using oxaliplatin, after intravenous fluorouracil and folinic acid. One month later he began adjuvant capecitabine plus oxaliplatin.

His postoperative recovery was largely uncomplicated apart from an episode of atrial fibrillation that responded to treatment. At the 6-month follow-up he was eating without discomfort and had no other symptoms, with cancer care continuing after the staged surgery and chemotherapy.