Modern Surgery for Gastric Cancer — Japanese Perspective

although the role of surgery is changing for gastric cancer due to increased role of non-surgical treatment, surgery continues to be the most important curative treatment of this disease (1). any patient with curable gastric cancer, from stage I to Iv, inclusive, were treated by D2 dissection in Japan, in the 1970’s and 80’s, until a large data base of T1 tumors revealed that some subgroups of these tumors seldom have any metastases, allowing local excision as a curative treatment. with the development of endoscopic instruments, T1 gastric cancer or “dysplasia” of 5 cm or even larger can be treated by endoscopic submucosal dissection (eSD) (2, 3, 4). For advanced gastric cancer, D2 dissection is the gold standard in the east asian countries in spite of the negative results of the two european trials (5, 6). In Japan, there is a high incidence of gastric cancer which results in high hospital volume; surgical mortality is very low since patients are generally in better condition for this procedure (7). Survival after D2 surgery has never been surpassed by any other treatment, including multimodal ones with more limited surgery for advanced gastric cancer. More extensive surgery than D2 dissection was often carried out in Japan in the 1980’s and early 1990’s, without any solid evidence of benefit of this procedure over D2 dissection (8). This issue was solved by a large clinical trial, which showed no survival benefit for patients who underwent super-extended surgery (9). For locally advanced gastric cancer, which is often incurable, wide regional resection, such as left upper abdominal evisceration with or without appleby’s procedure, was sometimes attempted. However, many of these tumors were eventually incurable, and some curable tumors carried a very poor prognosis even after such surgery. recently, neoadjuvant chemotherapy or chemoradiotherapy has been tried and seems to produce interesting results for these tumors. what kind of surgery should be performed after neoadjuvant treatment is not yet well studied.