[New challenges to perioperative safety in the era of neoadjuvant immunotherapy for gastric cancer: distinguishing immune-related adverse events from postoperative complications].

With the expanding use of immune checkpoint inhibitors (ICIs) in gastric cancer, surgical safety is facing new challenges. Perioperative immune-related adverse events (irAEs) can substantially overlap with postoperative complications in both time course and clinical presentation, increasing the risk of diagnostic confusion, missed or delayed recognition, and potentially fatal outcomes. Integrating evidence from prior studies and real-world clinical experience, this article focuses on perioperative irAEs in gastric cancer that are particularly prone to misclassification, such as ICI-related pneumonitis, hypophysitis, adrenal insufficiency, and hypothyroidism. We systematically summarize their epidemiology and common manifestations and, using a symptom-oriented approach, address typical perioperative scenarios including fatigue, hypotension, electrolyte disturbances, altered mental status, postoperative fever, hypoxemia, dyspnea, cough, and perioperative enzyme abnormalities. Practical diagnostic clues and management strategies are proposed to distinguish irAEs from surgical complications such as infection, hemorrhage, pulmonary complications, myocardial infarction, and surgery-related pancreatic injury. We further emphasize the need to establish a standardized, multidisciplinary team-based perioperative pathway in the era of neoadjuvant immunotherapy, incorporating comprehensive preoperative baseline assessment of cardiac, pulmonary, hepatic, and endocrine function; protocolized postoperative monitoring at key time points; and risk-stratified interventions. When irAEs are suspected, early specialist consultation and timely initiation of immunosuppressive therapy, particularly corticosteroids, are critical to reducing both diagnostic delay and unnecessary overtreatment, thereby maximizing the therapeutic benefit of immunotherapy while safeguarding surgical outcomes.