Aliyu S1 and Ningi AB2*
1Department of Surgery, University of Maiduguri Teaching Hospital, Nigeria
2Department of Surgery, Abubakar Tafawa-Balewa University Teaching Hospital, Nigeria
Background: Gastric cancer was once captioned as the “Captain of Death”. Although, it has lost the
ignominious title now, it is still a major cause of cancer related morbidity and mortality. According
to global cancer observatory report in May, 2019, gastric cancer still has a high prevalence rate in
Nigeria. It is responsible for 3.5% of all cancers seen in males in 2018 and responsible for 3% of
all cancer related deaths in Nigeria. Cancers involving the antrum and body of the stomach are
termed as distal, while those involving the cardia and siewert type 111 gastro-oesophageal cancers
are considered as proximal. Previous report from Irabor et al. indicated a low incidence for proximal
gastric cancers, a stable state prevalence for distal gastric cancers and rejected the role of H-pylori
related gastritis in the aetiopathogenesis of gastric cancers in Ibadan, South-western Nigeria.
We noted an increasing rise in the prevalence of proximal gastric cancers and a strong causal
relationship between H-pylori related gastric disorders and gastric cancers in North-eastern Nigeria.
Like previous reports, majority of our patients presented late with advanced gastric cancers and
the outcome is still abysmal despite years of experience and increased availability of adjuvant care.
Objectives: We aim to demonstrate an upward trend in the prevalence of proximal gastric cancers
in developing country like Nigeria and demonstrate the effect of H-pylori related gastric disorders on
the emergence of gastric cancers. We also aim to demonstrate the burden of advanced disease that
present to the surgeon in poor resource health facilities and the challenge of managing morbidities
associated with advanced gastric cancers.
Patients and Methods: This is a prospective cross-sectional study of 52 patients that presented
with various clinical types of gastric cancers from January 2004 to December 2012 at the general
surgery unit of University of Maiduguri Teaching Hospital, Borno State, Nigeria. Patients’
characteristics studied included the Biodata, relevant clinical and family history, H-pylori antibody
test, endoscopic biopsy and histopathologic assessment of gastric biopsy specimen, staging
radiological investigations and their results and the morbidities related to the indicated surgical
care or metastatic complications. Informed consent was obtained from all participants according to
the Helsinki guidelines and ethical clearance was given by the hospital authority.
Data Analysis: All data obtained was assessed using the statistical package for social 20.0 (IBM,
Armonk, NY, USA). Continuous variables were presented as mean ± SD. Categorical variables were
expressed as frequencies and percentages. The Pearson’s chi square test was used to determine the
relationship between two categorical variables. P<0.05 was considered statistically significant.
Results: The study populations were 52 patients. 50% were males and females each, giving a male
to female ratio of 1:1. The mean age was 50.5 (± 4.04) with an age range of 16 to 85 years. The
most common clinical type is early distal gastric cancer (34.6%), advanced distal gastric cancers,
28.8%. Early proximal gastric cancers constituted 23.1% and advanced proximal cancers 13.5%
respectively. 57.7% presented clinically as early disease and 42.3% as advanced gastric cancers. The
most common clinical symptom is dyspepsia, seen in 84.6% of all patients, followed by weight loss
(82.7%); anorexia (73.1%), projectile vomiting (30.8%) and dysphagia (25%). 34.6% have a positive
H-pylori serology. The most common cancer is adenocarcinoma (86.5%); followed by gastro-intestinal stromal tumors
(11.5%) and squamous cell carcinoma (1.9%). The most common histological sub-type is Intestinal
and diffuse adenocarcinoma, 21.2% each. Poorly differentiated adenocarcinoma 17.3%, moderately
differentiated 13.5% and well differentiated adenocarcinoma 11.5%. Rare sub-types were also seen.
Mucinous adenocarcinoma (9.6%) and signet ring carcinoma (5.8%).
The most frequent surgical procedure done was palliative feeding jejunostomy (40.4%). Billroth
2 gastrectomy (26.9%) was the preferred procedure for early distal gastric tumors and proximal
partial gastrectomy with primary gastro-oesophageal anastomosis (15.4%) for early proximal gastric
tumors. In this study, 9.6% of the patients had total gastrectomy with Roux-en-Y anastomosis and
Billroth 1 gastrectomy for early proximal and distal gastric tumors respectively. Post-operatively,
50% of the patients had no post-operative complications. The most common post-operative
morbidity was anastomotic leak (11.5%) and the least common were, late dumping syndrome,
duodenal blow out and anastomotic stump obstruction; 1.9% each.
34.6% of the patients did not survive up to a year after diagnosis. These are patients with advanced
disease. 38.5% lived for 3 years and above. But, only 5.7% of the patients were alive 5 years after
Conclusion: Proximal gastric cancer is on the rise in the African continent and distal gastric cancer
prevalence is not declining as observed in Western countries. The so-called “African Enigma” of
high H-pylori prevalence and low gastric cancer prevalence is at best a myth. There seem to be a
strong relationship between high H-pylori related gastric disorders and gastric cancers. Nothing
much has changed in the last two decades in terms of late presentation of gastric cancers. The
outcome of treatment is still abysmal as overall survival is still less than a year.
Rising proximal cancers; H-pylori related gastric cancer; Burden of advanced gastric cancers; Developing country
Aliyu S, Ningi AB. The Upward Trend of Proximal Gastric Cancers and the Challenges of Advanced Gastric Cancer Management in Nigeria: Our Experience in a Tertiary Health Facility in North-Eastern Nigeria. World J Surg Surgical Res. 2020; 3: 1205..