Escalation and de-escalation in surgery for gastric cancer

Surgical resection remains the cornerstone of curative treatment for gastric cancer, providing effective local control. Recent advances in systemic therapies and the development of various surgical technologies have significantly transformed treatment strategies for this disease. Multiple clinical trials of gastric cancer surgery have demonstrated that extended surgical procedures do not improve survival outcomes, whereas minimally invasive approaches-such as conventional laparoscopic and robot-assisted surgeries-, have been shown to offer favorable safety and efficacy. Moreover, with an aging patient population and substantial progress in multidisciplinary treatments, including immunotherapy, the role of surgery is being reassessed, even for patient groups deemed unsuitable for surgical intervention, such as older patients and those with initially unresectable advanced gastric cancer. Furthermore, the introduction of novel diagnostic technologies has expanded the potential for individualized surgical decision-making by enabling more precise assessment of residual diseases. This review examines the current evidence and future perspectives on gastric cancer surgery, focusing on surgical escalation and de-escalation. Four key aspects are addressed: (1) surgical approach, (2) extent of lymphadenectomy, (3) extent of resection, and (4) surgical indications. These insights aim to inform optimal surgical strategies for gastric cancer in the era of evolving treatment paradigms.