The aims of palliative surgery for gastric cancer are to relieve symptoms, i.e., pain, nausea, vomiting, and weight loss, and hereby improve the patient’s quality of life or to control an emergency situation, i.e., bleeding or infection due to gastric perforation. In the literature, the term “palliative surgery” is often applied to any type of non-curative surgery, which is not correct. Surgical palliation should be consistently defined as a procedure intended to control symptoms or improve quality of life. Palliative surgery is not intended to prolong life or prevent tumor-associated death. Thus, palliative surgery requires the presence of symptoms. Symptom control rather than overall survival should be the endpoint for any analysis of palliative surgery.

Specific questionnaires for patients with gastric cancer have been developed to measure quality of life. The EORTC QLQ-OG25, e.g., considers dysphagia, eating restrictions, reflux, odynophagia, pain, and anxiety in addition to standard measurements of quality of life. In particular, eating restriction and consecutive cachexia limit life quality of patients with advanced gastric cancer. Most studies evaluating the quality of life following palliative surgery used hospital-free survival as a surrogate marker for quality of life. Moreover, prospective studies dealing with life quality and palliative surgery are not available. Thus, the effect of palliative surgery in patients with advanced gastric cancer on quality of life is unknown. Studies in the field of quality of life require changes to improve the decision-making process for these patients.

It is important to emphasize that palliative surgery is not equal to non-curative resections in gastric cancer. The term non-curative surgery includes procedures performed with the intention to prolong survival that almost achieve the goal of complete resection of all gross and microscopic disease. Therefore, non-curative resections may or may not be considered palliative. The exact definition, however, is important for the interpretation of studies dealing with stage IV gastric cancer.

Non-curative resections have been shown to prolong survival in patients with distant lymph node metastases, liver metastasis, and locally advanced late-stage gastric cancer but not when peritoneal dissemination or multiorgan metastases are present [1]. Nonetheless, non-curative resection in patients with advanced gastric cancer does not represent the standard of care and should be performed only in selected patients according to an interdisciplinary tumor board decision. Currently, two prospective randomized controlled trials are comparing overall survival in patients with stage IV gastric cancer treated systemically with or without resection of the primary tumor. The results of these studies may change the strategy (Fig. 11.1) in the future.

In recent years, the therapeutic approach combining cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (HIPEC) for peritoneal carcinosis has been evaluated with promising results. The rationale, here, is to surgically resect all gross tumor masses and to treat any remaining microscopic disease with high intraperitoneal concentrations of cytotoxic agents. Prospective randomized controlled trials are still needed, but first results may justify this approach in selected patients with limited and resectable peritoneal carcinosis and without other organ metastases [2]. Patients need to be carefully selected for cytoreductive surgery and HIPEC: “Limited” peritoneal carcinosis means the peritoneal cancer index according to Sugarbaker et al. should be less than 19.¹ Moreover, patients should have a good or excellent performance status (ECOG 0 or 1). Finally, HIPEC should only be performed as part of a multimodal therapeutic approach.

Complications due to peritoneal carcinomatosis, i.e., stenosis, bleeding, or perforation, have to be treated considering tumor mass, distribution and localization, performance status, nutritional status, and overall prognosis. Potential surgical therapeutic approaches include small bowel resections, ileostomies or colostomies, bypass surgery, or percutaneous endoscopic gastrostomy (PEG) placement to drain gastric and small bowel fluid.

The development of ascites requiring repeated paracenteses massively impairs patients’ quality of life. For these patients, intraperitoneal administration of the trifunctional antibody catumaxomab can be considered. Catumaxomab binds T cells and the epithelial adhesion molecule EpCAM which is expressed by tumor cells but not healthy peritoneum. Application of catumaxomab has been shown to increase puncture-free survival from 11 to 46 days, which is associated with an improved quality of life [3]. Fever and a rise in C-reactive protein (CRP) are common side effects of this treatment. Alternatively, laparoscopic HIPEC without previous cytoreduction can be a palliative treatment option for refractory malignant ascites due to unresectable peritoneal carcinosis of gastric origin although this approach has to be considered experimental [4].

Gastric cancer may be complicated by bleeding, obstruction, or perforation. As most cases of bleeding and obstruction can be managed endoscopically and do not require surgery, prophylactic gastrectomy with the intention to avoid these complications is not indicated. Moreover, a relevant number of patients develop problems related to metastases and not to the primary tumor. In summary, complications should be treated as they occur.