Gastric Resection for Malignancy (Gastrectomy)

Gastric cancer represents a significant global health challenge, ranking as the fifth most common cancer worldwide and the third leading cause of cancer-related mortality. Annually, there are over 1 million new cases globally, with approximately 27,500 new diagnoses in the United States alone. The reported incidence stands at 5.6%, with a mortality rate of 7.7%, underscoring the need for effective management strategies. Advanced gastric cancer accounts for 50% to 80% of all gastric cancer cases, with many patients (35%–51%) failing to achieve desired responses to neoadjuvant chemotherapy and 15% experiencing tumor progression.  In Western populations, a multimodal approach has become the standard response to these challenges, combining innovative combinations of chemotherapeutic agents, radiotherapies, and immunomodulatory drugs tailored to individual patient and tumor characteristics. This personalized approach aims to minimize treatment-related toxicities while maximizing the effectiveness of conventional therapeutic strategies. However, despite these advancements, radical en bloc surgical resection of the tumor with concomitant lymph node dissection remains the cornerstone of management. Surgical options for gastric cancer resection include total, proximal, distal, and pylorus-preserving distal gastrectomies. The choice of surgical approach for gastric adenocarcinoma depends on factors such as where the epicenter of the tumor resides, the extent of stomach involvement, histological subtype, and genomic etiology. Given that gastric cancer is primarily a locoregional disease, the primary objective of surgery is to remove the primary tumor with a clear longitudinal and circumferential resection margin, preferably with a minimum distance of 5 cm from the palpable edge of the tumor. This involves achieving R0 resection, which may require combined organ resection, if necessary, along with lymph node dissection. Subsequently, the surgery aims to restore intestinal and biliary continuity safely to ensure sufficient nutritional intake. In cases of more extensive disease, selected patients may benefit from multivisceral resection (MVR) or cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). Traditionally, open gastrectomy has been the predominant method for gastric cancer resection. However, in recent years, minimally invasive surgical (MIS) techniques, such as laparoscopic gastrectomy and robotic-assisted gastrectomy, have gained popularity.  Proponents of MIS tout its benefits, including decreased morbidity, accelerated recovery, and improved cosmetic outcomes.  However, the selection of surgical approach remains multifactorial and is influenced by patient characteristics, disease pathology, and institutional expertise. Although MIS techniques offer compelling advantages, open gastrectomy retains its role in specific scenarios, underscoring the importance of individualized care in gastric cancer management. Since its inception in 1994, laparoscopic gastrectomy has evolved into a well-established surgical modality for early gastric carcinoma. Numerous multicenter, prospective, randomized clinical trials have demonstrated long-term oncological and survival outcomes comparable to open gastrectomy. Therefore, laparoscopic gastrectomy is considered a well-established surgical approach to managing early gastric carcinoma. Moreover, laparoscopic gastrectomy is increasingly recognized as a feasible, safe, and effective approach for radical resection of locally advanced distal gastric cancer. Despite these advancements, debates persist regarding disparities in postoperative and oncological outcomes between laparoscopic and open gastrectomy, alongside the technical intricacies and learning curve associated with laparoscopic techniques. Robotic-assisted surgery presents a promising solution to address the limitations of conventional laparoscopy in managing gastric cancers. Advantages include 3-dimensional vision, enhanced skill acquisition, increased dexterity, improved mobility, and better ergonomics for surgeons. However, despite these benefits, the adoption of robotic-assisted gastrectomy in upper gastrointestinal surgery, particularly for gastric cancer resections, has been slower compared to other specialties. Limited high-quality data, primarily from retrospective studies, hinders a comprehensive evaluation of robotic-assisted gastrectomy's role in gastric tumor resection, highlighting the need for further research to elucidate its long-term oncological outcomes and efficacy. Despite numerous randomized controlled trials and standard pairwise meta-analyses, consensus on the oncological and surgical safety of laparoscopic and robotic-assisted gastrectomy compared to open gastrectomy for gastric carcinoma resection remains elusive. Recent trials have reported short-term postoperative and survival outcomes following robotic-assisted gastrectomy, sparking optimism among gastroesophageal surgeons that these minimally invasive approaches may enhance patient outcomes. However, further research is necessary to establish a definitive consensus on the efficacy and safety of laparoscopic gastrectomy and robotic-assisted gastrectomy relative to open gastrectomy in managing gastric cancer. Another emerging modality for treating early gastric cancer is endoscopic submucosal dissection (ESD), particularly when lymph node metastasis risk is low. In contrast to surgical gastrectomy, ESD offers a minimally invasive approach with significant benefits, such as preserving the entire stomach and maintaining the patient's quality of life. Despite some drawbacks, this technique signifies a notable advancement in the management of early gastric cancer, offering patients effective treatment while minimizing the impact on their overall well-being. The evolution from traditional open procedures to minimally invasive techniques reflects a significant advancement in the surgical management of gastric malignancies, offering patients improved outcomes and a better quality of life. This activity explores the various surgical approaches for treating gastric cancer, discussing their advantages, limitations, and emerging trends in the field.