Upstaging of Operable Adenocarcinoma of the Stomach and Gastroesophageal Junction Following Staging Laparoscopy (SL): High-Risk Clinicopathological Features Requisite for Mandatory SL

Background: Accurate staging is paramount in optimizing outcomes for patients with operable adenocarcinoma of the stomach and gastroesophageal junction (GEJ). Cross-sectional imaging frequently underestimates the true extent of disease, particularly occult peritoneal metastases. Adding Staging laparoscopy (SL) enhances diagnostic precision, but its universal application remains debated. Identifying clinicopathological predictors of upstaging may enable the selective yet mandatory use of SL in high-risk subgroups. Methods: In this single-centre retrospective study, we analysed 182 patients with clinically operable adenocarcinoma of the stomach and GEJ who underwent SL as part of their staging work-up between June 2018 and December 2024. Clinical, radiological, and pathological variables were assessed to determine their association with upstaging. The primary endpoint was the detection of unsuspected metastatic disease or positive peritoneal cytology on SL. The secondary endpoint was to identify independent predictors of upstaging using multivariate logistic regression. Results: Of 182 patients evaluated, 37 patients (20.3%) were upstaged on SL, precluding curative-intent surgery. The most common route of upstaging was detection of peritoneal metastases 33(18.1%) and the rest of the patient had isolated positive cytology 4 (2.2%). High-risk features significantly associated with upstaging included minimal ascites (OR 5.87, p<0.001), signet ring cell histology (OR 4.15, p=0.007), linitis plastica morphology (OR 3.42, p=0.002), and tumor thickness ≥15 mm (OR 2.21, p=0.034). Notably, radiologically node-negative patients with none of the high-risk features had a low probability of upstaging. A risk-stratified algorithm based on these parameters improved the diagnostic yield of SL and reduced non-therapeutic laparotomies. Conclusion: Universal incorporation of staging laparoscopy into treatment algorithms for operable gastric and GEJ adenocarcinoma is challenging in many settings due to resource and economic constraints. While established guidelines endorse SL in selected scenarios, our findings suggest that, in addition to these proven indications, the consideration of SL in patients with linitis plastica morphology, tumour thickness >15 mm, signet ring cell carcinoma histology, and even mild ascites can further refine the staging accuracy. Targeting these high-risk subgroups enables a more personalised treatment approach, maximises the detection of occult metastases, and, importantly, reduces the incidence of non-therapeutic laparotomies.