Curative-intent treatment for distal gastric cancer with gastric outlet obstruction: Management pathways and clinical outcomes from a Swedish multicenter cohort

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BACKGROUND: Distal gastric cancer with gastric outlet obstruction (GOO) poses challenges to multimodal treatment. The optimal management strategy in patients undergoing curative-intent treatment remains unclear. This study aimed to characterize real-world management pathways and outcomes in patients with distal gastric cancer presenting with clinically significant GOO. METHODS: All consecutive patients undergoing curative-intent resection for distal gastric adenocarcinoma with GOO between 2006 and 2024 at two Swedish tertiary centers were identified from national registry and institutional databases with chart validation. Patients were categorized according to treatment strategy: neoadjuvant chemotherapy or up-front surgery. Primary outcome was overall survival. Survival was analyzed using Kaplan-Meier estimates and multivariable Cox regression adjusting for age, ASA class, clinical T stage and nodal status. RESULTS: A total of 103 patients were included; 36 (35.0%) received neoadjuvant chemotherapy and 67 (65.0%) underwent up-front surgery. Patients receiving neoadjuvant therapy were younger (median 63.7 vs 77 years, p < 0.001) and more frequently had cT3-4 and cN + disease (p < 0.001). Most patients completed planned neoadjuvant treatment. R1 resection rates were high and comparable between groups (30.6% vs 28.4%, p = 0.75). Median overall survival was 19.6 months after neoadjuvant therapy and 19.2 months after up-front surgery (log-rank p = 0.38). On multivariable analysis, treatment strategy was not independently associated with overall survival (HR 0.86, 95% CI 0.47-1.57; p = 0.63). CONCLUSION: GOO in distal gastric cancer should not be considered an absolute contraindication to neoadjuvant therapy when adequate nutritional and supportive strategies are employed. However, feasibility does not equal justification - in the absence of a survival benefit and in the context of increased severe postoperative complications, treatment decisions should be individualized through careful multidisciplinary assessment until better powered prospective studies are performed.

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