Surgical treatment of gastric cancer

Surgical treatment of gastric cancer

Jun-Te Hsu, Ta-Sen Yeh, Yi-Yin Jan

Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan

Correspondence to: Jun-Te Hsu, MD. Department of Surgery, Chang Gung Memorial Hospital at Linkou, No. 5, Fushing Street, Kweishan District, Taoyuan City. Email:

Received: 04 January 2018; Accepted: 20 January 2018; Published: 10 July 2018.

doi: 10.21037/dmr.2018.07.01

Gastric cancer (GC) is the fourth most common cancer and the third leading cause of cancer-related deaths worldwide (1). Most patients have inoperable disease at the time of diagnosis and encounter recurrence even after radical surgery (2). Curative resection including adequate lymphadenectomy provided the chance of a cure for localized disease (2,3). According to the Japanese guideline for surgical treatment of GC, D1 and D2 lymphadenectomy is suggested for selected early (T1) and advanced (T2–4) GC, respectively (4). Our previous studies have demonstrated a strong association between the numbers of lymph node retrieved and improved survival in advanced GC and therefore suggest retrieving more than 25 lymph nodes during radical surgery to improve outcomes (3,5). However, there is no survival benefit in early GC without nodal metastasis in terms of the numbers of lymph node retrieval (3,6). Furthermore, the addition of splenectomy to a D2 gastrectomy for the purpose of nodal clearance at the splenic hilum (No. 10) or along the distal splenic artery (No. 11) did not prolong patient survival in whom the GC was located at the lesser curvature of the stomach and there was significant nodal metastasis around the splenic hilum (3,7,8). Accordingly, routine splenectomy is not justified for treating proximal GC patients under those conditions (9,10).

Laparoscopic gastrectomy has been widely adopted for treating early-stage GC with comparable long-term oncologic outcomes and providing favorable immediate postoperative results as compared to conventional open gastrectomy in an experienced surgeon (11,12). For locally advanced GC, laparoscopic approach is still a matter of debate in the safety and oncologic concerns. A phase II multi-institutional prospective controlled trial is still ongoing (13). In recent years, robotic gastrectomy has been increasingly used for treating early-stage GC which has some advantages such as three-dimensional view, precise dissections and easier suturing as well as stable camera platform in comparison with laparoscopic gastrectomy (14,15). The modern technology greatly decreases the learning curve in performing complicated radical gastrectomy and reconstruction.

A number of evidence suggests that preoperative serum markers such as neutrophil to lymphocyte ratios or lymphocyte to monocyte ratios are associated with GC prognosis (16-19). This biomarker is clinically accessible and useful to predict surgical outcomes for resectable GC and should be as part of the preoperative risk stratification process.

Peritoneal carcinomatosis frequently occurs in advanced GC (especially in T4 lesion, N2-N3 tumor or positive peritoneal cytology) following radical resection during the course of disease. Few studies have indicated that GC patients presenting with peritoneal carcinomatosis benefit from treatment by cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPC) (20). A meta-analysis of 10 randomized controlled studies showed that prophylactic HIPC may prevent peritoneal recurrence and improve the overall survival rate for advanced GC with serosal invasion after radical surgery (21). However, the CS-HIPEC was associated high morbidity and mortality rates which compromise merits brought by CS-HIPEC (20). More effects should be made including the use of nanotechnology in more precise drug delivery systems or choice of more efficient chemotherapeutic agents/dosage, open or closed perfusion techniques and so on to improve patient outcomes (22).


Funding: This work was partly supported by the Chang Gung Medical Research Program, Taiwan (CORPG3E0151 and CORPG3E0152).


Conflicts of Interest: The authors have no conflicts of interest to declare.


  1. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136:E359-86. [Crossref] [PubMed]
  2. Cheng CT, Tsai CY, Hsu JT, et al. Aggressive surgical approach for patients with T4 gastric carcinoma: promise or myth? Ann Surg Oncol 2011;18:1606-14. [Crossref] [PubMed]
  3. Hsu JT, Lin CJ, Sung CM, et al. Prognostic significance of the number of examined lymph nodes in node-negative gastric adenocarcinoma. Eur J Surg Oncol 2013;39:1287-93. [Crossref] [PubMed]
  4. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 2011;14:113-23. [Crossref] [PubMed]
  5. Liu YY, Fang WL, Wang F, et al. Does a Higher Cutoff Value of Lymph Node Retrieval Substantially Improve Survival in Patients With Advanced Gastric Cancer?-Time to Embrace a New Digit. Oncologist 2017;22:97-106. [Crossref] [PubMed]
  6. Hsu JT, Yeh TS, Jan YY. Survival impact of the number of lymph node dissection on stage I-III node-negative gastric cancer. Transl Gastroenterol Hepatol 2016;1:9. [Crossref] [PubMed]
  7. Yu W, Choi GS, Chung HY. Randomized clinical trial of splenectomy versus splenic preservation in patients with proximal gastric cancer. Br J Surg 2006;93:559-63. [Crossref] [PubMed]
  8. Sano T, Sasako M, Mizusawa J, et al. Randomized Controlled Trial to Evaluate Splenectomy in Total Gastrectomy for Proximal Gastric Carcinoma. Ann Surg 2017;265:277-83. [Crossref] [PubMed]
  9. Hsu JT, Yeh TS, Jan YY. Role of splenectomy in proximal gastric cancer patients undergoing total gastrectomy. Transl Gastroenterol Hepatol 2016;1:84. [Crossref] [PubMed]
  10. Wang F, Chang YC, Chen TH, et al. Prognostic significance of splenectomy for patients with gastric adenocarcinoma undergoing total gastrectomy: a retrospective cohort study. Int J Surg 2014;12:557-65. [Crossref] [PubMed]
  11. Koeda K, Nishizuka S, Wakabayashi G. Minimally invasive surgery for gastric cancer: the future standard of care. World J Surg 2011;35:1469-77. [Crossref] [PubMed]
  12. Chen XZ, Wen L, Rui YY, et al. Long-term survival outcomes of laparoscopic versus open gastrectomy for gastric cancer: a systematic review and meta-analysis. Medicine (Baltimore) 2015;94. [Crossref] [PubMed]
  13. Inaki N, Etoh T, Ohyama T, et al. A Multi-institutional, Prospective, Phase II Feasibility Study of Laparoscopy-Assisted Distal Gastrectomy with D2 Lymph Node Dissection for Locally Advanced Gastric Cancer (JLSSG0901). World J Surg 2015;39:2734-41. [Crossref] [PubMed]
  14. Song J, Oh SJ, Kang WH, et al. Robot-assisted gastrectomy with lymph node dissection for gastric cancer: lessons learned from an initial 100 consecutive procedures. Ann Surg 2009;249:927-32. [Crossref] [PubMed]
  15. Herrera-Almario G, Strong VE. Minimally Invasive Gastric Surgery. Ann Surg Oncol 2016;23:3792-7. [Crossref] [PubMed]
  16. Chen J, Hong D, Zhai Y, et al. Meta-analysis of associations between neutrophil-to-lymphocyte ratio and prognosis of gastric cancer. World J Surg Oncol 2015;13:122. [Crossref] [PubMed]
  17. Hsu JT, Wang CC, Le PH, et al. Lymphocyte-to-monocyte ratios predict gastric cancer surgical outcomes. J Surg Res 2016;202:284-90. [Crossref] [PubMed]
  18. Hsu JT, Liao CK, Le PH, et al. Prognostic Value of the Preoperative Neutrophil to Lymphocyte Ratio in Resectable Gastric Cancer. Medicine (Baltimore) 2015;94. [Crossref] [PubMed]
  19. Wang SC, Chou JF, Strong VE, et al. Pretreatment Neutrophil to Lymphocyte Ratio Independently Predicts Disease-specific Survival in Resectable Gastroesophageal Junction and Gastric Adenocarcinoma. Ann Surg 2016;263:292-7. [Crossref] [PubMed]
  20. Beeharry MK, Liu WT, Yao XX, et al. A critical analysis of the cytoreductive surgery with hyperthermic intraperitoneal chemotherapy combo in the clinical management of advanced gastric cancer: an effective multimodality approach with scope for improvement. Transl Gastroenterol Hepatol 2016;1:77. [Crossref] [PubMed]
  21. Sun J, Song Y, Wang Z, et al. Benefits of hyperthermic intraperitoneal chemotherapy for patients with serosal invasion in gastric cancer: a meta-analysis of the randomized controlled trials. BMC Cancer 2012;12:526. [Crossref] [PubMed]
  22. Braam HJ, Schellens JH, Boot H, et al. Selection of chemotherapy for hyperthermic intraperitoneal use in gastric cancer. Crit Rev Oncol Hematol 2015;95:282-96. [Crossref] [PubMed]
doi: 10.21037/dmr.2018.07.01
Cite this article as: Hsu JT, Yeh TS, Jan YY. Surgical treatment of gastric cancer. Dig Med Res 2018;1:7.