Editor's Note: Gastric cancer remains a significant threat to human health. While breakthroughs in chemotherapy, targeted therapy, and immunotherapy have brought hope to patients, radical surgery remains the cornerstone of gastric cancer management. Recent years have seen substantial advancements in surgical treatment, including the refinement of standard radical gastrectomy, the development of minimally invasive techniques such as laparoscopic surgery, the establishment of perioperative multimodal treatment strategies for advanced gastric cancer, and the emergence of precision surgical approaches. At the 2024 CSCO Gastric Cancer Expert Committee Academic Conference, Dr. Jiangpeng Wei from the Department of Gastrointestinal Surgery, The First Affiliated Hospital of Air Force Medical University, provided an overview of key trends in gastric cancer surgery. The key points are summarized below.

I. Precision Staging: The Foundation of Surgical Decision-Making

• The Path to Unified Staging Systems

Staging is crucial for treatment decision-making in gastric cancer. In 2010, the International Union Against Cancer (UICC), American Joint Committee on Cancer (AJCC), and Japanese Gastric Cancer Association (JCGC) unified their staging systems for the first time. The 14th edition of the Japanese Gastric Cancer Treatment Guidelines adopted the UICC/AJCC staging standards, achieving worldwide consistency. This global standardization has enabled physicians to more accurately assess disease status and develop personalized treatment plans.

• The Importance and Value of Precision Staging

Precision staging is pivotal for gastric cancer treatment. It not only determines the disease status and treatment strategy but also helps select appropriate chemotherapy regimens and predict prognosis. Accurate staging provides crucial information about tumor size, location, depth of invasion, lymph node involvement, and distant metastases, guiding the most suitable treatment strategy for patients.

In surgical planning, precision staging facilitates the identification of candidates for function-preserving surgeries. For instance, in high-risk T1a and T1bNo patients, the surgical resection margin can be reduced while ensuring negative margins, allowing for function-preserving gastrectomy. These procedures achieve therapeutic goals while preserving gastric function, improving patients’ quality of life. Studies have shown that function-preserving gastrectomy significantly improves postoperative digestive function and nutritional status without compromising survival rates, enabling patients to resume normal life more quickly.

• Precise Selection of Function-Preserving Surgeries

For early-stage gastric cancer, precision staging helps determine surgical extent, reconstruction method, and functional preservation. Compared to standard radical gastrectomy, function-preserving surgeries reduce the extent of gastric resection and/or lymph node dissection.

Procedures such as endoscopic surgery are suitable for early gastric cancer without lymph node metastasis. Other approaches, including local gastrectomy (LG), segmental gastrectomy (SG), and proximal gastrectomy (PG), are applied under specific conditions. For instance, pylorus-preserving gastrectomy (PPG) is ideal for tumors in the lower stomach meeting specific criteria. These precise surgical options offer more opportunities for preserving gastric function.

A study on early gastric cancer patients found that those undergoing function-preserving surgeries demonstrated better postoperative weight maintenance and nutrient absorption compared to those receiving traditional radical surgery, with no significant difference in long-term survival rates.

II. Function-Preserving Surgeries: Enhancing Quality of Life

• Double-Scope Wedge Resection: A New Choice for Early Gastric Cancer

Double-scope wedge resection has shown promising outcomes in early gastric cancer treatment. The SENORITA study employed local resection combined with sentinel lymph node drainage area dissection for early gastric cancer. Results showed no significant differences in three- and five-year overall survival (OS) and disease-free survival (DFS) between double-scope surgery and traditional surgery. However, the double-scope group demonstrated superior outcomes in terms of quality of life and nutritional indicators.

This study, which randomized patients into double-scope wedge resection and traditional surgery groups, found that the double-scope group had better postoperative gastrointestinal function recovery, weight maintenance, and lower anemia rates during long-term follow-up. These findings suggest that double-scope surgery can preserve patients’ quality of life while maintaining oncological efficacy, offering a new treatment option for early gastric cancer patients.

III. Function-Preserving Surgeries: Enhancing Postoperative Outcomes

• Pylorus-Preserving Surgery: Addressing Postoperative Complications and Nutritional Status Pylorus-preserving gastrectomy (PPG) is a key technique in gastric cancer treatment and is recommended by the Japanese Gastric Cancer Treatment Guidelines as an option for early gastric cancer. The KLASS-04 trial compared laparoscopic PPG (LPPG) with laparoscopic distal gastrectomy (LDG), showing that the LPPG group had advantages in reducing gallstone formation and maintaining hemoglobin and albumin levels. Although LPPG was associated with higher rates of delayed gastric emptying and reflux esophagitis, there was no difference in the incidence of dumping syndrome within the first year post-surgery. This demonstrates that pylorus-preserving surgery can improve postoperative nutritional status and reduce certain complications.
• Combined Preservation of the Cardia and Pylorus: A Feasible Option for Selected Patients For specific cases of early gastric cancer, segmental gastrectomy with preservation of both the cardia and pylorus is a viable treatment option. The Japanese Gastric Cancer Guidelines provide clear criteria for this approach, such as cT1N0 tumors located at least 4 cm from the cardia (with 2–4 cm being a relative indication) and resection margins of at least 1.0–1.5 cm below the cardia. This technique maintains the stomach’s normal anatomical structure and function while ensuring oncological efficacy, significantly improving patients’ quality of life after surgery.

• Vagus Nerve-Preserving Surgery: Reducing Complications

Vagus nerve-preserving gastrectomy maintains oncological outcomes comparable to traditional surgeries while significantly reducing complications such as gallstones, diarrhea, gastrointestinal dysfunction, nutritional deficiencies, and weight loss. Adopting proper surgical approaches and extrafascial lymph node dissection facilitates this procedure, improving postoperative recovery and quality of life for gastric cancer patients.

IV. Esophagogastric Junction Tumors: Individualized Treatment Strategies

• Tumor Classification and Lymph Node Metastasis Characteristics Treatment of esophagogastric junction (EGJ) tumors remains challenging. The Siewert classification categorizes tumors into three types based on the tumor’s center relative to the esophageal dentate line:

1. Type I: 1–5 cm above the dentate line.
2. Type II: 1 cm above to 2 cm below the dentate line.
3. Type III: 2–5 cm below the dentate line.

Lymph node metastasis patterns differ by type. For instance, type I tumors frequently metastasize to mediastinal lymph nodes, whereas type III tumors more commonly involve abdominal lymph nodes. Accurate classification provides valuable insight into tumor biology and informs individualized treatment planning.

• Precision Lymph Node Dissection Lymph node dissection strategies for EGJ tumors vary by type. The 11th edition of the Japanese Esophageal Cancer Classification emphasizes mediastinal lymph node dissection for esophagus-dominant EGJ cancers, particularly first- and second-tier nodes. Conversely, the 6th edition of the Japanese Gastric Cancer Treatment Guidelines suggests dissection of groups 19 and 20 for stomach-dominant EGJ cancers, with lower mediastinal lymph node dissection recommended only for clinical research. These guidelines serve as critical references for surgeons in defining the scope of lymphadenectomy.
• Surgical Approaches and Function Preservation Common surgical procedures for Siewert III EGJ tumors include total gastrectomy and proximal gastrectomy. Total gastrectomy is indicated for T2–T4 or N+ tumors, while proximal gastrectomy is selectively applied under specific conditions. Post-proximal gastrectomy, efforts to preserve function have focused on anti-reflux techniques such as double-flap anastomosis, hand-sewn anastomosis, and semi-embedded flap anastomosis. While double-flap anastomosis has shown superior results in reducing reflux and improving quality of life, it is technically challenging. Hand-sewn anastomosis, though simpler, offers slightly less effective reflux control.

• Artificial Intelligence and Minimally Invasive Surgery: Driving the Future of Gastric Cancer Treatment
• Diverse Applications of Artificial Intelligence Artificial intelligence (AI) is playing an increasingly prominent role in gastric cancer diagnosis and treatment. In early gastric cancer screening, AI models enhance diagnostic accuracy by analyzing endoscopic images, blood metabolic markers, and tongue coating features. AI-based circulating EV marker GCInc1, for example, has demonstrated the ability to identify precancerous gastric mucosal lesions and early gastric cancer, even in CEA-, CA19-9-, and CA72-4-negative cases. During surgery, AI assists in tissue recognition to prevent injury, monitors laparoscopic distal gastrectomy stages to improve quality control, and predicts postoperative complications, treatment efficacy, and recurrence risk.
• Innovations in Minimally Invasive Surgery Minimally invasive surgery has become a cornerstone of gastric cancer treatment. The CLASS-01 study demonstrated that laparoscopic gastric cancer surgery achieves comparable three-year disease-free survival rates to open surgery. The use of indocyanine green (ICG) tracers in laparoscopic surgery has improved lymph node dissection precision. Reduced-port laparoscopic surgeries, such as the three-port method for distal gastrectomy, have shown safety and efficacy, with reduced blood loss and shorter hospital stays without compromising lymphadenectomy. Emerging technologies like 5G-enabled remote robotic surgery offer new opportunities to enhance surgical precision and accessibility.
• Future Prospects for Minimally Invasive Surgery With ongoing technological advancements, minimally invasive surgery will become even more integrated into gastric cancer treatment. Combining AI with minimally invasive techniques promises greater precision, personalized treatment plans, and improved outcomes. Remote surgical guidance and training via 5G networks and virtual reality simulations are expected to further expand access to advanced medical technologies and elevate surgical expertise, benefitting more gastric cancer patients.