A comprehensive overview of gastric cancer management from a surgical point of view

Abstract

Despite advancements in medical care, surgical technologies, and the development of novel treatments over the past decade, the prognosis for patients with gastric cancer (GC) has only modestly improved. This is primarily due to the fact that the majority of patients are diagnosed at advanced stages or present with metastatic disease. Radical resection remains the cornerstone of potentially curative treatment, yet the overall 5-year survival rate remains below 35%. The management of GC varies globally, influenced by factors such as geographical disparities, patient comorbidities and performance status, surgical approaches, and available medical resources. Multidisciplinary collaboration and a multimodal treatment approach are essential for optimizing patient outcomes. Surgeons must stay updated on emerging surgical concepts and make informed decisions regarding patient selection, timing of intervention, and the adoption of appropriate surgical techniques to improve both quality of life and prognosis. This review aims to provide a surgical perspective on the management of GC across all stages, highlighting the importance of a comprehensive treatment approach. Endoscopic resection may be a viable option for early GC in patients with minimal risk of lymph node metastasis, particularly in elderly patients with high surgical risk or severe comorbidities. For advanced GC, neoadjuvant therapy followed by surgery could be a promising strategy to improve patient outcomes. Conversion surgery offers a potential survival benefit for patients who respond to treatment with tumor downstaging. The treatment of peritoneal carcinomatosis remains challenging; however, hyperthermic intraperitoneal chemotherapy combined with complete cytoreductive surgery or pressurized intraperitoneal aerosolized chemotherapy may prolong survival or improve quality of life in highly selected patients.

Keywords: Conversion surgery; Gastric cancer; Intraperitoneal chemotherapy; Lymphadenectomy; Minimally invasive surgery; Neoadjuvant chemotherapy.

Fig. 1

Lymph node location according to the Japanese gastric cancer classification (2011, 3rd edition)³⁷.

Fig. 2

Algorithm of surgical treatment strategies for gastric cancer Abbreviations: #: invasion to the pancreas/duodenum/esophagocardia junction; CC: completeness of cytoreduction; CRS: cytoreductive surgery; HIPEC: hyperthermic; intraperitoneal chemotherapy; NAC: neoadjuvant chemotherapy; PCI: peritoneal cancer index; PIPEC: pressurized intraperitoneal aerosolized chemotherapy; PM: peritoneal metastasis; Tx: treatment.