The Surgical Anatomy of the Lymphatic System of the Stomach

The gastric lymphatic system is essential for immune function and the metastasis of gastric cancer. However, variations in lymphatic anatomy, drainage patterns, and staging frameworks complicate surgical planning and oncologic decision-making. This study aims to review the anatomy of the gastric lymphatic system, the history and variation of JCGC and UICC/AJCC TNM gastric lymphatic staging classifications, while also exploring the differences between lymphadenectomy strategies. A PRISMA-guided search across PubMed, PMC, ScienceDirect, Elsevier Science, Wiley, and SpringerLink retrieved eligible studies meeting pre-determined inclusion criteria. Of the 79 entries returned, 40 eligible studies were identified after application of our inclusion and exclusion criteria. The JCGC and UICC/AJCC TNM systems differ in their staging methods. While the JCGC categorizes lymph nodes by their location relative to the tumor, the UICC/AJCC categorizes the N stage by the number of positive lymph nodes detected. Though the UICC/AJCC staging system is dominant in multiple countries, efforts have been made in recent years to align the protocols in both staging systems. As a result, D2 lymphadenectomy is widely practiced in JCGC adhering countries, whereas UICC/AJCC protocols favor selective dissection combined with neoadjuvant chemotherapy. The complexity of gastric lymphatic anatomy and the absence of a globally standardized staging classification can lead to heterogeneous lymphadenectomy strategies and inconsistent oncologic outcomes. This review emphasizes the need for a unified classification system that incorporates anatomical, oncologic, and imaging perspectives to improve staging and optimize surgical decision-making.