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Gastric cancer is one of the most common cancers worldwide and remains a leading cause of mortality. The standard of care for localized gastric cancer remains radical surgery. Localized but locally advanced resectable gastric cancer (Stage II and III) is the most common presentation and this requires a judicious mix of modern chemotherapy and radical surgery.
This lecture highlights the importance of D2 lymph node dissection and explains the extent of D0, D1, D3 and D4 lymph node dissections. Critical steps and extent of gastric resections (based on tumor location) are discussed in detail. Measures to minimize perioperative morbidity and mortality are highlighted with special emphasis on standardization of procedure and later negotiating learning and proficiency curves. While radical surgery is the cornerstone for the cure of gastric cancer, this lecture also highlights the role of modern perioperative chemotherapy with global evidence. The extensive experience of the Tata Memorial Centre in Mumbai, India spanning 2 decades is presented. Furthermore, evidence is presented about the evolving role of minimal access surgery in locally advanced gastric cancer.
In summary, perioperative chemotherapy (viz. FLOT regimen) coupled with radical D2 lymphadenectomy provides the best chance of long-term survival. Unless directly involved by tumor, distal pancreatosplenectomy can be safely avoided without compromising oncologic outcomes. High-volume centers with dedicated gastric cancer specialists improve short and long-term outcomes of gastric cancer. The role of radiation in the multidisciplinary management of gastric cancer is not clearly defined in the modern era. Minimally invasive radical gastrectomy can be safely undertaken and outcomes are comparable to conventional open procedures; however, superiority has not been demonstrated as yet. Cytoreductive surgery (CRS) coupled with HIPEC is gradually evolving as an option in metastatic gastric cancer but consistently high-level evidence is yet to be made available.