Surgical approaches and outcomes in the treatment of gastric cancer.

Resection with extended lymphadenectomy in obtaining local-regional control with negative margins remains the only potentially curative modality in the treatment of gastric cancer. Complete (R0) resections, along with depth of invasion and adequate nodal staging, remain the most important prognostic factors. Because current chemotherapy regimens have limited benefit in advanced disease, the effectiveness of local-regional modalities takes on greater significance. The extent of surgical resection varies with the size, depth, location of the primary tumor, and the stage of disease. Studying patterns of recurrent disease and elucidating the impact of positive margins have led to insights into the biology of the disease and the limitations of local-regional therapies. Considerable controversy surrounds the notion of what defines an adequate lymph node dissection (LND). The recommendation of routine extended (D2) lymphadenectomy (ELND) is difficult to justify based on available randomized studies, but ELND may benefit selected patients when performed by surgeons who can accomplish the dissection with acceptable morbidity/mortality rates. An extended LND results in improved staging, allowing standardization of prognostic factors and survival data worldwide. Patient selection remains critical, limiting the role of surgery in advanced disease and reserving aggressive surgical resection for patients with high curative potential.