Optimal surgery for gastric cancer: is more always better?

The extent of surgical resection for carcinoma of the stomach has been debated for many years. The aims of surgery are to obtain complete histopathological clearance of all possible sites of disease based on oncological principles. This has included radical resection of the primary site with combined organ resection as required and resection of associated lymph nodes. Detailed understanding of the natural history of gastric cancer has resulted in the Pichlmayr total gastrectomy "en principe" approach being super-ceded by a tailored approach according to tumour and patient characteristics. Careful tumour staging is fundamental to the selection of surgical intervention. Endoscopic therapy is recommended for well differentiated, mucosal cancers less than 2 cm in size as the risk of nodal disease is 0-3 %. Recently, these criteria have been extended to include some larger and ulcerated cancers. Although extended lymphadenectomy has formed the basis of radical surgery, Japanese experience has also confirmed that for early gastric cancer involving the submucosa limited nodal resection can achieve the same outcome as standardised D2 lymphadenectomy. The approach to locally advanced T2, T3 and some T4 cancers has been defined by the Japanese rules specifying proximal and distal margins as well as extent of lymph node resection. Translation of Japanese results to Western patients has not been straightforward. Two randomised controlled trials have shown limited or no benefit over conventional limited nodal dissection. However, these studies have not been without criticism and individual specialist practice in the West now preferentially includes D2 lymphadenectomy in suitable patients. Extending conventional D2 lymphadenectomy has been evaluated but the results are not conclusive. Japanese RCTs have not shown an advantage but in selected cases several groups have reported a benefit. Historically, radical gastric surgery in the West was associated with significant morbidity and mortality reflecting the comorbidity of the patient groups. Perioperative approaches have shown that outcome approaching that of radical surgery can be achieved with multimodal therapies for high-risk patient groups for whom radical surgery would be contraindicated. Surgery for gastric cancer needs to be determined by a multidisciplinary team to ensure appropriate procedure selection for an individual patient. This allows all relevant information to be considered and to provide the best chance for high-quality patient outcome.