• Surgery with lymph node dissection is the primary treatment option in early stage/resectable gastric cancer
  • Though majority still relapse following resection, it is potentially curative
  • For ≥stage 1B combined modality approaches are standard

• Standard goal is complete resection with negative margins
  • Extent of resection is determined by preoperative stage of the cancer

• Gastrectomy with D1 or a modified D2 lymph node dissection with a goal of examining at least 16 lymph nodes for patients with localized resectable cancer

Endoscopic Therapies

• Endoscopic resection is necessary to accurately stage early-stage cancers (T1a or T1b) 
• For the treatment of patients with early stage (Tis or T1a) gastric cancer, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been used as an alternative to surgery
• ESD is the treatment of choice for most gastric superficial neoplasmic lesions
• EMR or ESD of focal nodules (≤2 cm) performed during early-stage cancer can provide more information on the degree of differentiation, presence of lymphovascular invasion and depth of invasion, and can be potentially therapeutic
• It has been shown that en-bloc excision by ESD is more effective than EMR in curing early gastric cancer
• For lesions >5 cm in diameter, complete resection rates were significantly better for ESD while in lesions <5 cm in diameter, there were no difference between EMR and ESD rates regardless of location
• T4 tumors require en bloc resection of involved structures
• Indications for EMR or ESD includes:
  • Carcinoma in situ
  • Lesions ≤2 cm in diameter
  • Well or moderately differentiated lesions
  • Confined to the mucosa
  • With clear lateral and deep margins
  • Not ulcerated
  • Without lymph node metastases or lymphovascular invasion

Gastrectomy

• Distal, subtotal or total gastrectomy is recommended for T1b-T3 tumors

Subtotal Gastrectomy

• A procedure that involves removal of a section of the stomach, and may include part of the esophagus or 1st part of the duodenum; the remaining section of the stomach is then reattached
• Preferred approach for distal gastric cancers
• May be carried out if a macroscopic proximal margin of 5 cm can be achieved between the tumor and esophagogastric junction
• Eating is much easier after surgery

Total Gastrectomy

• A procedure involving the surgical removal of the stomach as a whole, including adjacent lymph nodes and omentum, as well as part of the esophagus that is attached to the small intestines
• Preferred gastrectomy for patients with stage IB-III gastric cancer
• Proximal gastrectomy and total gastrectomy are both indicated for proximal gastric cancers and are typically associated with postoperative nutritional impairment
  • A margin of 8 cm is recommended for diffuse type cancers

Lymph Node Dissection

• It is the removal of regional lymph nodes
• It should be included in gastric resection
• Classification depends on the extent of lymph nodes removed during gastrectomy:
  • D0 refers to incomplete resection of N1 lymph nodes
  • D1 involves gastrectomy and the removal of the involved proximal or distal part of the stomach or the entire stomach, including the greater and lesser omental lymph nodes
  • D2 involves D1 with additional removal of the anterior leaf of the transverse mesocolon and all the nodes along the corresponding arteries

Laparoscopic Surgery

• An alternative to open surgery due to potential benefits of:
  • Less blood loss
  • Reduced postoperative pain or morbidity
  • Reduced recovery time
  • Early return to normal bowel function
  • Reduced hospital stay

• Not recommended for T4b or N2 bulky gastric cancer
• Although there are concerns about long-term outcomes and the possibility for reduced nodal harvest