Stomach cancer surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Fahad Hasan, M.D.[2] Parminder Dhingra, M.D. [3] Mohammed Abdelwahed M.D[4]

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## Overview

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Surgery remains the only potentially curative treatment for stomach cancer and is central to the multidisciplinary management of gastric cancer. Endoscopic resection is the treatment of choice for early gastric cancer meeting absolute or expanded indication criteria, as defined by the Japanese Gastric Cancer Association (JGCA) 2021 (6th edition) treatment guidelines.[1] Methods for endoscopic resection include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Side effects of endoscopy include bleeding and perforation. For T1 tumors, a gross resection margin of 2 cm should be obtained. A proximal margin of at least 3 cm is recommended for T2 or deeper tumors with an expansive growth pattern and 5 cm for those with an infiltrative growth pattern. For tumors invading the esophagus, a 5-cm margin is not necessarily required, but intraoperative frozen section examination of the resection line is preferred to confirm an R0 resection.

Lymph node dissection is defined by extent. D1 lymphadenectomy refers to dissection of only the perigastric lymph nodes (stations 1-7). D1+ lymphadenectomy adds stations 8a, 9, and (for total gastrectomy) 11p to the D1 dissection and is used for cT1 tumors not indicated for D1 alone. D2 lymphadenectomy is an extended lymph node dissection that additionally removes nodes along the hepatic, left gastric, celiac, and splenic arteries, and, when indicated, the splenic hilum; it is the standard of care for potentially curable T2-T4 tumors. D3 (super-extended) dissection adds D2 plus removal of nodes within the porta hepatis and para-aortic regions; prophylactic para-aortic dissection added to D2 did not improve survival in the randomized JCOG9501 trial and is not routinely recommended outside clinical trials.[2]

Laparoscopic and robot-assisted minimally invasive gastrectomy with D2 lymphadenectomy are now supported by long-term randomized data as oncologically equivalent, and in some outcomes superior, alternatives to open gastrectomy for both early and locally advanced gastric cancer.[3][4][5] For resectable locoregional adenocarcinoma (cT2 or higher, or node-positive), perioperative systemic chemotherapy with FLOT (fluorouracil, leucovorin, oxaliplatin, and docetaxel) — now increasingly combined with the anti-PD-L1 monoclonal antibody durvalumab — has replaced older anthracycline-based (ECF/MAGIC) regimens as the perioperative standard of care.[6][7] For metastatic disease, gastrectomy is not routinely recommended for palliation alone, based on the randomized REGATTA trial, and first-line systemic therapy — chemotherapy plus the anti-PD-1 monoclonal antibody nivolumab in appropriate candidates — is preferred over surgery-first approaches.[8][9]

### Differential diagnosis

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Before proceeding to surgery, gastric cancer must be distinguished from other benign and malignant conditions that can produce a similar gastric mass, ulceration, or wall thickening on endoscopy or computed tomography.

Condition  | Distinguishing features

|

Peptic ulcer disease | Benign ulcer with smooth, flat margins on endoscopy; heals on repeat endoscopy after acid-suppression therapy; biopsy negative for malignancy
Gastrointestinal stromal tumor (GIST)  | Submucosal mass with intact overlying mucosa; spindle cell morphology; positive for CD117/KIT on immunohistochemistry
Gastric MALT lymphoma | Diffuse mucosal thickening/nodularity; associated with Helicobacter pylori infection; monoclonal B-cell population on histology
Gastric polyp (hyperplastic or fundic gland)  | Discrete, usually small, sessile lesion without invasive features; low malignant potential
Ménétrier disease | Giant rugal hypertrophy with hypoalbuminemia; foveolar hyperplasia without malignant cells on biopsy
Gastric neuroendocrine tumor | Positive chromogranin A and synaptophysin staining; often associated with atrophic gastritis or Zollinger-Ellison syndrome
Linitis plastica from metastatic breast cancer or other primary  | Diffuse wall thickening resembling primary signet ring cell carcinoma; immunohistochemistry (e.g., GATA3, estrogen receptor) identifies the primary site

## Surgical Management Of Early Gastric Cancer

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* Early gastric cancer is an invasive gastric cancer that invades no more than the submucosa whatever the lymph node metastasis condition (T1 and any N).
* Endoscopic resection is the preferred treatment for lesions meeting absolute or expanded indication criteria (below); surgical gastrectomy with lymphadenectomy remains standard for lesions outside these criteria or after non-curative endoscopic resection.
* Long-term oncologic outcomes after appropriately-indicated, curative endoscopic resection are comparable to primary surgical resection.[10]

### Indications for endoscopic resection

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Endoscopic indications are now categorized as absolute or expanded, per the JGCA 2021 (6th edition) guidelines and the 2023 ASGE guideline, superseding the earlier single size-cutoff criteria used in most Western practice.[1][11]

Absolute indication (endoscopic resection is curative if pathology confirms an eCura A result, with no need for additional surgery):

* Differentiated-type intramucosal (cT1a) adenocarcinoma without ulceration, regardless of size
* Differentiated-type intramucosal (cT1a) adenocarcinoma with ulceration, ≤3 cm in diameter

Expanded indication (endoscopic resection is acceptable, but curability must be confirmed pathologically using the eCura scoring system):

* Undifferentiated-type intramucosal (cT1a) adenocarcinoma without ulceration, ≤2 cm in diameter[12]

The ASGE similarly suggests ESD over EMR for well- or moderately-differentiated, non-ulcerated intestinal-type early gastric adenocarcinoma measuring 20-30 mm, and either ESD or EMR for lesions <20 mm.[11]

### Methods of endoscopic resection

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The following are the different types of endoscopic resection techniques for gastric cancer:[13]

* Endoscopic mucosal resection (EMR):
* The lesion and the surrounding mucosa are lifted by submucosal injection of saline and removed using a steel snare.
* Endoscopic submucosal dissection (ESD):
* The mucosa surrounding the lesion is incised using a high-frequency electric knife.
* ESD is more likely to result in complete (en bloc) resection of early gastric cancer, and is now the preferred technique over EMR for most lesions meeting expanded indication, but requires more time and endoscopic skill.

### Side effects and complications

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###### Bleeding

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* Bleeding[14]
* A tumor size of more than 4 cm is a risk factor for acute bleeding.
* Antithrombotic drug therapy is a risk factor for delayed bleeding.
* Bleeding treatment is injection therapy, electrocoagulation, ligation with a detachable snare, and endoscopic clipping.

###### Perforation

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* Perforation rate for ESD is 4.5 percent, compared with 1.0 percent for EMR.[15]
* Tumor location in the upper stomach and size more than 2 cm have been associated with an increased risk of perforation with ESD.
* Treatment of a perforation is endoscopic clipping, or open or laparoscopic surgery in case of failed clipping.

### Curative resection and the eCura scoring system

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Historically, curative endoscopic resection required en bloc removal of a lesion meeting all of the following:[16]

* En bloc resection
* Tumor size ≤2 cm
* Differentiated histology
* Depth of invasion ≤T1a
* Negative horizontal margin
* Negative vertical margin
* No lymphatic or vascular invasion

This binary framework has largely been superseded by the eCura system, a validated scoring tool that stratifies patients after ESD into risk categories using tumor size, depth of invasion, lymphovascular invasion, and horizontal/vertical margin status: eCura A and B denote curative or near-curative resection appropriate for surveillance alone, while eCura C-1 (met size/depth criteria but positive horizontal margin only) and eCura C-2 (all other non-curative resections, carrying a substantially higher risk of lymph node metastasis) generally warrant consideration of additional gastrectomy with lymphadenectomy in medically fit patients.[17] The eCura system allows individualized decision-making, particularly in elderly or frail patients in whom the operative risk of completion gastrectomy may outweigh the absolute risk of occult nodal metastasis.

### Management of non-curative (eCura C) resection

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* There is no single mandated approach for eCura C-1/C-2 resections; the decision balances the estimated risk of residual lymph node metastasis against operative risk.[17]
* Completion gastrectomy with standard lymph node dissection is generally recommended for eCura C-2 resections in patients fit for surgery.[18]
* Occult lymph node metastasis is identified in a minority of patients who undergo completion gastrectomy and lymph node dissection after non-curative resection; risk varies by eCura subcategory and underlying histologic risk factors rather than being a fixed rate for all non-curative resections.[17]

### Management of positive margins[19]

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* Patients with only positive lateral (horizontal) margins can be managed with repeat endoscopic therapy rather than surgery (eCura C-1).
* Almost 90 percent of lateral positive margins were followed endoscopically with no recurrences.
* Patients with positive vertical margins, submucosal invasion beyond criteria, or lymphovascular invasion (eCura C-2) are generally treated with completion surgery.

### Local recurrence after EMR/ESD

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Local mucosal recurrence after EMR/ESD for tumors that had fulfilled the criteria for indication for endoscopic resection may be treated by another ESD.[20]

### Follow-up after endoscopic resection

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##### Follow-up after curative (eCura A/B) resection

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* Annual endoscopy with abdominal ultrasonography or CT scan follow-up is recommended.
* Helicobacter pylori should be tested for and treated (eradication therapy reduces metachronous gastric cancer risk).

##### Follow-up after non-curative (eCura C) resection managed conservatively

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* Closer endoscopic and cross-sectional imaging surveillance is warranted; residual or recurrent disease may be treated with repeat endoscopic coagulation (laser or argon-plasma coagulation) or surgery as appropriate.

## Surgical Management Of Invasive Gastric Cancer

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Surgical management of a gastric tumor with resection of adjacent lymph nodes, integrated with perioperative systemic therapy, presents the best chance for long-term survival in invasive gastric cancer.

### Initial Management

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* Diagnostic upper endoscopy with biopsy, followed by locoregional staging with endoscopic ultrasonography and computed tomography of the chest, abdomen, and pelvis; PET-CT and diagnostic staging laparoscopy (with peritoneal washings/cytology) are used selectively to exclude occult metastatic disease before committing a patient to curative-intent surgery.
* Tumor tissue should be tested for HER2 overexpression/amplification, PD-L1 combined positive score, microsatellite instability/mismatch-repair status, and, where relevant, claudin 18.2 expression, as these biomarkers guide selection of perioperative and later-line systemic therapy.
* Cases should be reviewed in a multidisciplinary tumor board (surgery, medical oncology, radiation oncology, gastroenterology, and pathology) before initiating treatment, per current NCCN and JGCA guidance.[1]
* For tumors of the esophagogastric junction, Siewert classification and the 2023 Upper GI Oncology Summit consensus guide the choice between esophagectomy and gastrectomy-based approaches.[21]

### Medical Therapy

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* For resectable, locally advanced adenocarcinoma (generally cT2 or higher, or clinically node-positive), perioperative FLOT (fluorouracil, leucovorin, oxaliplatin, docetaxel) improved 5-year overall survival compared with anthracycline-based ECF/ECX and is preferred over surgery-alone or older MAGIC-type regimens.[6]
* The addition of the anti-PD-L1 agent durvalumab to perioperative FLOT (MATTERHORN trial) significantly improved event-free survival (hazard ratio 0.71) and pathologic complete response (19.2% vs 7.2%) compared with FLOT alone, and is now an FDA-approved perioperative option for resectable gastric and gastroesophageal junction adenocarcinoma.[7]
* For unresectable locally advanced or metastatic disease, first-line chemotherapy plus the anti-PD-1 agent nivolumab (CheckMate 649) improved overall survival and progression-free survival compared with chemotherapy alone, with the greatest benefit in tumors with a high PD-L1 combined positive score.[9]
* HER2-positive metastatic disease is treated with trastuzumab-based regimens added to chemotherapy (± immunotherapy), per current NCCN and JGCA recommendations.[1]
* Gastrectomy added to chemotherapy does not improve survival in patients with a single non-curable factor (REGATTA trial: 2-year overall survival 25% with gastrectomy plus chemotherapy vs 32% with chemotherapy alone) and should not be performed for palliative intent alone outside of symptom control.[8]

### Procedural / Surgical Therapy

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#### Types of gastric surgery

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##### Curative surgery

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* Standard gastrectomy: Two-thirds of the stomach is resected; it is the principal surgical procedure used.
* Non-standard gastrectomy: The extent of gastric resection and lymphadenectomy is altered according to tumor stage.
* Modified surgery: The extent of gastric resection and lymphadenectomy is reduced compared with standard surgery (e.g., for favorable early tumors not meeting endoscopic resection criteria).
* Extended surgery: Gastrectomy with resection of adjacent involved organs, or with extended lymphadenectomy.

##### Non-curative surgery

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* Palliative surgery: Palliative gastrectomy or gastrojejunostomy, selected according to resectability and surgical risk, to relieve bleeding or obstruction; reserved for symptoms not controllable by endoscopic or radiologic means, given the lack of survival benefit shown in REGATTA.[8]
* Reduction surgery: Aims to prolong survival by reducing tumor volume; evidence for a survival benefit is weak and this is not routinely recommended.

#### Types of resection

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* Total gastrectomy: Resection of the entire stomach, including the cardia and pylorus.
* Distal gastrectomy: Resection including the pylorus; the cardia is preserved.
* Pylorus-preserving gastrectomy: Resection preserving the upper third of the stomach and the pylorus with a portion of the antrum.
* Proximal gastrectomy: Resection including the cardia; the pylorus is preserved.
* Segmental gastrectomy: Circumferential resection preserving the cardia and pylorus.
* Local resection
* Non-resectional surgery (bypass surgery, gastrostomy, and jejunostomy)

#### Determination of gastric resection margin

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* For T1 tumors, a gross resection margin of 2 cm should be obtained.
* A proximal margin of at least 3 cm is recommended for T2 or deeper tumors with an expansive growth pattern and 5 cm for those with an infiltrative growth pattern.
* For tumors invading the esophagus, a 5-cm margin is not necessarily required, but intraoperative frozen section examination of the resection line is preferred to confirm an R0 resection.
* When the tumor border is unclear, preoperative endoscopic marking with clips based on biopsy mapping helps define the resection line.

#### Selection of the surgery

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* The standard surgical procedure is total or distal gastrectomy, increasingly performed by a minimally invasive (laparoscopic or robotic) approach when technically feasible (see below).
* Pancreaticosplenectomy: Pancreatic invasion by tumor requires total gastrectomy regardless of tumor location.
* Total gastrectomy with splenectomy: Considered for tumors along the greater curvature with metastasis to station 4 lymph nodes; routine prophylactic splenectomy is otherwise avoided due to increased morbidity without proven survival benefit.
* Esophagectomy and proximal gastrectomy: Considered for adenocarcinoma located on the proximal side of the esophagogastric junction, per Siewert classification.[21]
* Pylorus-preserving gastrectomy: For tumors in the middle third of the stomach with the distal tumor border at least 4 cm proximal to the pylorus.
* Vagal nerve preservation: Preservation of the hepatic branch of the anterior vagus and the celiac branch of the posterior vagus improves postoperative quality of life by reducing post-gastrectomy gallstone formation, diarrhea, and weight loss; in pylorus-preserving gastrectomy the hepatic branch is preserved to maintain pyloric function.
* Omentectomy: Removal of the greater omentum is usually integrated into standard gastrectomy for T3 or deeper tumors; for T1/T2 tumors, omentum more than 3 cm from the gastroepiploic arcade may be preserved.
* Bursectomy:[22] removal of the inner peritoneal surface of the bursa omentalis; avoided in T1/T2 tumors to prevent injury to the pancreas and adjacent blood vessels, but shows a modest survival benefit in T3/T4a tumors.

#### Minimally invasive and robotic gastrectomy

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* Laparoscopic distal gastrectomy with D2 lymphadenectomy is non-inferior to open surgery for locally advanced gastric cancer, with fewer early (15.7% vs 23.4%) and late (4.7% vs 9.5%) complications; long-term individual-patient-data meta-analysis of KLASS-02 and CLASS-01 shows comparable overall survival (82.7% vs 83.3%) and recurrence-free survival (76.9% vs 77.9%) between laparoscopic and open approaches.[3][4][5]
* A randomized phase 2 trial of robotic versus laparoscopic distal gastrectomy reported a 3-year disease-free survival of 85.8% with robotic surgery versus 73.2% with laparoscopic surgery, alongside less blood loss and more retrieved lymph nodes with the robotic approach; confirmatory phase III data (JCOG1907/MONA LISA) are awaited.[23]
* Adding complete mesogastric excision to D2 lymphadenectomy (D2+CME) improved 3-year disease-free survival compared with conventional D2 dissection alone in the randomized DCGC01 trial, without a statistically significant difference in overall survival.[24]
* Laparoscopic sentinel node navigation surgery for stomach preservation did not meet the pre-specified non-inferiority margin for 3-year disease-free survival compared with standard laparoscopic gastrectomy in the SENORITA trial, although 5-year overall and disease-free survival did not differ significantly between groups; routine adoption outside of expert centers and clinical trials is not currently recommended.[25]

### Lymph node resection

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* One of the most debated areas in the surgical management of gastric cancer is the optimal extent of lymph node dissection.[26]
* The draining lymph nodes for the stomach are divided into 16 stations by the JGCA classification; stations 1 to 6 are perigastric, and the remaining stations lie adjacent to major vessels, behind the pancreas, and along the aorta.[27]

D1 lymphadenectomy

* Dissection of only the perigastric lymph nodes (stations 1-7).
* Indicated for T1a tumors that do not meet criteria for EMR/ESD and for T1bN0 tumors that are histologically differentiated and 1.5 cm or smaller in diameter, without lymphovascular invasion.

D1+ lymphadenectomy

* D1 plus stations 8a, 9, and (for total gastrectomy) 11p.
* Indicated for cT1 tumors not meeting criteria for D1 dissection alone.

D2 lymphadenectomy

* Extended lymph node dissection, including removal of nodes along the hepatic, left gastric, celiac, and splenic arteries, as well as the splenic hilum when indicated.
* Standard of care for potentially curable T2-T4 tumors and whenever nodal involvement is suspected.

D3 (super-extended) dissection

* D2 plus removal of nodes within the porta hepatis and para-aortic regions.
* Prophylactic para-aortic dissection added to D2 did not improve overall survival in the randomized JCOG9501 trial and is not routinely recommended.[2]

### Local palliative procedures

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* Therapeutic options to control symptoms of local disease progression — nausea, pain, bleeding, and obstruction — include palliative surgical resection, surgical bypass (gastrojejunostomy), radiation therapy, and endoscopic techniques.
* Palliative resection: Palliative gastrectomy should be reserved for highly symptomatic cases where less invasive methods cannot be used, given the absence of a survival benefit over chemotherapy alone shown in the REGATTA trial.[8][28]
* Gastrojejunostomy: Palliative gastrojejunostomy for gastric outlet obstruction associated with unresectable advanced gastric cancer can improve food intake and is reserved for cases where less invasive methods cannot be used.[29]
* Endoscopic stent placement:[30] a less invasive alternative to surgery for symptom palliation of obstruction, with comparable efficacy and complication rates to palliative gastrojejunostomy in randomized comparisons, and possibly better short-term quality of life.
* Endoscopic hemostatic/ablative therapy: Laser photocoagulation or argon plasma coagulation can be effective for control of tumor-related bleeding, particularly for large tumors with diffuse bleeding.[31]

### Reconstruction after gastrectomy

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Total gastrectomy

* Roux-en-Y esophagojejunostomy[32]
* Jejunal interposition
* Double tract method

Distal gastrectomy

* Billroth I gastroduodenostomy[33]
* Billroth II gastrojejunostomy
* Roux-en-Y gastrojejunostomy
* Jejunal interposition

Pylorus-preserving gastrectomy[34]

* Gastro-gastrostomy
* Proximal gastrectomy
* Esophagogastrostomy
* Jejunal interposition
* Double tract method

### Long-Term Management

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* Surveillance after curative-intent gastrectomy typically includes history and physical examination every 3-6 months for the first 1-2 years, then every 6-12 months up to 5 years; cross-sectional imaging (CT) and laboratory studies (including complete blood count and vitamin B12/iron levels) are performed at intervals guided by risk of recurrence.[1]
* Surveillance endoscopy is performed periodically to evaluate the anastomosis and remnant stomach (if present) and to screen for metachronous gastric cancer.
* Nutritional support, including monitoring for and treatment of vitamin B12 deficiency, iron deficiency, osteoporosis, and dumping syndrome, is an essential component of long-term post-gastrectomy care.
* Helicobacter pylori eradication should be confirmed, as persistent infection increases the risk of metachronous gastric neoplasia after both endoscopic and surgical resection.

### Special Populations

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* Elderly and frail patients: Endoscopic resection and, when surgery is required, less extensive lymphadenectomy or minimally invasive approaches may be preferred to reduce operative morbidity; outcomes of EMR and gastrectomy for early gastric cancer in elderly patients are comparable to those in younger patients when appropriately selected.[10]
* HER2-positive and microsatellite instability-high/mismatch-repair-deficient tumors: Biomarker-directed therapy (anti-HER2 or immune checkpoint

## References

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1. ↑ 1.0 1.1 1.2 1.3 1.4 Japanese Gastric Cancer Association (2023). "Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition)". Gastric Cancer. 26 (1): 1–25. doi:10.1007/s10120-022-01331-8. PMC 9813208 Check `|pmc=` value (help). PMID 36342574 Check `|pmid=` value (help).
2. ↑ 2.0 2.1 Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A; et al. (2008). "D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer". N Engl J Med. 359 (5): 453–62. doi:10.1056/NEJMoa0707035. PMID 18669424.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 Son SY, Hur H, Hyung WJ, Park YK, Lee HJ, An JY, Kim W, Kim HI, Kim HH, Ryu SW, Kim MC, Kong SH, Cho GS, Kim JJ, Park DJ, Ryu KW, Kim YW, Kim JW, Lee JH, Yang HK, Han SU (2022). "Laparoscopic vs Open Distal Gastrectomy for Locally Advanced Gastric Cancer: 5-Year Outcomes of the KLASS-02 Randomized Clinical Trial". JAMA Surg. 157 (10): 879–886. doi:10.1001/jamasurg.2022.2749. PMC 9301593 Check `|pmc=` value (help). PMID 35857305 Check `|pmid=` value (help).
4. ↑ 4.0 4.1 Huang C, Liu H, Hu Y, Sun Y, Su X, Cao H, Hu J, Wang K, Suo J, Tao K, He X, Wei H, Ying M, Hu W, Du X, Yu J, Zheng C, Liu F, Li Z, Zhao G, Zhang J, Chen P, Li G (2022). "Laparoscopic vs Open Distal Gastrectomy for Locally Advanced Gastric Cancer: Five-Year Outcomes From the CLASS-01 Randomized Clinical Trial". JAMA Surg. 157 (1): 9–17. doi:10.1001/jamasurg.2021.5104. PMC 8529527 Check `|pmc=` value (help). PMID 34668963 Check `|pmid=` value (help).
5. ↑ 5.0 5.1 Hu Y, Hyung WJ, Huang H, Huang C, Yang HK, Sun Y, Park YK, Su X, Lee HJ, Cao H, An JY, Hu J, Kim W, Wang K, Kim HI, Suo J, Kim HH, Tao K, Ryu SW, He X, Hur H, Wei H, Kim MC, Kong SH, Ying M, Cho GS, Hu W, Kim JJ, Du X, Park DJ, Yu J, Ryu KW, Liu H, Kim YW, Li Z, Kim JW, Ji J, Lee JH, Li G, Han SU (2025). "Long-term outcomes of laparoscopic distal gastrectomy for locally advanced gastric cancer: An individual patient data meta-analysis of KLASS-02 and CLASS-01 randomized controlled trials". Chin J Cancer Res. 37 (3): 365–376. doi:10.21147/j.issn.1000-9604.2025.03.06. PMC 12240251 Check `|pmc=` value (help). PMID 40642493 Check `|pmid=` value (help).
6. ↑ 6.0 6.1 Al-Batran SE, Homann N, Pauligk C, Goetze TO, Meiler J, Kasper S, Kopp HG, Mayer F, Haag GM, Luley K, Lindig U, Schmiegel W, Pohl M, Stoehlmacher J, Folprecht G, Probst S, Prasnikar N, Fischbach W, Mahlberg R, Trojan J, Koenigsmann M, Martens UM, Thuss-Patience P, Egger M, Block A, Heinemann V, Illerhaus G, Moehler M, Schenk M, Kullmann F, Behringer DM, Heike M, Pink D, Teschendorf C, Löhr C, Bernhard H, Schuch G, Rethwisch V, von Weikersthal LF, Hartmann JT, Kneba M, Daum S, Schulmann K, Weniger J, Belle S, Gaiser T, Oduncu FS, Güntner M, Hozaeel W, Reichart A, Jäger E, Kraus T, Mönig S, Bechstein WO, Schuler M, Schmalenberg H, Hofheinz RD (2019). "Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial". Lancet. 393 (10184): 1948–1957. doi:10.1016/S0140-6736(18)32557-1. PMID 30982686.
7. ↑ 7.0 7.1 Janjigian YY, Al-Batran SE, Wainberg ZA, Kim YW, Elimova E, Barros-Sotolongo A, Boku N, Chao J, Ho G, Lorenzen S, Aprile G, Chau I, Sun W, Kim JG, Rueschoff J, Chen LT, Bhagia P, Zhao J, Watson P, Molife LR, Shitara K (2025). "Perioperative Durvalumab in Gastric and Gastroesophageal Junction Cancer". N Engl J Med. 393 (3): 217–230. doi:10.1056/NEJMoa2503701. PMID 40454643 Check `|pmid=` value (help). Vancouver style error: initials (help)
8. ↑ 8.0 8.1 8.2 8.3 Fujitani K, Yang HK, Mizusawa J, Kim YW, Terashima M, Han SU, Iwasaki Y, Hyung WJ, Takagane A, Park DJ, Yoshikawa T, Hahn S, Nakamura K, Park CH, Kurokawa Y, Bang YJ, Park BJ, Sasako M, Tsujinaka T (2016). "Gastrectomy plus chemotherapy versus chemotherapy alone for advanced gastric cancer with a single non-curable factor (REGATTA): a phase 3, randomised controlled trial". Lancet Oncol. 17 (3): 309–318. doi:10.1016/S1470-2045(15)00553-7. PMID 26822397.
9. ↑ 9.0 9.1 Janjigian YY, Shitara K, Moehler M, Garrido M, Salman P, Shen L, Wyrwicz L, Yamaguchi K, Skoczylas T, Campos Bragagnoli A, Liu T, Schenker M, Yanez P, Tehfe M, Kowalyszyn R, Karamouzis MV, Bruges R, Zander T, Pazo-Cid R, Hitre E, Feeney K, Cleary JM, Poulart V, Cullen D, Lei M, Xiao H, Kondo K, Li M, Ajani JA (2021). "First-line nivolumab plus chemotherapy versus chemotherapy alone for advanced gastric, gastro-oesophageal junction, and oesophageal adenocarcinoma (CheckMate 649): a randomised, open-label, phase 3 trial". Lancet. 398 (10294): 27–40. doi:10.1016/S0140-6736(21)00797-2. PMID 34102137 Check `|pmid=` value (help).
10. ↑ 10.0 10.1 Etoh T, Katai H, Fukagawa T, Sano T, Oda I, Gotoda T; et al. (2005). "Treatment of early gastric cancer in the elderly patient: results of EMR and gastrectomy at a national referral center in Japan". Gastrointest Endosc. 62 (6): 868–71. doi:10.1016/j.gie.2005.09.012. PMID 16301028.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
11. ↑ 11.0 11.1 (ASGE Standards of Practice Committee), Forbes N, Elhanafi SE, Al-Haddad MA, Thosani NC, Draganov PV, Othman MO, Ceppa EP, Kaul V, Feely MM, Sahin I, Buxbaum JL, Calderwood AH, Chalhoub JM, Coelho-Prabhu N, Desai M, Fujii-Lau LL, Kohli DR, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan W, Sheth SG, Storm AC, Thiruvengadam NR, Qumseya BJ (2023). "American Society for Gastrointestinal Endoscopy guideline on endoscopic submucosal dissection for the management of early esophageal and gastric cancers: summary and recommendations". Gastrointest Endosc. 98 (3): 271–284. doi:10.1016/j.gie.2023.03.015. PMID 37498266 Check `|pmid=` value (help). Vancouver style error: initials (help)
12. ↑ Lee JH, Choi MG, Min BH, Noh JH, Sohn TS, Bae JM; et al. (2012). "Predictive factors for lymph node metastasis in patients with poorly differentiated early gastric cancer". Br J Surg. 99 (12): 1688–92. doi:10.1002/bjs.8934. PMID 23023388.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
13. ↑ Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A; et al. (2015). "Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline". Endoscopy. 47 (9): 829–54. doi:10.1055/s-0034-1392882. PMID 26317585.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
14. ↑ Nishide N, Ono H, Kakushima N, Takizawa K, Tanaka M, Matsubayashi H; et al. (2012). "Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in remnant stomach or gastric tube". Endoscopy. 44 (6): 577–83. doi:10.1055/s-0031-1291712. PMID 22402983.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
15. ↑ Abe Y, Inamori M, Iida H, Endo H, Akiyama T, Yoneda K; et al. (2009). "Clinical characteristics of patients with gastric perforation following endoscopic submucosal resection for gastric cancer". Hepatogastroenterology. 56 (91–92): 921–4. PMID 19621730.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
16. ↑ Japanese Gastric Cancer Association (2017). "Japanese gastric cancer treatment guidelines 2014 (ver. 4)". Gastric Cancer. 20 (1): 1–19. doi:10.1007/s10120-016-0622-4. PMC 5215069. PMID 27342689.
17. ↑ 17.0 17.1 17.2 Hatta W, Gotoda T, Oyama T, Kawata N, Takahashi A, Yoshifuku Y, Hoteya S, Nakagawa M, Hirano M, Esaki M, Matsuda M, Ohnita K, Yamanouchi K, Yoshida M, Dohi O, Takada J, Tanaka K, Yamada S, Tsuji T, Ito H, Hayashi Y, Nakaya N, Nakamura T, Shimosegawa T (2017). "A Scoring System to Stratify Curability after Endoscopic Submucosal Dissection for Early Gastric Cancer: "eCura system"". Am J Gastroenterol. 112 (6): 874–881. doi:10.1038/ajg.2017.95. PMID 28397873.
18. ↑ FLY OA, PRIESTLEY JT, COMFORT MW, GAGE RP (May 1958). "Total gastrectomy: mortality and survival". Ann. Surg. 147 (5): 760–8, discussion 768–70. PMC 1450692. PMID 13521695.
19. ↑ Wang SY, Yeh CN, Lee HL, Liu YY, Chao TC, Hwang TL, Jan YY, Chen MF (October 2009). "Clinical impact of positive surgical margin status on gastric cancer patients undergoing gastrectomy". Ann. Surg. Oncol. 16 (10): 2738–43. doi:10.1245/s10434-009-0616-0. PMID 19636636.
20. ↑ Chaves DM, Maluf Filho F, de Moura EG, Santos ME, Arrais LR, Kawaguti F, Sakai P (April 2010). "Endoscopic submucosal dissection for the treatment of early esophageal and gastric cancer--initial experience of a western center". Clinics (Sao Paulo). 65 (4): 377–82. doi:10.1590/S1807-59322010000400005. PMC 2862673. PMID 20454494.
21. ↑ 21.0 21.1 Kitagawa Y, Matsuda S, Gotoda T, Kato K, Wijnhoven B, Lordick F, Bhandari P, Kawakubo H, Kodera Y, Terashima M, Muro K, Takeuchi H, Mansfield PF, Kurokawa Y, So J, Mönig SP, Shitara K, Rha SY, Janjigian Y, Takahari D, Chau I, Sharma P, Ji J, de Manzoni G, Nilsson M, Kassab P, Hofstetter WL, Smyth EC, Lorenzen S, Doki Y, Law S, Oh DY, Ho KY, Koike T, Shen L, van Hillegersberg R, Kawakami H, Xu RH, Wainberg Z, Yahagi N, Lee YY, Singh R, Ryu MH, Ishihara R, Xiao Z, Kusano C, Grabsch HI, Hara H, Mukaisho KI, Makino T, Kanda M, Booka E, Suzuki S, Hatta W, Kato M, Maekawa A, Kawazoe A, Yamamoto S, Nakayama I, Narita Y, Yang HK, Yoshida M, Sano T (2024). "Clinical practice guidelines for esophagogastric junction cancer: Upper GI Oncology Summit 2023". Gastric Cancer. 27 (3): 401–425. doi:10.1007/s10120-023-01457-3. PMID 38386238 Check `|pmid=` value (help).
22. ↑ Hirao M, Kurokawa Y, Fujita J, Imamura H, Fujiwara Y, Kimura Y; et al. (2015). "Long-term outcomes after prophylactic bursectomy in patients with resectable gastric cancer: Final analysis of a multicenter randomized controlled trial". Surgery. 157 (6): 1099–105. doi:10.1016/j.surg.2014.12.024. PMID 25704429.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
23. ↑ Lu J, Zheng CH, Xu BB, Xie JW, Wang JB, Lin JX, Chen QY, Cao LL, Lin M, Tu RH, Huang ZN, Lin JL, Zheng HL, Li P, Huang CM (2024). "Robotic versus laparoscopic distal gastrectomy for resectable gastric cancer: a randomized phase 2 trial". Nat Commun. 15 (1): 4668. doi:10.1038/s41467-024-49013-6. PMC 11143299 Check `|pmc=` value (help). PMID 38821945 Check `|pmid=` value (help).
24. ↑ Xie D, Shen J, Liu L, Cao B, Xiao A, Qin J, Wu J, Yan Q, Hu Y, Yang C, Cao Z, Hu J, Yin P, Gong J (2024). "Randomized clinical trial on D2 lymphadenectomy versus D2 lymphadenectomy plus complete mesogastric excision in patients undergoing gastrectomy for cancer (DCGC01 study)". Br J Surg. 111 (5): znae106. doi:10.1093/bjs/znae106. PMID 38713611 Check `|pmid=` value (help).
25. ↑ Kim YW, Min JS, Yoon HM, An JY, Eom BW, Hur H, Cho GS, Kim CY, Choi IJ, Park CH, Lim CH, Song MK, Hyung WJ, Yoo MW, Park YK, Park DJ, Ryu SW, Kim W, Ryu KW, Choi CI, Yook JH, Lee JI, Lee KY, Nam BH, Yang HK (2022). "Laparoscopic Sentinel Node Navigation Surgery for Stomach Preservation in Patients With Early Gastric Cancer: A Randomized Clinical Trial". J Clin Oncol. 40 (21): 2342–2351. doi:10.1200/JCO.21.02242. PMID 35324317 Check `|pmid=` value (help).
26. ↑ Noguchi Y, Yoshikawa T, Tsuburaya A, Motohashi H, Karpeh MS, Brennan MF (2000). "Is gastric carcinoma different between Japan and the United States?". Cancer. 89 (11): 2237–46. PMID 11147594.CS1 maint: Multiple names: authors list (link)
27. ↑ Japanese Gastric Cancer Association (2011). "Japanese classification of gastric carcinoma: 3rd English edition". Gastric Cancer. 14 (2): 101–12. doi:10.1007/s10120-011-0041-5. PMID 21573743.
28. ↑ Kikuchi S, Arai Y, Kobayashi N, Tsukamoto H, Shimao H, Sakakibara Y; et al. (2000). "Is extended lymphadenectomy valuable in palliatively gastrectomized patients with gastric cancer and simultaneous peritoneal metastasis?". Hepatogastroenterology. 47 (32): 563–6. PMID 10791239.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
29. ↑ Ouchi K, Sugawara T, Ono H, Fujiya T, Kamiyama Y, Kakugawa Y; et al. (1998). "Therapeutic significance of palliative operations for gastric cancer for survival and quality of life". J Surg Oncol. 69 (1): 41–4. PMID 9762890.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
30. ↑ Jeurnink SM, van Eijck CH, Steyerberg EW, Kuipers EJ, Siersema PD (2007). "Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review". BMC Gastroenterol. 7: 18. doi:10.1186/1471-230X-7-18. PMC 1904222. PMID 17559659.CS1 maint: Multiple names: authors list (link)
31. ↑ Freitas D, Gouveia H, Sofia C, Cabral JP, Donato A (1995). "Endoscopic Nd-YAG laser therapy as palliative treatment for esophageal and cardial cancer". Hepatogastroenterology. 42 (5): 633–7. PMID 8751226.CS1 maint: Multiple names: authors list (link)
32. ↑ Xiao JW, Liu ZL, Ye PC, Luo YJ, Fu ZM, Zou Q; et al. (2015). "Clinical comparison of antrum-preserving double tract reconstruction vs roux-en-Y reconstruction after gastrectomy for Siewert types II and III adenocarcinoma of the esophagogastric junction". World J Gastroenterol. 21 (34): 9999–10007. doi:10.3748/wjg.v21.i34.9999. PMC 4566393. PMID 26379405.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
33. ↑ Byun C, Cui LH, Son SY, Hur H, Cho YK, Han SU (2016). "Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis". Surg Endosc. 30 (10): 4505–14. doi:10.1007/s00464-016-4783-3. PMID 26895918.CS1 maint: Multiple names: authors list (link)
34. ↑ Song P, Lu M, Pu F, Zhang D, Wang B, Zhao Q (2014). "Meta-analysis of pylorus-preserving gastrectomy for middle-third early gastric cancer". J Laparoendosc Adv Surg Tech A. 24 (10): 718–27. doi:10.1089/lap.2014.0123. PMID 25243417.CS1 maint: Multiple names: authors list (link)

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