Skip to main content

Modified Devine Exclusion for Unresectable Gastric Cancer – Bridge from Palliative to Curative Treatment

Authors
Joana Fontaínhas1, António P. Gomes2, Vítor Nunes2

Affiliations

  1. General Surgery Department, Hospital Prof. Dr. Fernando Fonseca, Portugal
  2. General Surgery Department, Hospital Vila Franca de Xira, Portugal

Introduction
The modified Devine exclusion technique is a surgical procedure reserved for the management of malignant gastric outlet obstruction in locally advanced/unresectable disease.

Methods
Clinical case report

Results
A 75-year-old female presented in the emergency department exhibiting a 6-month history of vomiting, epigastric pain, and weight loss. After concluding detailed research, the patient was diagnosed with undifferentiated-type gastric adenocarcinoma by upper endoscopy. Tumor staging revealed it to be locally advanced with direct invasion of the liver, pancreatic head, duodenum, and transverse colon. Stage laparoscopy showed no evidence of peritoneal disease or liver metastases.

For symptomatic relief and nutritional status improvement, after multidisciplinary discussion, the patient was proposed for modified Devine exclusion, followed by systemic chemotherapy. After surgery the patient completed seven cycles of systemic therapy (EOX) with tolerance and good radiologic response.

One year after initial diagnosis, after clinical, biochemical, and radiological response were confirmed, tumor resection was attempted. The patient was submitted to an uneventful open subtotal gastrectomy with D2 lymphadenectomy. Pathological examination of the surgical specimen showed a tubular gastric carcinoma ypT2 pN0, R0.

5-year follow-up after definitive surgery confirms she remains asymptomatic and without signs of cancer recurrence.

Conclusion
Even though this surgery has demonstrated better functional results in comparison with conventional gastrojejunostomy, it is still an uncommon choice in Western practice.

With the progress of chemotherapy, modified Devine may have not merely a palliative role, but also a bridge to surgery since it allows for the improvement of nutritional status and general patient condition for definitive surgery.

Further research on this topic is critical to understand if this procedure may have the potential to extend the survival rate through chemotherapy and conversion surgery. Until then, a personalized approach may be considered depending on patient status and tumor features.