[Stage-adapted radical principles in gastric carcinoma]

The aim of any surgical approach to gastric carcinoma should be a complete resection with no residual tumor left behind, that is, a R0-resection according to UICC. Complete tumor resection in this respect refers to the primary tumor as well as to the lymphatic drainage and requires an adequate safety margin. The indications for surgical therapy of gastric cancer and the choice of procedure should consequently be guided by the tumor stage. This requires accurate preoperative staging, which can today be achieved with endoscopic ultrasonography and surgical laparoscopy. Gastric carcinoma stage IA (mucosa carcinoma) can be cured by local excision. In patients with tumor Stages IB (submucosa carcinoma), II, and IIIA, lymph node metastases are common. Based on the available data, this group of patients benefits from radical resection and D2 lymph node dissection. The overall 5-year survival rate of 50% for the large number of patients undergoing gastric resection for cancer seems to demonstrate convincingly the value of extended lymphadenectomy. In patients with advanced gastric carcinoma, that is, tumor stages IIIB and IV, a complete tumor removal usually can not be achieved by surgical dissection. Neoadjuvant therapeutic modalities should consequently be assessed in these patients. Based on tumor location and growth pattern, a total gastrectomy is the procedure of choice in patients with middle and proximal third gastric cancer. A subtotal gastrectomy may be performed in patients with tumors of the distal third and "Laurens intestinal type" growth pattern. The distal site of the main lesion must be investigated carefully to ensure that incidental concomitant lesions are not overlooked. Depending on the individual tumor situation, the gastrectomy can be extended toward varying portions of the distal esophagus or the pancreas, preserving splenectomy and resection of the retroperitoneal lymph nodes. The high incidence of locoregional recurrences and distant metastases after curative surgery for gastric cancer calls for improved locoregional control and systemic adjuvant treatment.