Current status of surgery for gastric cancer: a review

In the last three decades, considerable progress has been made in the diagnosis and management of gastric cancer. This was initiated by the Japanese and taken up by other focus groups in Asia, the United States, and Europe. Exciting prospects have been identified with the molecular characterization of the mutated gene causative for familial gastric cancer, and new developments in endoscopy and laparoscopy for diagnosis, management, and treatment continue. It is now clear that the extent of the gastric resection requires only that an R0 resection be performed and that total gastrectomy is not necessary for all patients with gastric adenocarcinoma. The extent of nodal dissection is defined as a major factor in staging and can influence outcome by stage. The recent development of defining adequate staging based on at least 15 nodes being sampled is a clear example of a simple system that can make major differences in overall management. The role of extended node dissection has been studied in prospective randomized trials showing no overall survival benefit but perhaps benefit to selected subgroups. The importance of the hospital and surgical experience in improving mortality and long-term survival is established. The role of adjuvant therapy, both pre- and postoperative, continues to be evaluated with some frustration that a single trial, as yet unconfirmed by subsequent trials, is considered the "standard of care" in the United States. The international gastric cancer community can help define the important issues that need to be answered in the coming decades.