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Overview and Recommendations
Background
- •Gastric cancer is the fifth most common cancer worldwide and the third leading cause of cancer death. Surgical resection with curative intent is the mainstay for localized disease, with the goal of R0 resection and adequate lymphadenectomy. The management is stage-dependent: early gastric cancer (T1) may be amenable to endoscopic resection or limited surgery, while locally advanced disease (T2-4 or N+) requires D2 gastrectomy with perioperative chemotherapy.
- •The paradigm has shifted from surgery alone to multimodality therapy. In the West, perioperative chemotherapy (MAGIC trial: ECF; FLOT regimen) improved overall survival (HR 0.75). In Asia, adjuvant S-1 (ACTS-GC) and neoadjuvant DOS followed by S-1 (PRODIGY) have become standards. The four pillars of modern management are adequate surgery, perioperative systemic therapy, lymphadenectomy, and ERAS.
- •Key surgical approaches include distal gastrectomy, total gastrectomy, and proximal gastrectomy. Lymphadenectomy extent (D1 vs D2) impacts outcomes: D2 dissection improves disease-specific survival compared with D1 (HR 0.807; NNT = 10). At least 16 lymph nodes should be assessed for adequate staging.
- •Laparoscopic gastrectomy has been validated in multiple randomized controlled trials (KLASS-01, KLASS-02, LOGICA, CLASS-02) as oncologically noninferior to open surgery, with equivalent 5-year overall survival and fewer early and late complications. Robotic gastrectomy offers technical advantages in lymph node dissection, particularly in narrow spaces.
- •Function-preserving techniques are emerging for early gastric cancer. Pylorus-preserving gastrectomy (PPG) for middle-third cT1N0 tumors reduces bile reflux, gallstone formation, and nutritional deficiencies. Sentinel node navigation surgery (LSNNS) allows stomach preservation in 74.8% of patients with cT1N0 tumors ≤3 cm, with 3-year disease-specific survival of 99.1%.
- •Enhanced recovery after surgery (ERAS) protocols have become standard of care. ERAS shortens hospital stay by ~1.8 days, reduces overall complications (OR 0.63), and improves 3-year overall survival in stage III gastric cancer (; HR 0.57). Core elements include prehabilitation, opioid-sparing analgesia, early oral feeding, and selective omission of abdominal drains.
Evaluation
- •Suspect gastric cancer in patients with dyspepsia, weight loss, early satiety, iron deficiency anemia, or hematemesis. Upper endoscopy with biopsy is the diagnostic gold standard; obtain multiple biopsies from the tumor and surrounding mucosa.
- •Stage with contrast-enhanced CT of chest, abdomen, and pelvis to assess T stage, nodal involvement, and distant metastases. Endoscopic ultrasound (EUS) is essential for accurate T and N staging, especially for early tumors where endoscopic resection or limited surgery may be considered.
- •Assess HER2, MSI, and PD-L1 status on biopsy specimens to guide perioperative and systemic therapy decisions. HER2-positive tumors benefit from trastuzumab; MSI-high tumors are highly responsive to immune checkpoint inhibitors.
- •For early gastric cancer (cT1N0), evaluate eligibility for endoscopic resection (differentiated type, ≤2 cm, no ulceration) or sentinel node navigation (tumor ≤3 cm). If not eligible, proceed to laparoscopic gastrectomy with D1+ lymphadenectomy.
- •For locally advanced disease (cT2-4 or N+), multidisciplinary discussion is essential. Consider neoadjuvant chemotherapy: FLOT (docetaxel 50 mg/m², oxaliplatin 85 mg/m², leucovorin 200 mg/m², 5-FU 2600 mg/m² as 24h infusion) every 2 weeks for 4 cycles in the West; DOS (docetaxel 50 mg/m², oxaliplatin 100 mg/m², S-1 80-120 mg/day) in Asia.
- •Assess patient fitness for surgery: performance status (ECOG 0-2), nutritional status (NRS-2002), and frailty (Geriatric 8 score). Use preoperative risk stratification tools such as the Comprehensive Inflammatory-Metabolic Index (CIMI) to predict complications (AUC 0.748).
- •Preoperative imaging should include assessment of left gastric vein (LGV) anatomy on CT. Type C LGV (dorsal to splenic artery) predicts a 17.9% risk of postoperative pancreatic fistula (POPF) vs 1.7% for other types.
- •Consider staging laparoscopy for patients at high risk of peritoneal metastases: signet ring histology, diffuse type, advanced T stage (T3/T4), or suspicious findings on CT. Laparoscopy can detect occult peritoneal disease and avoid unnecessary laparotomy.
- •For metastatic disease (stage IV), surgery is reserved for palliation of obstruction or bleeding. Systemic therapy is primary; trastuzumab plus chemotherapy for HER2-positive, nivolumab plus chemotherapy for PD-L1 CPS ≥5, and apatinib for third-line therapy.
- •Also consider fertility preservation in young patients with early gastric cancer. Pylorus-preserving gastrectomy or sentinel node navigation may be appropriate to maintain reproductive potential and long-term quality of life.
Management
- •For early gastric cancer (cT1N0, ≤3 cm): offer laparoscopic sentinel node navigation surgery (LSNNS) if available; stomach preservation achieved in 74.8% of patients. If not eligible, perform laparoscopic distal gastrectomy with D1+ lymphadenectomy. For middle-third tumors, consider pylorus-preserving gastrectomy (PPG) to reduce bile reflux and nutritional deficiencies.
- •For locally advanced gastric cancer (cT2-4 or N+): administer perioperative chemotherapy. In the West, use FLOT (docetaxel 50 mg/m², oxaliplatin 85 mg/m², leucovorin 200 mg/m², 5-FU 2600 mg/m² as 24h infusion) every 2 weeks for 4 cycles before and 4 cycles after surgery. In Asia, neoadjuvant DOS (docetaxel 50 mg/m², oxaliplatin 100 mg/m², S-1 80-120 mg/day) followed by D2 gastrectomy and adjuvant S-1 for 1 year.
- •Perform D2 lymphadenectomy (removal of perigastric nodes plus nodes along celiac axis, splenic artery, common hepatic artery, and left gastric artery). Aim for at least 16 lymph nodes. Use indocyanine green (ICG) fluorescence to improve nodal yield, especially after neoadjuvant therapy (mean difference 9.3 nodes) and in obese patients (mean difference 10.94 nodes).
- •For patients who undergo upfront surgery without neoadjuvant therapy and have T3+ or node-positive disease: administer adjuvant chemoradiation (45 Gy with 5-FU/leucovorin) per INT-0116. However, after D2 dissection, adjuvant chemotherapy alone (S-1 or SOX) is preferred based on CRITICS and ARTIST 2 data.
- •For stage III node-positive disease after D2: use S-1 (80-120 mg/day, 4 weeks on/2 weeks off for 1 year) plus docetaxel (JACCRO GC-07) to improve 3-year relapse-free survival from 50% to 66% (NNT=6). Alternatively, SOX (S-1 80-120 mg/day days 1-14, oxaliplatin 130 mg/m² day 1, every 3 weeks for 6 months) is effective (ARTIST 2).
- •For HER2-positive advanced disease: add trastuzumab (8 mg/kg loading, then 6 mg/kg every 3 weeks) to chemotherapy (capecitabine/cisplatin or 5-FU/oxaliplatin). After trastuzumab failure, anbenitamab plus chemotherapy improves PFS (HR 0.25) and OS (HR 0.29).
- •For MSI-high advanced disease: use pembrolizumab or nivolumab plus chemotherapy. Anti-PD-1 regimens yield OS HR 0.34 in MSI-high vs 0.85 in MSS (P interaction = 0.003).
- •Intraoperative management: use a pancreas-contactless technique to reduce POPF (from 7.6% to 0% in open gastrectomy). Perform intraoperative air-leak test for anastomotic integrity. Have a low threshold for conversion to open if bleeding is not rapidly controlled laparoscopically.
- •Postoperative ERAS: initiate early oral feeding (clear liquids on POD 1, soft diet by POD 3-4), multimodal opioid-sparing analgesia (subcostal TAP block, acetaminophen, COX-2 inhibitors), early mobilization, and selective omission of abdominal drains. Discharge criteria: tolerating oral intake, pain controlled with oral analgesics, afebrile, ambulating independently.
- •Monitor for complications: pancreatic fistula (POPF) - manage with drainage, nil per os, parenteral nutrition, somatostatin analogues; anastomotic leak - endoscopic stenting or percutaneous drainage; reoperation for large defects. Use preoperative LGV anatomy to stratify POPF risk.
- •Avoid: non-dihydropyridine CCBs (diltiazem, verapamil) - exacerbate gastroparesis; routine abdominal drainage - increases complications (OR 0.53 for omission); routine radiotherapy after D2 dissection - no benefit (ARTIST 2); ELFE, FAMTX, or FEMTX regimens - no survival benefit; adjuvant nivolumab/ipilimumab for ypN+/R1 after neoadjuvant chemo - inferior to chemotherapy (VESTIGE).
- •Refer to medical oncology for perioperative therapy and management of advanced disease. Refer to radiation oncology if adjuvant chemoradiation is indicated (inadequate lymphadenectomy or R1 resection). Refer to palliative care for symptom management in advanced disease.
- •For young patients with early gastric cancer: consider pylorus-preserving gastrectomy or sentinel node navigation to preserve fertility and long-term quality of life. Discuss fertility preservation options preoperatively.
- •Long-term surveillance: clinical follow-up with history, physical exam, and contrast-enhanced CT every 3-6 months for first 2 years, then every 6-12 months. Endoscopy as indicated for symptoms. Monitor nutritional status with NRS-2002 every 2 weeks for first 3 months; oral nutritional supplements if needed, target 25-30 kcal/kg/day and protein 1.0-1.5 g/kg/day.
Board Review — High Yield
- •MAGIC trial, Perioperative ECF chemotherapy improved overall survival (HR 0.75) compared to surgery alone for resectable gastric cancer.
- •D2 lymphadenectomy, Improves disease-specific survival over D1 (HR 0.807); at least 16 lymph nodes required for adequate staging.
- •KLASS-01, Laparoscopic distal gastrectomy noninferior to open for stage I gastric cancer (5-year OS 94.2% vs 93.3%).
- •S-1 plus docetaxel (JACCRO GC-07), For stage III after D2, improves 3-year RFS from 50% to 66% (NNT=6).
- •ERAS (GISSG1901), Reduces complications, hospital stay, and improves 3-year survival in stage III gastric cancer (HR 0.57).
- •Sentinel node navigation (SENORITA), For cT1N0 tumors ≤3 cm, detection rate 97.5%, accuracy 99%; stomach preservation in 74.8%.
- •Pylorus-preserving gastrectomy (KLASS-04), For middle-third early gastric cancer, reduces bile reflux, gallstone formation, and nutritional deficiencies.
- •ICG fluorescence, Increases lymph node yield by 6.9 nodes (mean), especially after neoadjuvant therapy and in obese patients.
- •CRITICS trial, After D2, adjuvant chemotherapy alone superior to chemoradiation (5-year OS 57.9% vs 45.5%; adjusted HR 1.62).
- •VESTIGE trial, Nivolumab/ipilimumab inferior to chemotherapy for ypN+/R1 after neoadjuvant chemo (median DFS 11.4 vs 20.8 months; HR 1.55).
Deep Dive — Evidence Details
Indications by Stage
- ▸Surgical eligibility is stage-gated: early (T1) disease may be managed with sentinel node navigation or standard gastrectomy; locally advanced (T2-4, N+) requires D2 gastrectomy with perioperative chemotherapy; metastatic disease is primarily treated with systemic therapy.
- ▸D2 lymphadenectomy improves disease-specific survival over D1 (HR 0.807; NNT = 10) and is the preferred extent for curative-intent resection.
- ▸Adjuvant chemotherapy alone after D2 dissection (CRITICS, JACCRO GC-07) may be superior to chemoradiation in this setting, while perioperative chemotherapy (MAGIC, PRODIGY) remains the global standard for locally advanced disease.
Surgical management of is stage-dependent, with treatment algorithms stratified by depth of invasion, nodal status, and presence of metastases. The goal of curative-intent surgery is an R0 resection with adequate lymphadenectomy, guided by preoperative staging and multidisciplinary discussion [20]B2a.
Early Gastric Cancer (T1)
For clinical stage IA (T1N0) tumors ≤3 cm, laparoscopic sentinel node navigation surgery (LSNNS) allows stomach preservation in 81% of patients, with 3-year disease-specific survival of 99.1% versus 99.5% for standard and better long-term quality of life and nutritional outcomes [18]A1b. However, LSNNS did not meet noninferiority for 3-year disease-free survival (91.8% vs 95.5%; difference 3.7%, 95% CI -0.6 to 8.1) [18]A1b. For patients not eligible for sentinel node navigation, laparoscopic or open gastrectomy with D1+ lymphadenectomy is standard; the LOGICA trial confirmed that laparoscopic gastrectomy for cT1-4aN0-3bM0 disease yields equivalent oncologic outcomes (R0 resection 95% in both arms, median lymph node yield 29) and similar 1-year overall survival (76% vs 78%) [16]A1b.
Locally Advanced Gastric Cancer (T2-4, N+)
The standard of care is D2 gastrectomy combined with perioperative chemotherapy. The MAGIC trial established perioperative , , and fluorouracil (ECF) chemotherapy, improving overall survival (HR 0.75, 95% CI 0.60-0.93) [7]A1b. In Asia, the PRODIGY trial demonstrated that neoadjuvant , , and S-1 (DOS) followed by D2 surgery and adjuvant S-1 improved progression-free survival (HR 0.70, 95% CI 0.52-0.95) and overall survival (HR 0.72, 95%; 8-year OS 63.0% vs 55.1%) compared with surgery plus adjuvant S-1 alone [10]A1b[13]A1b. For patients who undergo upfront surgery, adjuvant chemoradiation (INT-0116) reduces relapse (HR for RFS 1.51, 95% CI 1.25-1.83) and improves overall survival (HR 1.32, 95% CI 1.10-1.60) for T3+ or node-positive disease [14]A1b. Alternatively, adjuvant chemotherapy alone after D2 dissection is supported by the CRITICS per-protocol analysis, which showed superior 5-year overall survival with chemotherapy (57.9%) versus chemoradiation (45.5%; adjusted HR 1.62, 95% CI 1.24-2.12) [5]A1b, and by JACCRO GC-07, where S-1 plus docetaxel improved 3-year relapse-free survival from 50% to 66% (HR 0.632, 99.99% CI 0.400-0.998) for stage III disease [12]A1b.
Lymphadenectomy extent matters: D2 dissection improves disease-specific survival compared with D1 (HR 0.807, 95% CI 0.705-0.924; NNT = 10) [4]A1a. At least 16 lymph nodes should be assessed for adequate staging [20]B2a. Emerging strategies include adding and low-dose to S-1 and oxaliplatin (SOX), which increased pathologic complete response from 5.0% to 18.3% (OR 4.5, 95% CI 2.1-9.9) in T3-4aN+M0 disease, though survival data are pending [15]A1b.
Metastatic Gastric Cancer (Stage IV)
Surgery is reserved for palliation of symptoms such as obstruction or bleeding [20]B2a. For peritoneal metastases, cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) did not improve overall survival (median 14.9 months in both arms) but improved progression-free survival (7.1 vs 3.5 months; P = 0.047) [11]A1b. Systemic therapy is primary; plus chemotherapy is recommended for HER2-positive advanced disease [1]A1c.
High-Risk Features After Neoadjuvant Therapy
Patients with ypN+ or R1 status after neoadjuvant chemotherapy and resection have high recurrence risk. Adjuvant / did not improve disease-free survival compared with chemotherapy (median 11.4 vs 20.8 months; HR 1.55, 95% CI 1.07-2.25) [19]B2b; standard adjuvant chemotherapy remains the comparator.
Pearl: For locally advanced gastric cancer, D2 gastrectomy with perioperative chemotherapy (MAGIC-style ECF/X or PRODIGY-style DOS) is the evidence-based standard; adjuvant chemoradiation is an alternative for patients who did not receive neoadjuvant therapy, but after D2 dissection, adjuvant chemotherapy alone may be preferred based on CRITICS data.
Operative Techniques
- ▸Laparoscopic distal gastrectomy with D2 lymphadenectomy is oncologically equivalent to open surgery for both stage I and locally advanced gastric cancer, with fewer early and late complications.
- ▸D2 lymphadenectomy is the standard for curative-intent resection in advanced non-metastatic gastric cancer; at least 16 lymph nodes should be assessed for adequate staging.
- ▸ICG fluorescence lymphography improves nodal yield by a mean of 6.9 nodes, particularly in neoadjuvant-treated and obese patients.
The previous section outlined the stage-based indications for curative resection. Once the decision for surgery is made, the operative technique, open, laparoscopic, or robotic, and the extent of gastric resection and lymphadenectomy must be selected based on tumor location, stage, and patient physiology. The key principles are a negative (R0) resection margin, adequate lymph node assessment (≥16 nodes), and a D2 lymphadenectomy for advanced non-metastatic disease [20]B2a.
Laparoscopic vs Open
Laparoscopic gastrectomy has been rigorously evaluated in multiple randomized controlled trials and is now considered a standard approach for appropriately selected patients. The KLASS-01 trial, enrolling 1,416 patients with stage I , demonstrated noninferiority of laparoscopic distal gastrectomy compared with open surgery: 5-year overall survival was 94.2% in the laparoscopic group vs 93.3% in the open group (difference, 0.9 percentage points; 1-sided 97.5% CI, -1.6 to infinity) [24]A1b. The KLASS-02 trial extended this evidence to locally advanced gastric cancer, showing that laparoscopic distal gastrectomy with D2 lymphadenectomy had a 3-year relapse-free survival rate of 80.3% vs 81.3% (HR 1.02; 95% CI, 0.75 to 1.39; P for noninferiority = 0.030) and was associated with fewer early complications (15.7% vs 23.4%) and late complications (4.7% vs 9.5%) [21]A1b. The LOGICA trial, a Western multicenter RCT, found that laparoscopic gastrectomy did not shorten hospital stay (median 7 days in both arms) but reduced blood loss (150 vs 300 mL) and had similar postoperative complications (44% vs 42%), mortality, and 1-year overall survival [16]A1b. For , the CLASS02 trial confirmed that laparoscopic total gastrectomy with lymphadenectomy for clinical stage I gastric cancer is safe, with comparable morbidity and mortality to open total gastrectomy [23]A1b. A meta-analysis of 10 randomized trials demonstrated that 5-year overall survival (RR 1.009; 95% CI, 0.994 to 1.025) and disease-free survival (RR 1.007; 95% CI, 0.985 to 1.030) were equivalent between minimally invasive and open gastrectomy [29]A1a.
| Trial | Population | Approach | Key Findings |
|---|---|---|---|
| KLASS-01 [24]A1b | Stage I, distal gastrectomy | Laparoscopic vs open | 5-year OS 94.2% vs 93.3%; noninferior |
| KLASS-02 [21]A1b | Locally advanced, distal gastrectomy | Laparoscopic vs open | 3-year RFS 80.3% vs 81.3%; noninferior; fewer complications |
| LOGICA [16]A1b | Predominantly advanced, Western | Laparoscopic vs open | Median stay 7 days both; similar complications and survival |
| CLASS02 [23]A1b | Stage I, total gastrectomy | Laparoscopic vs open | Safety comparable; morbidity 18.1% vs 17.4% |
| Chinese D2 RCT [17]A1b | T2-4aN0-3M0, distal gastrectomy | Laparoscopic vs open D2 | Morbidity 15.2% vs 12.9%; safe in experienced hands |
Lymphadenectomy: D2 as Standard
For advanced non-metastatic gastric cancer, a D2 lymphadenectomy (removal of perigastric nodes plus nodes along the celiac axis, splenic artery, common hepatic artery, and left gastric artery) is the preferred approach [20]B2a[26]D5. The compliance rate with D2 dissection is high in experienced centers: 99.4% in the laparoscopic group and 99.6% in the open group in the Chinese D2 RCT [17]A1b. Regionalization of gastric cancer care, as demonstrated in the Kaiser Permanente Northern California experience, increased D2 lymphadenectomy from 2% to 80% and dissection of ≥15 lymph nodes from 61% to 95%, with a corresponding improvement in 2-year survival among surgical patients (72.7% pre vs 85.5% post; P < 0.03) [28]B2b. At least 16 lymph nodes should be assessed for adequate staging [20]B2a.
Function-Preserving Approaches: Pylorus-Preserving Gastrectomy and Sentinel Node Navigation
Pylorus-preserving gastrectomy (PPG) is indicated for clinically T1N0M0 early gastric cancer located in the middle third of the stomach, at least 4 cm proximal from the pylorus [32]A1b. By preserving the hepatic branch of the vagus nerve and the infrapyloric vessels, PPG maintains pyloric function and reduces the incidence of gallstone formation, bile reflux, and postoperative nutritional deficiencies, as shown in the Korean KLASS-04 trial [32]A1b. Although technically demanding, PPG can be safely performed with minimally invasive techniques. If postoperative pathology reveals advanced disease, standard adjuvant therapy is typically sufficient without requiring additional resection [32]A1b. Sentinel node navigation surgery (LSNNS) for early gastric cancer (stage IA, ≤3 cm) allowed stomach-preserving surgery in 81% of patients, with better long-term quality of life and nutrition, although 3-year disease-free survival (91.8% vs 95.5%) did not meet noninferiority criteria; disease-specific and overall survival were similar after rescue surgery for recurrence or metachronous cancer [18]A1b.
Robotic and Novel Minimally Invasive Approaches
Robotic gastrectomy offers technical advantages in lymph node dissection, particularly in narrow spaces. A randomized trial comparing a novel 3-arm + 2-port laparoscopic-like model with the traditional 4-arm + 1-port model in robot-assisted distal gastrectomy found significantly shorter total operative time (207.14 vs 221.38 min; P < 0.001), more lymph nodes harvested from station 4sb, and lower operating room costs (CNY 15,140 vs 18,650; P < 0.001) [33]A1b. Single-incision laparoscopic surgery (SILS) for locally advanced gastric cancer, compared with multi-port laparoscopy, achieved comparable lymph node yields (SMD -0.08; P = 0.15) and complication rates (OR 0.87; P = 0.18), with reduced blood loss and smaller incision lengths [35]A1a.
Lymph Node Mapping with Indocyanine Green
Indocyanine green (ICG) fluorescence lymphography during minimally invasive gastrectomy significantly improves nodal yield. A meta-analysis of 21 studies (8,633 patients) reported that ICG-guided lymphadenectomy retrieved 6.91 more lymph nodes (95% CI, 5.47 to 8.35; P < 0.00001) compared with standard techniques, with greater benefit in patients receiving neoadjuvant therapy (mean difference 9.3 nodes; 95% CI, 6.73 to 11.88) and in overweight/obese patients (mean difference 10.94 nodes; 95% CI, 3.25 to 18.64) [30]A1a. ICG also reduced operative time and blood loss without increasing complications [30]A1a.
Pearl: For patients with resectable gastric cancer, laparoscopic distal gastrectomy with D2 lymphadenectomy is the evidence-based standard for both early and locally advanced disease, offering equivalent oncologic outcomes and fewer complications than open surgery. The use of ICG fluorescence can further optimize nodal yield, especially in neoadjuvant-treated or obese patients.
Fertility-Sparing Surgery
- ▸Pylorus-preserving gastrectomy (PPG) is a well-established function-preserving surgery for cT1N0M0 early gastric cancer in the middle third, preserving the pylorus, vagal branches, and infrapyloric vessels.
- ▸PPG reduces gallstone formation, bile reflux, and nutritional deficiencies compared with standard distal gastrectomy, as shown in the KLASS-04 trial, making it particularly suitable for young patients.
- ▸Intraoperative ICG imaging and robotic platforms are being integrated to improve safety and expand the applicability of PPG beyond traditional indications.
Building on the operative techniques described above, function-preserving approaches are particularly relevant for young patients with early-stage , where the goal is to achieve oncologic cure while minimizing long-term morbidity that could affect quality of life and, in women of childbearing age, fertility. The strongest evidence for a function-preserving strategy comes from pylorus-preserving (PPG).
Pylorus-Preserving Gastrectomy
PPG is indicated for clinically T1N0M0 (cT1N0M0) early gastric cancer (EGC) located in the middle third of the stomach, at least 4 cm proximal from the pylorus [32]A1b. By preserving the peri-pyloric tissues, including the hepatic branch of the vagus nerve and the infrapyloric vessels, PPG maintains physiological pyloric function without compromising oncologic safety [32]A1b. Several randomized controlled trials (RCTs) have demonstrated the functional advantages of PPG. In particular, the Korean multicenter RCT (KLASS-04) reported a lower incidence of gallstone formation, bile reflux, and postoperative nutritional deficiencies [32]A1b. These benefits are critical for young patients who may be at risk of long-term nutritional consequences that could impair fertility or pregnancy outcomes. While PPG is technically demanding and associated with concerns regarding delayed gastric emptying (DGE), recent advances in minimally invasive surgery and intraoperative assessment tools, including augmented imaging technology using indocyanine green (ICG), have facilitated its safe implementation [32]A1b.
Although PPG is currently indicated for cT1N0M0 EGC, emerging evidence suggests that patients pathologically confirmed as advanced disease postoperatively may still achieve favorable outcomes with standard adjuvant therapy without requiring additional surgery, suggesting potential oncological acceptability of PPG in carefully selected patients with advanced disease [32]A1b. The integration of robotic platforms and navigation-guided visualization with augmented imaging technology may further enhance oncologic safety and technical feasibility [32]A1b.
Pearl: For young patients with cT1N0M0 gastric cancer in the middle third, pylorus-preserving gastrectomy should be the preferred function-preserving approach, as it reduces postoperative nutritional deficiencies and bile reflux, supporting long-term quality of life and potentially fertility.
Sentinel Lymph Node Mapping
- ▸SLN mapping is standard for cT1N0M0 gastric cancer with tumors < 4 cm, achieving >97% detection rate and 99% accuracy.
- ▸Intraoperative single-section HE staining is sufficient for detecting macrometastasis; negative frozen section allows safe sentinel basin dissection.
- ▸Advanced pathological stage (IB/IIA) is the strongest predictor of stomach preservation failure after sentinel node navigation surgery.
Building on the principles of function preservation, sentinel lymph node (SLN) mapping offers a minimally invasive approach to assess nodal status in early , potentially sparing patients the morbidity of extended lymphadenectomy when nodes are negative.
Technique and Patient Selection
The standardized dual tracer endoscopic injection technique uses a combination of a blue dye and a radioactive colloid (or indocyanine green [ICG] for fluorescence) injected submucosally at four points around the tumor under endoscopy, typically the day before surgery [55]B2b. The Japanese multicenter phase II trial established the eligibility criteria: patients with previously untreated cT1 or cT2 gastric adenocarcinomas < 4 cm in gross diameter [55]B2b. After injection, sentinel nodes are identified intraoperatively using a gamma probe and visual inspection of blue-stained nodes, or with near-infrared fluorescence imaging when ICG is used. The identified sentinel nodes are then biopsied, followed by mandatory D2 or modified D2 per Japanese guidelines [55]B2b.
Diagnostic Performance
In the landmark ASCO multicenter trial of 397 eligible patients, the SLN detection rate was 97.5% (387 of 397) [55]B2b. Among 57 patients with lymph node metastasis on conventional hematoxylin and eosin staining, 93% (53 of 57) had positive sentinel nodes, and the accuracy of nodal evaluation for metastasis was 99% (383 of 387) [55]B2b. Only four false-negative sentinel node biopsies were observed; three of those were pT2 or tumors > 4 cm, underscoring the importance of strict patient selection [55]B2b. No serious adverse effects related to endoscopic tracer injection or the mapping procedure were reported [55]B2b.
Intraoperative Assessment
The SENORITA trial evaluated intraoperative pathologic examination of sentinel nodes using a single-section hematoxylin-eosin (HE) staining method at the largest plane of the node [62]C4. This approach was sufficient for detecting macrometastasis, with a failure rate of 0% for macrometastases identified on frozen section [62]C4. For patients with negative sentinel nodes on frozen section but micrometastasis on permanent sections, no lymph node recurrence occurred during follow-up (0%, 0/6) [62]C4. However, when frozen sections were positive, metastases in non-sentinel basins were detected in 8.3% (2/24) of cases, indicating that standard gastrectomy with lymphadenectomy is required when sentinel nodes are positive [62]C4.
Clinical Outcomes
The SENORITA phase III trial demonstrated that laparoscopic sentinel node navigation surgery (LSNNS) achieved stomach preservation in 74.8% (193/258) of patients who underwent the procedure [58]A1b. The most common cause of failure to preserve the stomach was intraoperative failure (53.8% of failures), including sentinel basin detection failure, metastatic lymph nodes, positive resection margins, and complications [58]A1b. Advanced pathological stage was the only independent risk factor for failure, with stage IB and IIA patients showing 5.9- and 45.0-fold higher failure risks, respectively [58]A1b. A post hoc analysis of the SENORITA trial confirmed that regional lymphadenectomy omitting sentinel node navigation was insufficient: the sensitivity and negative predictive value of sentinel node navigation were significantly higher than those of regional lymphadenectomy (96.8% vs. 80.6% and 99.5% vs. 97.2%, respectively) [60]C4. Metastasis to non-sentinel basins with tumor-free sentinel basins occurred in only 0.4% (1/237) of patients [60]C4.
Alternative Tracers
The FUTURE-01 randomized trial compared carbon nanoparticle suspension injection (CNSI) with ICG for guiding lymph node dissection during radical gastrectomy. CNSI yielded a significantly higher mean number of retrieved lymph nodes (69.8 vs. 53.6, P<0.001) and micro-lymph nodes (19.9 vs. 11.6, P=0.001) [61]A1b. Both tracers had high diagnostic value for detecting metastatic lymph nodes, with CNSI showing higher sensitivity (72.1% vs. 42.8%) [61]A1b. CNSI does not require fluorescence imaging equipment, making it more accessible in resource-limited settings [61]A1b.
Accurate SLN mapping thus guides the extent of surgery and informs adjuvant therapy decisions, which are discussed in the next section.
Pearl: For early gastric cancer (cT1N0M0, tumor < 4 cm), sentinel node mapping with dual tracer yields >97% detection and 99% accuracy; if frozen section is negative, sentinel basin dissection alone is safe, but if positive, proceed to standard D2 gastrectomy.
| Parameter | Value | Source |
|---|---|---|
| Detection rate | 97.5% (387/397) | [55]B2b |
| Sensitivity for metastasis | 93% (53/57) | [55]B2b |
| Accuracy | 99% (383/387) | [55]B2b |
| False-negative rate | 7% (4/57) | [55]B2b |
| Metastasis to non-sentinel basins (sentinel negative) | 0.4% (1/237) | [60]C4 |
| Stomach preservation success (SENORITA) | 74.8% (193/258) | [58]A1b |
Adjuvant Therapy Triggers (Post-op Risk Criteria)
- ▸Adjuvant therapy triggers are defined by pathologic stage II/III, nodal positivity, or T3+ disease after R0 D2 gastrectomy.
- ▸S-1 monotherapy for 1 year is the Asian standard; adding docetaxel improves 3-year RFS (NNT = 6) in stage III disease.
- ▸After D2 gastrectomy, chemoradiation does not improve DFS over chemotherapy alone; chemotherapy is preferred.
The sentinel node concept has not yet been validated for routine use in , so pathologic staging remains the standard gateway to adjuvant therapy decisions. The decision to administer postoperative chemotherapy, chemoradiation, or both hinges on risk stratification derived from the final pathology report. The triggers for adjuvant therapy are defined by landmark trials, which consistently enroll patients with pathologic stage II or III disease, nodal involvement, or T3+ primaries after R0 resection with adequate lymphadenectomy.
Risk Stratification From Pivotal Trials
| Trial | Entry Criteria | Regimen | 5-Year OS (or RFS) | NNT (to prevent one death/recurrence) |
|---|---|---|---|---|
| ACTS-GC [77]A1b | Stage II-III, D2 | S-1 × 1 year vs surgery alone | 71.7% vs 61.1% (OS) | NNT = 9 at 5 years |
| JACCRO GC-07 [12]A1b | Stage III, D2 | S-1 + vs S-1 alone | 66% vs 50% (3-year RFS) | NNT = 6 at 3 years |
| PRODIGY [13]A1b | cT2-3N+ or T4Nany, D2 | Neoadjuvant DOS + S-1 vs S-1 alone | 63.0% vs 55.1% (8-year OS) | NNT = 13 at 8 years |
| ARTIST 2 [73]A1b | Stage II-III, node-positive, D2 | SOX (or SOXRT) vs S-1 alone | 74.3% vs 64.8% (3-year DFS) | NNT = 11 at 3 years |
| INT-0116 [14]A1b | T3+ or node-positive, non-D2 | FU/LV + 45 Gy vs surgery alone | 44% vs 41% (median OS, HR 1.32) | NNT not calculable from reported data |
Treatment of Choice
For Asian patients with D2-resected stage II/III gastric cancer: S-1 monotherapy (80-120 mg/day, 4 weeks on/2 weeks off for 1 year) is the standard, based on the ACTS-GC trial [77]A1b. For node-positive stage III disease, adding docetaxel to S-1 improved 3-year relapse-free survival from 50% to 66% (HR 0.632; NNT = 6) and is an option [12]A1b. Alternatively, SOX (S-1 plus 130 mg/m² every 3 weeks) for 6 months can be used [73]A1b.
For Western patients: Perioperative chemotherapy (e.g., FLOT) or postoperative chemoradiation (45 Gy with FU/LV) is standard, based on INT-0116 [14]A1b and MAGIC-like trials. After D2 surgery, the CRITICS trial showed that postoperative chemotherapy alone outperformed chemoradiation (5-year OS 57.9% vs 45.5%; adjusted HR 1.62) [5]A1b.
What NOT to Do
- Do not use ELFE regimen ( , leucovorin, , ), it does not improve OS over surgery alone [74]A1b.
- Do not use FAMTX or FEMTX, no benefit compared with surgery alone [2]A1a.
- Do not use ECF before and after chemoradiation, no survival advantage over FU/LV + chemoradiation (CALGB 80101) [76]A1b.
- Do not use adjuvant / in ypN+ or R1 patients after neoadjuvant chemotherapy, it was inferior to chemotherapy (VESTIGE) [19]B2b.
- Do not routinely add radiotherapy to adjuvant chemotherapy after D2 ; ARTIST 2 and ARTIST found no significant DFS benefit from adding 45 Gy to SOX or XP [73]A1b[75]A1b.
Monitoring Schedule
The retrieved evidence does not report a defined monitoring schedule for surveillance during or after adjuvant therapy. In practice, clinical follow-up with history, physical examination, and contrast-enhanced CT is performed every 3-6 months for the first 2 years, then every 6-12 months, with endoscopy as indicated for symptoms.
Controversies and Guideline Disagreement
| Question | Position A (Asia) | Position B (West) | Strength | Implication |
|---|---|---|---|---|
| Role of chemoradiation after D2 | No benefit; adjuvant chemotherapy alone is standard [73]A1b[75]A1b | Chemoradiation is standard for non-D2; after D2, chemotherapy alone is preferred [5]A1b | Category 1/2A | Surgeon should ensure adequate lymphadenectomy to avoid need for radiotherapy |
| Perioperative vs postoperative alone | Neoadjuvant DOS + adjuvant S-1 improves OS vs adjuvant S-1 alone [13]A1b | Perioperative chemotherapy (FLOT) is standard | Category 1 in both | Perioperative approach is gaining acceptance in Asia |
Pearl: For patients with D2-resected, node-positive stage III gastric cancer, the addition of docetaxel to S-1 yields a 3-year relapse-free survival benefit of 16 percentage points (NNT = 6) and should be considered the new standard in Asia, while routine radiotherapy after D2 dissection is not supported by current evidence.
| Trial | Entry Criteria | Regimen | 5-Year OS (or RFS) | NNT |
|---|---|---|---|---|
| ACTS-GC [77]A1b | Stage II-III, D2 | S-1 × 1 year vs surgery alone | 71.7% vs 61.1% (OS) | 9 |
| JACCRO GC-07 [12]A1b | Stage III, D2 | S-1 + docetaxel vs S-1 alone | 66% vs 50% (3-year RFS) | 6 |
| PRODIGY [13]A1b | cT2-3N+ or T4Nany, D2 | Neoadjuvant DOS + S-1 vs S-1 alone | 63.0% vs 55.1% (8-year OS) | 13 |
| ARTIST 2 [73]A1b | Stage II-III, node-positive, D2 | SOX vs S-1 alone | 74.3% vs 64.8% (3-year DFS) | 11 |
| INT-0116 [14]A1b | T3+ or node-positive, non-D2 | FU/LV + 45 Gy vs surgery alone | median OS 44% vs 41% | NNR |
Intraoperative Considerations and Complications
- ▸Left gastric vein anatomy (Type C: dorsal to splenic artery) predicts a 17.9% risk of postoperative pancreatic fistula; preoperative CT assessment allows targeted prevention.
- ▸Pancreas-contactless dissection reduces POPF from 7.6% to 0% and intra-abdominal abscess from 12.1% to 3.2% in open gastrectomy.
- ▸The Comprehensive Inflammatory-Metabolic Index (CIMI) predicts overall complications with AUC 0.748 (OR 7.77 for high-risk group) and guides perioperative resource allocation.
Having weighed the risk of recurrence that guides adjuvant therapy decisions, the surgeon must now navigate the immediate hazards of the operation itself. Intraoperative complications are not merely technical setbacks; they propagate into longer hospital stays, delayed chemotherapy, and worse survival [83]A1b. This section reviews the key intraoperative complications by anatomic structure, management strategies, conversion criteria, and tools for preoperative risk stratification.
Hemorrhage and Vascular Injury
Intraoperative bleeding remains the most common reason for conversion to open surgery. The D2+PAND trial reported a median of 230 mL greater blood loss when para-aortic dissection was added to D2 lymphadenectomy [85]A1b. In the CLASS02 trial, one death resulted from intra-abdominal bleeding secondary to splenic artery hemorrhage [23]A1b. A meta-analysis of robotic vs laparoscopic found a weighted mean difference of -21.97 mL favoring robotic assistance [87]B2a. The most vulnerable vessels are the splenic artery, left gastric artery, and portal vein tributaries. Prevention relies on meticulous dissection of the celiac axis and splenic hilum, early vascular control, and low threshold for conversion when bleeding is not rapidly controlled laparoscopically. Management follows a stepwise algorithm: compression, clip or suture repair, and if unsuccessful, immediate conversion to open laparotomy.
Pancreatic Fistula and Pancreatic Injury
Postoperative pancreatic fistula (POPF) is a particularly morbid complication of suprapancreatic lymphadenectomy. The preoperatively assessed left gastric vein (LGV) anatomy on CT predicts POPF risk: when the LGV courses dorsal to the splenic artery (Type C), POPF incidence is 17.9% vs 1.7% for other types [93]C4. A pancreas-contactless technique, retracting the root of the transverse mesocolon without direct pancreatic compression, reduced POPF from 7.6% to 0% in open gastrectomy and reduced intra-abdominal abscess from 12.1% to 3.2% [94]B3b. In the CLASS02 trial, POPF was not separately reported, but overall intraoperative complications were 2.9% in the laparoscopic group [23]A1b. Robotic gastrectomy may reduce pancreatic fistula; in high-risk patients (mACCI ≥4), POPF occurred in 0% after robotic vs 3.3% after laparoscopic gastrectomy [98]B3b. Prevention begins with preoperative CT assessment of LGV anatomy, use of pancreas-contactless dissection, and careful energy device application near the pancreas. Management of POPF includes adequate drainage, nil per os, parenteral nutrition, and somatostatin analogues; reoperation is reserved for uncontrolled sepsis.
Anastomotic leak rates after vary by approach. In a Western single-center cohort, leak occurred in 10.3% after robot-assisted and 6.1% after laparoscopic total gastrectomy (P = 0.364) [97]B3b. The D2+PAND trial reported no significant difference in anastomotic leakage between D2 alone and D2+PAND [85]A1b. Prevention requires ensuring a tension-free anastomosis with good blood supply, routine intraoperative air-leak testing, and careful stapler technique. Management options include endoscopic stenting, percutaneous drainage of collections, and for large defects, reoperation with takedown and revision.
Injury to Surrounding Structures
Extended lymphadenectomy, especially para-aortic nodal dissection, places the ureter, celiac plexus, and adrenal vessels at risk [85]A1b. The D2+PAND trial showed no survival benefit with additional dissection, making such injury harder to justify [85]A1b. The left gastric vein anatomy classification also guides safe dissection [93]C4. Prevention relies on thorough knowledge of retroperitoneal anatomy, routine identification of the ureter during para-aortic dissection, and use of energy devices with minimal lateral thermal spread. Autonomic nerve injury during D2 dissection can lead to delayed gastric emptying and diarrhea; the nerves are preserved by staying anterior to the celiac plexus during lymphadenectomy.
Conversion Criteria
Conversion from laparoscopic or robotic to open gastrectomy is indicated for uncontrolled bleeding, inability to achieve adequate lymph node dissection due to tumor factors or adhesions, suspicion of T4b invasion, or failure to progress. Although specific conversion rates are not uniformly reported across trials, the CLASS02 study demonstrated comparable safety without mandatory conversion and reported no significant difference in mortality between laparoscopic and open total gastrectomy [23]A1b. A robust preoperative plan should include criteria for conversion and ensure the team is prepared for immediate open surgery.
Preoperative Risk Stratification Tools
Several preoperative indices can identify patients at highest risk of intraoperative and postoperative complications, allowing the surgeon to plan accordingly.
Comprehensive Inflammatory-Metabolic Index (CIMI), derived from preoperative white blood cell count, serum globulin, and visceral adiposity index, predicts overall complications with an AUC of 0.748 in the development cohort (OR for high-risk vs low-risk group: 7.77, 95% CI 4.39-13.75) [83]A1b. An online calculator is available at https://onlinecimicalculator.shinyapps.io/CIMIcalculator/ [83]A1b.
Frailty and sarcopenia, combined frailty and sarcopenia in patients aged ≥70 years independently predicted 30-day Clavien-Dindo grade ≥II complications (OR 2.73, 95% CI 1.07-6.98) and worse overall survival (HR 3.11) [91]C4.
Preoperative quality of life, global health status, stomach pain, anxiety, and body image scores from the EORTC QLQ-C30 and STO22 questionnaires predicted complications with an AUC of 0.630 (95% CI 0.583-0.676) [96]B3b.
C-reactive protein-albumin-lymphocyte (CALLY) index, lower values were associated with higher major postoperative complications (RR 1.48, P = 0.02) in [90]B2a.
These tools complement clinical judgment and should be integrated into the preoperative workup to trigger enhanced perioperative monitoring and proactive management of high-risk patients.
Table: Intraoperative and Early Postoperative Complications
| Complication | Frequency | Prevention | Management |
|---|---|---|---|
| Intraoperative bleeding | LTG 2.9%, OTG 3.7% [23]A1b; D2+PAND +230 mL vs D2 alone [85]A1b | Meticulous vascular control, early ligation of feeding vessels, careful splenic hilum dissection | Compression, suture/clip repair; low threshold for conversion to open |
| Pancreatic fistula (POPF) | 2.5% overall [93]C4; 17.9% in LGV Type C [93]C4; 0% in pancreas-contactless open [94]B3b | Preoperative CT assessment of LGV anatomy; pancreas-contactless dissection; robotic approach in high-risk patients [98]B3b | Drainage, nil per os, parenteral nutrition, somatostatin analogues; reoperation for sepsis |
| Anastomotic leak | Robot 10.3%, lap 6.1% (P=0.364) [97]B3b; no significant difference D2 vs D2+PAND [85]A1b | Tension-free anastomosis, good blood supply, intraoperative air-leak test | Endoscopic stenting, percutaneous drainage; reoperation for large defects |
| Abdominal abscess | 12.1% contact vs 3.2% contactless [94]B3b; limited LN dissection reduces RR 0.15 [88]B2a | Pancreas-contactless technique, meticulous hemostasis, avoid pancreatic injury | Percutaneous drainage, |
| Splenic injury | 1 death in CLASS02 from splenic artery hemorrhage [23]A1b | Careful dissection at splenic hilum, avoid excessive traction on short gastric vessels | Splenorrhaphy; splenectomy if uncontrolled |
| Injury to ureter/autonomic nerves | Not reported separately; risk with PAND [85]A1b | Identify ureter during para-aortic dissection; preserve celiac plexus | Urology consultation; nerve injury is irreversible |
The choice of surgical approach, conventional laparoscopic, reduced-port, or robotic, also influences the risk profile. Robotic gastrectomy has been associated with fewer moderate-to-severe complications (Clavien-Dindo ≥III, OR 0.71) and lower overall complication rates (OR 0.77) compared with laparoscopy [87]B2a. In high-morbidity patients (mACCI ≥4), robotic gastrectomy reduced postoperative complications from 8.2% to 2.7% (P = 0.036) [98]B3b. These data support a tailored approach: the sickest patients may derive the greatest benefit from the enhanced precision of the robotic platform, while lower-risk patients can be managed safely with conventional laparoscopy [33]A1b[92]B3b.
These intraoperative decisions and complication profiles directly influence the duration of recovery, timing of oral intake, and readiness for adjuvant therapy, all of which are optimized through the ERAS pathways discussed in the next section.
Pearl: Preoperative CT assessment of left gastric vein anatomy (Type C) identifies patients at highest risk for pancreatic fistula, and routine use of a pancreas-contactless technique can reduce POPF to near zero, a simple, reproducible maneuver that avoids a morbid complication.
Postoperative Recovery and ERAS
- ▸ERAS reduces postoperative hospital stay by ~1.8 days, overall complications by ~37%, and accelerates gastrointestinal recovery without increasing readmission or mortality.
- ▸ERAS improves 3-year overall and disease-free survival in stage III gastric cancer, with a number needed to treat of approximately 7 to prevent one death.
- ▸Multimodal opioid-sparing analgesia, early oral feeding, and selective avoidance of routine abdominal drainage are core ERAS components supported by high-quality evidence.
Having addressed intraoperative complications, the postoperative phase centers on the Enhanced Recovery After Surgery (ERAS) pathway, which has become the standard of care for surgery. ERAS is a multidisciplinary, evidence-based protocol designed to attenuate surgical stress and accelerate functional recovery through coordinated interventions across the perioperative period [102]A1a[103]A1a.
Core ERAS Components and Evidence
A meta-analysis of 13 randomized controlled trials (RCTs) involving 1,915 patients undergoing laparoscopic radical demonstrated that ERAS significantly shortens postoperative hospital stay (mean difference [MD] -1.82 days), reduces overall complications (OR 0.63, 95% CI 0.48-0.82), and accelerates time to first flatus (MD -0.53 days), first oral intake (MD -0.91 days), and ambulation (MD -1.04 days) [102]A1a. C-reactive protein levels were lower on postoperative days 1, 3, and 5, indicating a reduced systemic inflammatory response [102]A1a. An updated meta-analysis of 27 trials (n = 3,274) confirmed these benefits, with a risk ratio for complications of 0.73 (95% CI 0.56-0.96) in sensitivity analyses [103]A1a.
Key ERAS elements include:
- Prehabilitation: In older frail patients (Geriatric 8 score ≤14), a multimodal prehabilitation program for ≥2 weeks reduced 30-day complications from 28.7% to 17.2% (P = 0.01) and improved functional capacity [107]A1b.
- Multimodal opioid-sparing analgesia: A protocol using subcostal transversus abdominis plane block, preoperative oral non-opioid analgesics, and regular postoperative acetaminophen/cyclooxygenase-2 inhibitors reduced pain scores and cumulative consumption by a median of 500 μg over 72 hours [109]A1b.
- Early oral feeding: Early oral feeding after gastrectomy is safe and reduces hospital stay by 1.82 days and time to first flatus by 0.85 days without increasing complications [104]A1a.
- Avoidance of routine abdominal drainage: A meta-analysis of 21 RCTs under ERAS found that omitting routine drainage accelerates gastrointestinal recovery (standardized MD -1.30) and reduces total complications (OR 0.53, 95% CI 0.40-0.70), particularly and pulmonary infection [118]A1a. However, the ADIGE trial reported that avoiding drains increased the need for reoperation or percutaneous drainage from 7.7% to 15% (difference 7.2%, 90% CI 2.1-12.4), supporting selective rather than universal omission [111]A1b.
- Opioid stewardship: New persistent opioid use occurs in 10.4% of opioid-naïve patients after curative-intent cancer surgery, with doses equivalent to six tablets/day of 5-mg hydrocodone at one year [113]D5. ERAS protocols that minimize opioid exposure may mitigate this risk.
Long-Term Outcomes
The GISSG1901 multicenter RCT (n = 370) demonstrated that ERAS in laparoscopic distal gastrectomy improved 3-year overall survival (86.56% vs 80.11%; HR 0.57, 95% CI 0.35-0.94) and disease-free survival (79.57% vs 69.57%; log-rank P = 0.027) compared with conventional care [110]A1b. The benefit was most pronounced in stage III disease (3-year OS 79.41% vs 64.47%; P = 0.046). ERAS also enabled earlier initiation of adjuvant chemotherapy (29 vs 32 days; P = 0.035) and reduced overall complications (21.0% vs 30.4%; P = 0.037) [110]A1b. A perioperative psychosocial intervention targeting resilience and sleep further improved 2-year disease-free survival (78.6% vs 64.3%; HR 0.58, 95% CI 0.37-0.91) and overall survival (84.3% vs 70.7%; HR 0.52, 95% CI 0.31-0.87) [106]A1b.
Home Nutritional Management
After discharge, all patients remain at risk of malnutrition. The NRS-2002 tool is recommended for screening every two weeks for the first three months [105]A1a. Oral nutritional supplements are first-line; home enteral nutrition is reserved for those with inadequate intake. Energy targets of 25-30 kcal/kg/day and protein 1.0-1.5 g/kg/day are advised [105]A1a.
Pearl: ERAS is not merely about faster discharge, the GISSG1901 trial showed it improves 3-year survival in stage III gastric cancer (NNT ≈ 7 to prevent one death), likely through reduced complications, attenuated inflammation, and earlier adjuvant chemotherapy [110]A1b.
| Component | Evidence Summary | Key Reference |
|---|---|---|
| Prehabilitation (frail patients) | Reduces 30-day complications from 28.7% to 17.2% | [107]A1b |
| Multimodal opioid-sparing analgesia | Reduces pain scores and fentanyl consumption by 500 μg/72 h | [109]A1b |
| Early oral feeding | Reduces hospital stay by 1.82 days; safe without increased complications | [104]A1a |
| Avoidance of routine drainage | Faster recovery, fewer complications (OR 0.53); ADIGE trial shows increased reintervention risk | [118]A1a[111]A1b |
| Psychosocial intervention | Improves 2-year DFS (HR 0.58) and OS (HR 0.52) | [106]A1b |
Outcomes by Stage and Approach
- ▸Laparoscopic gastrectomy is oncologically noninferior to open gastrectomy with similar survival, recurrence, and complication rates.
- ▸Adjuvant SOX improves 3-year DFS to 74.3% in node-positive D2-resected gastric cancer (NNT=11).
- ▸Nivolumab plus chemotherapy yields 5-year OS of 16% vs 6% in PD-L1 CPS≥5 advanced disease (NNT=10).
Beyond the immediate postoperative recovery, long-term oncologic outcomes and functional results vary by disease stage and surgical approach. For patients with resectable disease, the choice of operative technique and perioperative therapy determines survival and recurrence patterns, while in advanced disease, systemic therapy dominates prognosis.
Outcomes by Disease Stage
Resectable (Stage II-III): Adjuvant chemotherapy after D2 improves disease-free survival (DFS). In the ARTIST 2 trial, patients with D2-resected, node-positive stage II-III who received S-1 plus (SOX) for 6 months had a 3-year DFS of 74.3% compared with 64.8% for S-1 alone (95%; NNT = 11 to prevent one recurrence) [73]A1b. Adding radiotherapy to SOX did not further reduce recurrence (HR 0.97, P = 0.88) [73]A1b. Neoadjuvant chemotherapy also confers benefit: the PRODIGY trial showed that perioperative , oxaliplatin, and S-1 (DOS) improved progression-free survival (PFS) versus surgery plus adjuvant S-1 alone (adjusted HR 0.70, 95% CI 0.52-0.95) [10]A1b. For patients with T3 or node-positive disease after R0 resection, postoperative chemoradiation (45 Gy with fluorouracil/leucovorin) reduced relapse and improved overall survival (OS) (HR for OS 1.32 favoring treatment, 95% CI 1.10-1.60; HR for relapse-free survival 1.51, 95% CI 1.25-1.83) [14]A1b. However, patients with diffuse histology derived minimal nonsignificant benefit [14]A1b.
Advanced/Metastatic: First-line plus chemotherapy in patients with PD-L1 combined positive score (CPS) ≥5 yields sustained OS benefit at 5 years: 16% versus 6% (HR 0.71, 95% CI 0.61-0.81; NNT = 10 to achieve one additional survivor at 5 years) [120]A1b. Objective response rate was 58% versus 46%, and median duration of response 8.5 versus 6.9 months [120]A1b. In HER2-positive disease after failure, anbenitamab plus chemotherapy improved PFS (median 7.1 vs 2.7 months; HR 0.25, 95% CI 0.17-0.39) and OS (median 19.6 vs 11.5 months; HR 0.29, 95% CI 0.17-0.50) [121]A1b. For third-line therapy, apatinib (VEGFR-2 TKI) prolonged OS versus placebo (median 6.5 vs 4.7 months; HR 0.71, 95% CI 0.54-0.94) [123]A1b. Second-line chemotherapy overall reduces death risk by 36% (HR 0.64, 95% CI 0.52-0.79) compared with best supportive care [125]B2a.
Microsatellite instability (MSI) status is a strong predictive factor: anti-PD-1-based regimens yield an OS HR of 0.34 (95% CI 0.21-0.54) in MSI-high versus 0.85 (95% CI 0.71-1.00) in microsatellite-stable tumors (P for interaction = 0.003) [128]A1a.
Outcomes by Surgical Approach
Laparoscopic gastrectomy has been compared with open gastrectomy in Western and Asian randomized trials. The LOGICA trial (Netherlands, predominantly advanced stage, 67%-78% receiving preoperative chemotherapy) found no difference in median hospital stay (7 days both), postoperative complications (44% vs 42%), in-hospital mortality (4% vs 7%), R0 resection rate (95% both), lymph node yield (29 nodes both), or 1-year OS (76% vs 78%) [16]A1b. A large Chinese trial (CLASS-01) of laparoscopic versus open D2 distal gastrectomy for clinical stage T2-4aN0-3M0 gastric cancer reported similar morbidity (15.2% vs 12.9%) and mortality (0.4% vs 0%) [17]A1b. These data confirm that laparoscopic gastrectomy is oncologically noninferior to open surgery when performed by experienced surgeons.
Prognostic Factors
| Factor | Good Prognosis | Poor Prognosis |
|---|---|---|
| Nodal response after preoperative therapy | ypN0 (nodal response associated with HR 0.54 for survival) [79]B3b | ypN+ (residual nodal disease) [79]B3b |
| Histologic subtype | Intestinal/mixed | Diffuse (minimal benefit from chemoradiation) [14]A1b |
| MSI status (for immunotherapy) | MSI-high (OS HR 0.34 with anti-PD-1) [128]A1a | Microsatellite stable |
| PD-L1 CPS | ≥5 (benefit from nivolumab + chemo) [120]A1b | <5 |
| HER2 status | HER2+ (benefit from trastuzumab, anbenitamab) [121]A1b | HER2- |
| Resection margin | R0 | R1 (high recurrence risk) [19]B2b |
Pearl: Nodal response (ypN0) after preoperative therapy is a stronger predictor of survival than primary tumor response; patients with ypN+ disease have poor outcomes regardless of postoperative therapy [79]B3b.
Controversies and Guideline Disagreement
| Question | Position A | Position B | Strength | Implication |
|---|---|---|---|---|
| Adjuvant immunotherapy for high-risk (ypN+/R1) after neoadjuvant chemo | EORTC VESTIGE: nivolumab/ inferior to chemotherapy (median DFS 11.4 vs 20.8 months; HR 1.55) [19]B2b | NCCN/ESMO: no recommendation for adjuvant IO in this setting | Category 1 against | Chemotherapy remains standard; IO not indicated |
| Role of radiotherapy after D2 gastrectomy | ARTIST 2: no benefit of adding RT to SOX [73]A1b | INT-0116: benefit with chemoradiation after limited lymphadenectomy [14]A1b | D2 resection obviates need for RT | RT reserved for inadequate lymphadenectomy or R1 |
Related Pages
Part of the Gastric Cancer family. Cross-cutting management is split across dedicated child pages:
- , diagnostic page (definition, epidemiology, staging, biomarkers, prognosis)
- Gastric Cancer Radiation Management , EBRT + image-guided brachytherapy + concurrent chemoradiation, dose / fractionation, OAR constraints
- , concurrent / adjuvant / metastatic chemotherapy, targeted therapy, immune checkpoint inhibitors
- Gastric Cancer Palliative Care , early integration, symptom management, palliative procedures, end-of-life care
- Gastric Cancer Surveillance and Follow-up , post-treatment surveillance schedule, late toxicity, survivorship, patient counselling
- Gastric Cancer Recurrent and Metastatic Disease , local-regional salvage, distant metastatic systemic therapy, oligometastatic disease
Pearl: Use these links to hop between management modalities; the parent Gastric Cancer page carries diagnosis + staging that informs every decision here.
References
- [1]
Ajani JA, Bentrem DJ, Besh S et al.. “Gastric cancer, version 2.2013: featured updates to the NCCN Guidelines.” Journal of the National Comprehensive Cancer Network : JNCCN (2013). PMID: 23667204 ↗
L1GUIDELINECited in: Indications by Stage - [2]
Nitti D, Wils J, Dos Santos JG et al.. “Randomized phase III trials of adjuvant FAMTX or FEMTX compared with surgery alone in resected gastric cancer. A combined analysis of the EORTC GI Group and the ICCG.” Annals of oncology : official journal of the European Society for Medical Oncology (2005). PMID: 16293676 ↗
L1SR_MA_RCTCited in: Indications by Stage, Adjuvant Therapy Triggers (Post-op Risk Criteria), Outcomes by Stage and Approach - [3]
Shen L, Shan YS, Hu HM et al.. “Management of gastric cancer in Asia: resource-stratified guidelines.” The Lancet. Oncology (2013). PMID: 24176572 ↗
L1GUIDELINECited in: Indications by Stage - [4]
Mocellin S, Nitti D. “Lymphadenectomy extent and survival of patients with gastric carcinoma: a systematic review and meta-analysis of time-to-event data from randomized trials.” Cancer treatment reviews (2015). PMID: 25814393 ↗
L1SR_MA_RCTCited in: Indications by Stage - [5]
de Steur WO, van Amelsfoort RM, Hartgrink HH et al.. “Adjuvant chemotherapy is superior to chemoradiation after D2 surgery for gastric cancer in the per-protocol analysis of the randomized CRITICS trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2020). PMID: 33227408 ↗
L1RCTCited in: Indications by Stage, Adjuvant Therapy Triggers (Post-op Risk Criteria) - [6]
Fazio N, Biffi R, Maibach R et al.. “Preoperative versus postoperative docetaxel-cisplatin-fluorouracil (TCF) chemotherapy in locally advanced resectable gastric carcinoma: 10-year follow-up of the SAKK 43/99 phase III trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2015). PMID: 26712905 ↗
L1RCTCited in: Indications by Stage, Adjuvant Therapy Triggers (Post-op Risk Criteria) - [7]
Smyth EC, Nyamundanda G, Cunningham D et al.. “A seven-Gene Signature assay improves prognostic risk stratification of perioperative chemotherapy treated gastroesophageal cancer patients from the MAGIC trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2018). PMID: 30481267 ↗
L1RCTCited in: Indications by Stage, Adjuvant Therapy Triggers (Post-op Risk Criteria) - [8]
Okines AF, Thompson LC, Cunningham D et al.. “Effect of HER2 on prognosis and benefit from peri-operative chemotherapy in early oesophago-gastric adenocarcinoma in the MAGIC trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2012). PMID: 23233651 ↗
L1RCTCited in: Indications by Stage - [9]
Kwee RM, Kwee TC. “Imaging in local staging of gastric cancer: a systematic review.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2007). PMID: 17513817 ↗
L2SR_COHORTCited in: Indications by Stage - [10]
Kang YK, Yook JH, Park YK et al.. “PRODIGY: A Phase III Study of Neoadjuvant Docetaxel, Oxaliplatin, and S-1 Plus Surgery and Adjuvant S-1 Versus Surgery and Adjuvant S-1 for Resectable Advanced Gastric Cancer.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2021). PMID: 34133211 ↗
L1RCTCited in: Indications by Stage, Adjuvant Therapy Triggers (Post-op Risk Criteria), Outcomes by Stage and Approach - [11]
Rau B, Lang H, Koenigsrainer A et al.. “Effect of Hyperthermic Intraperitoneal Chemotherapy on Cytoreductive Surgery in Gastric Cancer With Synchronous Peritoneal Metastases: The Phase III GASTRIPEC-I Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2023). PMID: 37906724 ↗
L1RCTCited in: Indications by Stage - [12]
Yoshida K, Kodera Y, Kochi M et al.. “Addition of Docetaxel to Oral Fluoropyrimidine Improves Efficacy in Patients With Stage III Gastric Cancer: Interim Analysis of JACCRO GC-07, a Randomized Controlled Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2019). PMID: 30925125 ↗
L1RCTCited in: Indications by Stage, Adjuvant Therapy Triggers (Post-op Risk Criteria), Postoperative Recovery and ERAS - [13]
Kang YK, Kim HD, Yook JH et al.. “Neoadjuvant Docetaxel, Oxaliplatin, and S-1 Plus Surgery and Adjuvant S-1 for Resectable Advanced Gastric Cancer: Updated Overall Survival Outcomes From Phase III PRODIGY.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2024). PMID: 38996201 ↗
L1RCTCited in: Indications by Stage, Adjuvant Therapy Triggers (Post-op Risk Criteria) - [14]
Smalley SR, Benedetti JK, Haller DG et al.. “Updated analysis of SWOG-directed intergroup study 0116: a phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2012). PMID: 22585691 ↗
L1RCTCited in: Indications by Stage, Adjuvant Therapy Triggers (Post-op Risk Criteria), Outcomes by Stage and Approach - [15]
Li C, Tian Y, Zheng Y et al.. “Pathologic Response of Phase III Study: Perioperative Camrelizumab Plus Rivoceranib and Chemotherapy Versus Chemotherapy for Locally Advanced Gastric Cancer (DRAGON IV/CAP 05).” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2024). PMID: 39383487 ↗
L1RCTCited in: Indications by Stage, Outcomes by Stage and Approach - [16]
van der Veen A, Brenkman HJF, Seesing MFJ et al.. “Laparoscopic Versus Open Gastrectomy for Gastric Cancer (LOGICA): A Multicenter Randomized Clinical Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2021). PMID: 34581617 ↗
L1RCTCited in: Indications by Stage, Operative Techniques, Outcomes by Stage and Approach - [17]
Hu Y, Huang C, Sun Y et al.. “Morbidity and Mortality of Laparoscopic Versus Open D2 Distal Gastrectomy for Advanced Gastric Cancer: A Randomized Controlled Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2016). PMID: 26903580 ↗
L1RCTCited in: Indications by Stage, Operative Techniques, Outcomes by Stage and Approach - [18]
Kim YW, Min JS, Yoon HM et al.. “Laparoscopic Sentinel Node Navigation Surgery for Stomach Preservation in Patients With Early Gastric Cancer: A Randomized Clinical Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2022). PMID: 35324317 ↗
L1RCTCited in: Indications by Stage, Operative Techniques, Intraoperative Considerations and Complications - [19]
Lordick F, Mauer ME, Stocker G et al.. “Adjuvant immunotherapy in patients with resected gastric and oesophagogastric junction cancer following preoperative chemotherapy with high risk for recurrence (ypN+ and/or R1): European Organisation of Research and Treatment of Cancer (EORTC) 1707 VESTIGE study.” Annals of oncology : official journal of the European Society for Medical Oncology (2024). PMID: 39542422 ↗
L2RCT_PHASE2Cited in: Indications by Stage, Adjuvant Therapy Triggers (Post-op Risk Criteria), Outcomes by Stage and Approach - [20]
Coburn N, Cosby R, Klein L et al.. “Staging and surgical approaches in gastric cancer: A systematic review.” Cancer treatment reviews (2017). PMID: 29275224 ↗
L2SR_COHORTCited in: Indications by Stage, Operative Techniques - [21]
Hyung WJ, Yang HK, Park YK et al.. “Long-Term Outcomes of Laparoscopic Distal Gastrectomy for Locally Advanced Gastric Cancer: The KLASS-02-RCT Randomized Clinical Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2020). PMID: 32816629 ↗
L1RCTCited in: Operative Techniques - [22]
Ajani JA, Winter K, Okawara GS et al.. “Phase II trial of preoperative chemoradiation in patients with localized gastric adenocarcinoma (RTOG 9904): quality of combined modality therapy and pathologic response.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2006). PMID: 16921048 ↗
L2NON_RANDOMIZED_TRIALCited in: Operative Techniques - [23]
Liu F, Huang C, Xu Z et al.. “Morbidity and Mortality of Laparoscopic vs Open Total Gastrectomy for Clinical Stage I Gastric Cancer: The CLASS02 Multicenter Randomized Clinical Trial.” JAMA oncology (2020). PMID: 32815991 ↗
L1RCTCited in: Operative Techniques, Intraoperative Considerations and Complications - [24]
Kim HH, Han SU, Kim MC et al.. “Effect of Laparoscopic Distal Gastrectomy vs Open Distal Gastrectomy on Long-term Survival Among Patients With Stage I Gastric Cancer: The KLASS-01 Randomized Clinical Trial.” JAMA oncology (2019). PMID: 30730546 ↗
L1RCTCited in: Operative Techniques - [25]
Ding PA, Yang S, Meng LJ et al.. “A Multimodal Deep Learning Model for Preoperative Prediction of Postoperative Complications in Gastric Cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2026). PMID: 42463045 ↗
L4PROSPECTIVE_COHORTCited in: Operative Techniques - [26]
Badgwell B. “Multimodality Therapy of Localized Gastric Adenocarcinoma.” Journal of the National Comprehensive Cancer Network : JNCCN (2016). PMID: 27697984 ↗
L5NARRATIVE_REVIEWCited in: Operative Techniques - [27]
Ly QP, Sasson AR. “Modern surgical considerations for gastric cancer.” Journal of the National Comprehensive Cancer Network : JNCCN (2008). PMID: 18926098 ↗
L5NARRATIVE_REVIEWCited in: Operative Techniques - [28]
Teh SH, Uong S, Lin TY et al.. “Clinical Outcomes Following Regionalization of Gastric Cancer Care in a US Integrated Health Care System.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2021). PMID: 34339289 ↗
L2PROSPECTIVE_COHORTCited in: Operative Techniques - [29]
Nasri S, Laamiri G, Ben Safta A et al.. “Five-year survival after minimally invasive versus open gastrectomy: A meta-analysis of randomized controlled trials with trial sequential analysis.” Surgical oncology (2026). PMID: 42364595 ↗
L1SR_MA_RCTCited in: Operative Techniques - [30]
Deidda L, Pisanu A, Ielpo B et al.. “Guiding role of indocyanine green fluorescence lymphography compared to standard techniques in lymphadenectomy for gastric cancer during minimally invasive surgery: a systematic review and meta-analysis.” Updates in surgery (2026). PMID: 42223895 ↗
L1SR_MA_RCTCited in: Operative Techniques, Sentinel Lymph Node Mapping - [31]
Kim HH, Han SU, Kim MC et al.. “Long-term results of laparoscopic gastrectomy for gastric cancer: a large-scale case-control and case-matched Korean multicenter study.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2014). PMID: 24470012 ↗
L3CASE_CONTROLCited in: Operative Techniques - [32]
Kim SH, Lee HJ. “Pylorus-Preserving Gastrectomy for Gastric Cancer: Current Evidence and Future Directions.” Annals of gastroenterological surgery (2026). PMID: 42495678 ↗
L1RCTCited in: Operative Techniques, Fertility-Sparing Surgery, Sentinel Lymph Node Mapping - [33]
Zhang Y, Lao LST, Shen X et al.. “Perioperative outcomes of a novel laparoscopic-like "3-arm + 2-port" model in robot-assisted distal gastrectomy in patients with resectable, non-metastatic gastric cancer: a randomized controlled trial.” Journal of robotic surgery (2026). PMID: 42484711 ↗
L1RCTCited in: Operative Techniques, Fertility-Sparing Surgery, Intraoperative Considerations and Complications - [34]
Das P, Jiang Y, Lee JH et al.. “Multimodality approaches to localized gastric cancer.” Journal of the National Comprehensive Cancer Network : JNCCN (2010). PMID: 20410334 ↗
L5OTHERCited in: Operative Techniques - [35]
Lin R, Wei S. “Comparison of the efficacy and safety of single-incision versus multi-port laparoscopic D2 lymphadenectomy for locally advanced gastric cancer: a systematic review and meta-analysis.” Journal of gastrointestinal oncology (2026). PMID: 42169910 ↗
L1SR_MA_RCTCited in: Operative Techniques - [36]
Cui Y, Zhang T, Du Y et al.. “Photodynamic therapy: research progress and paradigm evolution from mechanism innovation to clinical breakthrough in cancers.” Medical gas research (2026). PMID: 42157432 ↗
L1RCTCited in: Operative Techniques - [37]
Miao L, She Y, Wang Y et al.. “The incidence of gastric neoplastic lesions in autoimmune gastritis: a systematic review and meta-analysis.” Surgical endoscopy (2026). PMID: 42493616 ↗
L2SR_COHORTCited in: Fertility-Sparing Surgery - [38]
Mandrina M, Gevorkyan T, Zvezda S et al.. “Correction: Gastric cancer survival prediction using artificial intelligence models based on electronic health records: a systematic review and meta-analysis.” Frontiers in digital health (2026). PMID: 42495053 ↗
L2SR_COHORTCited in: Fertility-Sparing Surgery - [39]
Wang GQ, Li SR, Li SY et al.. “Metabolic Syndrome, Component Burden, and Incident Gastric Cancer Risk: A Prospective Cohort Study in the UK Biobank.” Cancer research communications (2026). PMID: 42490138 ↗
L2PROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [40]
Wen T, Zhang X, Zhang X et al.. “Perioperative nutritional support is associated with attenuated early postoperative albumin decline after gastrectomy for gastric cancer: a retrospective cohort study and machine learning prediction model.” Frontiers in medicine (2026). PMID: 42487944 ↗
L2PROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [41]
Zheng G, Chai X, Jin P et al.. “Multiscale Spatial Fusion Feature-Driven Characterization of Gastric Cancer Invasive Margins: A Multicenter Cohort Study for Preoperative Accurate Differentiation Between T4a and T4b Subtypes.” Advanced science (Weinheim, Baden-Wurttemberg, Germany) (2026). PMID: 42474705 ↗
L2PROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [42]
Seyyedsalehi MS, Vrtev A, Lanza M et al.. “Occupational exposure to polycyclic aromatic hydrocarbons and the risk of upper gastrointestinal cancers: a systematic review and meta-analysis of cohort studies.” European journal of cancer prevention : the official journal of the European Cancer Prevention Organisation (ECP) (2026). PMID: 42467956 ↗
L2SR_COHORTCited in: Fertility-Sparing Surgery - [43]
Huang Z, Gu L, Shi Y et al.. “Association of Helicobacter pylori infection with the correa cascade: a single-center, retrospective cohort study.” Frontiers in cellular and infection microbiology (2026). PMID: 42488421 ↗
L3RETROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [44]
Han YP, Yu HL, Wei YL et al.. “Construction and validation of a nomogram for predicting pathological upgrading/progression of gastric low-grade intraepithelial neoplasia.” Frontiers in medicine (2026). PMID: 42482913 ↗
L3COHORTCited in: Fertility-Sparing Surgery - [45]
Shi Y, Zhang J, Gu J et al.. “Dynamic Changes in Circulating and Tissue Biomarkers and Therapeutic Response to HER2/PD-1 Dual Blockade in HER2-Positive Gastric Cancer.” Digestion (2026). PMID: 42479643 ↗
L3COHORTCited in: Fertility-Sparing Surgery - [46]
Karaoglan BB, Terán E, Mascaró Baselga P et al.. “Survival Outcomes in ERBB2-Low vs ERBB2-Null Advanced Gastric Cancer.” JAMA network open (2026). PMID: 42479431 ↗
L3RETROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [47]
Wei Y, Tian Y, Liu X et al.. “Residual tumor deposits after neoadjuvant therapy and 3-year survival outcomes in gastric cancer: a single-center retrospective cohort study.” World journal of surgical oncology (2026). PMID: 42477761 ↗
L4RETROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [48]
Gao X, Han W, Lu L et al.. “Incidence, risk factors and tumor spectrum of second primary cancers after gastric cancer: a multicenter cohort study with long-term follow-up.” BMC medicine (2026). PMID: 42477705 ↗
L3COHORTCited in: Fertility-Sparing Surgery - [49]
Sagawa T, Umehara K, Izumi M et al.. “Real-world implementation of a standardized administration protocol for zolbetuximab-associated nausea and vomiting: a retrospective supportive-care cohort study.” Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer (2026). PMID: 42477146 ↗
L4RETROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [50]
Díaz Del Arco C, Fernández Aceñero MJ, Sánchez Pernaute A et al.. “Combined quantitative-anatomical assessment of metastatic lymph nodes refines prognostic stratification in resected gastric cancer.” Surgical oncology (2026). PMID: 42475787 ↗
L3RETROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [51]
Yanagimoto Y, Yamamoto K, Yamamoto K et al.. “Zolbetuximab-induced gastric mucosal injury and hypoalbuminemia: a mechanism-informed clinical analysis.” Cancer chemotherapy and pharmacology (2026). PMID: 42474748 ↗
L3COHORTCited in: Fertility-Sparing Surgery - [52]
Fujii Y, Hisamori S, Hoshino N et al.. “Comparison of minimally invasive surgery and open surgery following chemotherapy for cStage IVb gastric cancer: a multicenter retrospective cohort study.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2026). PMID: 42474616 ↗
L3RETROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [53]
Skogar ML, Lindblad M, Linder G. “Obesity and outcomes after esophagectomy: A nationwide population-based cohort study.” Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society (2026). PMID: 42473743 ↗
L3COHORTCited in: Fertility-Sparing Surgery - [54]
Gokcek S, Kanbur B, Yetginoglu O et al.. “Prognostic value of the lung immune prognostic index in metastatic gastric cancer: a single-center retrospective cohort study.” Future oncology (London, England) (2026). PMID: 42469963 ↗
L3RETROSPECTIVE_COHORTCited in: Fertility-Sparing Surgery - [55]
Kitagawa Y, Takeuchi H, Takagi Y et al.. “Sentinel node mapping for gastric cancer: a prospective multicenter trial in Japan.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2013). PMID: 24019550 ↗
L2NON_RANDOMIZED_TRIALCited in: Sentinel Lymph Node Mapping - [56]
Liang Y, Yan Z, Wei M et al.. “Indocyanine green fluorescence-guided proximal margin identification in laparoscopic distal gastrectomy: a randomized clinical trial.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2026). PMID: 41489800 ↗
L1RCTCited in: Sentinel Lymph Node Mapping - [57]
Zhong Q, Wu D, Liu ZY et al.. “Long-term oncological outcomes of indocyanine green fluorescence imaging-guided laparoscopic lymphadenectomy for gastric cancer: 5-year outcomes from the FUGES-012 randomized clinical trial.” BMC medicine (2025). PMID: 40859341 ↗
L1RCTCited in: Sentinel Lymph Node Mapping - [58]
Jeong SH, Min JS, Kim YW et al.. “Clinicopathological Factors Affecting Stomach Preservation Following Laparoscopic Sentinel Node Navigation Surgery in Patients with Early Gastric Cancer: A Secondary Analysis of the Multicenter Randomized Phase III SENORITA Trial.” Annals of surgical oncology (2025). PMID: 40117015 ↗
L1RCTCited in: Sentinel Lymph Node Mapping - [59]
Yan Z, Wei M, Zhang T et al.. “Vagus Nerve Preservation for Early Distal Gastric Cancer With Monitoring and Indocyanine Green Labeling: A Randomized Clinical Trial.” JAMA surgery (2025). PMID: 39535740 ↗
L1RCTCited in: Sentinel Lymph Node Mapping - [60]
Park SH, Kim YW, Min JS et al.. “Feasibility of Regional Lymphadenectomy for Stomach-Preserving Surgery in Early Gastric Cancer Omitting Sentinel Node Navigation: A Post Hoc Analysis of the SENORITA Trial.” Annals of surgical oncology (2024). PMID: 39085549 ↗
L4RCTCited in: Sentinel Lymph Node Mapping - [61]
Tian Y, Pang Y, Yang P et al.. “Effect of carbon nanoparticle suspension injection versus indocyanine green tracer in guiding lymph node dissection during radical gastrectomy (FUTURE-01): a randomized clinical trial.” International journal of surgery (London, England) (2025). PMID: 38954670 ↗
L1RCTCited in: Sentinel Lymph Node Mapping - [62]
Park SH, Chung SY, Lee JH et al.. “Feasibility of intraoperative pathologic examination for sentinel lymph nodes during sentinel node navigation surgery in early gastric cancer: results of pathologic protocol for SENORITA trial.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2024). PMID: 38647977 ↗
L4RCTCited in: Sentinel Lymph Node Mapping - [63]
Huang ZN, Tang YH, Zhong Q et al.. “Assessment of Laparoscopic Indocyanine Green Tracer-guided Lymphadenectomy After Neoadjuvant Chemotherapy for Locally Advanced Gastric Cancer: A Randomized Controlled Trial.” Annals of surgery (2024). PMID: 38375670 ↗
L1RCTCited in: Sentinel Lymph Node Mapping - [64]
Zhao L, Zhao J, Wang Y et al.. “A randomized trial of combined indocyanine green and endoscopic ultrasound for lymph node evaluation in gastric cancer surgery.” Quantitative imaging in medicine and surgery (2025). PMID: 41081114 ↗
L1RCTCited in: Sentinel Lymph Node Mapping - [65]
Kruszyna B, Orzechowska D, Setlak Z et al.. “Efficacy of near-infrared indocyanine green imaging in D2 lymphadenectomy for gastric cancer: A systematic review and meta-analysis comparing eastern and western cohorts.” Surgical oncology (2026). PMID: 42202594 ↗
L2SR_COHORTCited in: Sentinel Lymph Node Mapping - [66]
Fernandes MHF, Valério-Alves AP, Colares RA et al.. “Indocyanine green-guided lymphadenectomy in gastric cancer after neoadjuvant chemotherapy: A systematic review and meta-analysis.” European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology (2025). PMID: 41092717 ↗
L2SR_COHORTCited in: Sentinel Lymph Node Mapping - [67]
Slim N, Anbu D, Darzi A et al.. “The use of indocyanine green and near-infrared fluorescence in the detection of metastatic lymph nodes during oesophageal and gastric cancer resection: a systematic review and meta-analysis.” Surgical endoscopy (2025). PMID: 40251309 ↗
L4SR_COHORTCited in: Sentinel Lymph Node Mapping - [68]
Peristeri DV, Raptis DN, Mantzoros I et al.. “Clinical Value of Fluorescent Lymphography with Indocyanine Green During Robotic Surgery for Gastric Cancer in Guided Lymph Node Dissection: A Systematic Review and Meta-Analysis.” Journal of personalized medicine (2026). PMID: 42188338 ↗
L2SR_COHORTCited in: Sentinel Lymph Node Mapping - [69]
Mourdi N, Wu Y, Su Y et al.. “The role of indocyanine green in the intraoperative navigation of gastric cancer surgery: a systematic review and meta-analysis.” BMC cancer (2025). PMID: 41299421 ↗
L4SR_COHORTCited in: Sentinel Lymph Node Mapping - [70]
Fan Y, Zhang C, Liang P et al.. “Indocyanine Green-Guided Lymphadenectomy During Robot-Assisted Pylorus and Vagus Nerve Preserving Gastrectomy for Early Gastric Cancer: A Single-Centre Study.” The international journal of medical robotics + computer assisted surgery : MRCAS (2025). PMID: 41044819 ↗
L2NON_RANDOMIZED_TRIALCited in: Sentinel Lymph Node Mapping - [71]
Van Du N, Anh Tuan N, Ngoc Cuong L. “Comparative study of ICG and non-ICG-guided laparoscopic gastrectomy for gastric cancer: a propensity score-matched analysis at a single center.” BMJ surgery, interventions, & health technologies (2025). PMID: 40051652 ↗
L2NON_RANDOMIZED_TRIALCited in: Sentinel Lymph Node Mapping - [72]
Salobir J, Horvat G, Trotovšek B et al.. “Safe Introduction of Robotic Gastrectomy Facilitated by ICG-Guided Lymphography.” Journal of clinical medicine (2026). PMID: 42355706 ↗
L4PROSPECTIVE_COHORTCited in: Sentinel Lymph Node Mapping - [73]
Park SH, Lim DH, Sohn TS et al.. “A randomized phase III trial comparing adjuvant single-agent S1, S-1 with oxaliplatin, and postoperative chemoradiation with S-1 and oxaliplatin in patients with node-positive gastric cancer after D2 resection: the ARTIST 2 trial☆.” Annals of oncology : official journal of the European Society for Medical Oncology (2020). PMID: 33278599 ↗
L1RCTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria), Outcomes by Stage and Approach - [74]
De Vita F, Giuliani F, Orditura M et al.. “Adjuvant chemotherapy with epirubicin, leucovorin, 5-fluorouracil and etoposide regimen in resected gastric cancer patients: a randomized phase III trial by the Gruppo Oncologico Italia Meridionale (GOIM 9602 Study).” Annals of oncology : official journal of the European Society for Medical Oncology (2007). PMID: 17525087 ↗
L1RCTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria) - [75]
Park SH, Sohn TS, Lee J et al.. “Phase III Trial to Compare Adjuvant Chemotherapy With Capecitabine and Cisplatin Versus Concurrent Chemoradiotherapy in Gastric Cancer: Final Report of the Adjuvant Chemoradiotherapy in Stomach Tumors Trial, Including Survival and Subset Analyses.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2015). PMID: 25559811 ↗
L1RCTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria) - [76]
Fuchs CS, Niedzwiecki D, Mamon HJ et al.. “Adjuvant Chemoradiotherapy With Epirubicin, Cisplatin, and Fluorouracil Compared With Adjuvant Chemoradiotherapy With Fluorouracil and Leucovorin After Curative Resection of Gastric Cancer: Results From CALGB 80101 (Alliance).” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2017). PMID: 28976791 ↗
L1RCTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria) - [77]
Sasako M, Sakuramoto S, Katai H et al.. “Five-year outcomes of a randomized phase III trial comparing adjuvant chemotherapy with S-1 versus surgery alone in stage II or III gastric cancer.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2011). PMID: 22010012 ↗
L1RCTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria) - [78]
Lee J, Lim DH, Kim S et al.. “Phase III trial comparing capecitabine plus cisplatin versus capecitabine plus cisplatin with concurrent capecitabine radiotherapy in completely resected gastric cancer with D2 lymph node dissection: the ARTIST trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2011). PMID: 22184384 ↗
L1RCTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria) - [79]
Sada YH, Smaglo BG, Tan JC et al.. “Prognostic Value of Nodal Response After Preoperative Treatment of Gastric Adenocarcinoma.” Journal of the National Comprehensive Cancer Network : JNCCN (2019). PMID: 30787129 ↗
L3RETROSPECTIVE_COHORTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria), Outcomes by Stage and Approach - [80]
Wang JT, Li H, Zhang H et al.. “Intratumoral IL17-producing cells infiltration correlate with antitumor immune contexture and improved response to adjuvant chemotherapy in gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2019). PMID: 30445581 ↗
L4PROSPECTIVE_COHORTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria) - [81]
Jiang Y, Wang H, Wu J et al.. “Noninvasive imaging evaluation of tumor immune microenvironment to predict outcomes in gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2020). PMID: 32240794 ↗
L2PROSPECTIVE_COHORTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria) - [82]
Schwartz GK, Winter K, Minsky BD et al.. “Randomized phase II trial evaluating two paclitaxel and cisplatin-containing chemoradiation regimens as adjuvant therapy in resected gastric cancer (RTOG-0114).” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2009). PMID: 19273696 ↗
L2RCT_PHASE2Cited in: Adjuvant Therapy Triggers (Post-op Risk Criteria) - [83]
Zhang LK, Shang-Guan ZX, Zheng HL et al.. “Association of comprehensive inflammatory-metabolic status and perioperative outcomes in gastric cancer: insights from four randomized controlled trials.” ESMO open (2026). PMID: 41962309 ↗
L1RCTCited in: Adjuvant Therapy Triggers (Post-op Risk Criteria), Intraoperative Considerations and Complications - [84]
McNair AG, Brookes ST, Davis CR et al.. “Communicating the results of randomized clinical trials: do patients understand multidimensional patient-reported outcomes?” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2010). PMID: 20065187 ↗
L1RCTCited in: Intraoperative Considerations and Complications - [85]
Sasako M, Sano T, Yamamoto S et al.. “D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer.” The New England journal of medicine (2008). PMID: 18669424 ↗
L1RCTCited in: Intraoperative Considerations and Complications - [86]
Menegat BLRS, Menegat ALRS, Dantas CR et al.. “Safety and feasibility of subtotal gastrectomy compared with completion total gastrectomy for remnant gastric cancer: A systematic review and meta-analysis.” Surgical oncology (2026). PMID: 42248045 ↗
L4SR_COHORTCited in: Intraoperative Considerations and Complications - [87]
Shen ZY, Wang ZQ, Yu TC et al.. “Robotic versus laparoscopic gastrectomy for gastric cancer: a systematic review and meta-analysis of perioperative outcome and long-term survival.” Journal of robotic surgery (2026). PMID: 42010147 ↗
L2SR_COHORTCited in: Intraoperative Considerations and Complications - [88]
Miki Y, Bito T, Makuuchi R et al.. “Limited lymphadenectomy for elderly patient with gastric cancer: a systematic review and meta-analysis.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2026). PMID: 41879959 ↗
L2SR_COHORTCited in: Intraoperative Considerations and Complications - [89]
Yang D, Liu H, Xia Y et al.. “Dynamic machine learning model integrating resting energy expenditure for predicting postoperative complications after gastrectomy for gastric cancer.” Journal of cancer research and clinical oncology (2026). PMID: 42107025 ↗
L2PROSPECTIVE_COHORTCited in: Intraoperative Considerations and Complications - [90]
Rayyan Y, Odeh N, Theeb L et al.. “Prognostic role of C-reactive protein-albumin-lymphocyte (CALLY) index in gastrointestinal malignancies: a systematic review and meta-analysis.” BMC gastroenterology (2026). PMID: 41963801 ↗
L2SR_COHORTCited in: Intraoperative Considerations and Complications - [91]
Lee E, Yoo M, Jeon D et al.. “Impact of Combined Frailty and Sarcopenia on Postoperative Outcomes and Survival in Elderly Gastric Cancer Patients Undergoing Gastrectomy.” Journal of gastric cancer (2026). PMID: 42411167 ↗
L4COHORTCited in: Intraoperative Considerations and Complications - [92]
Lim D, Han J, Noh J et al.. “Comparison of textbook outcomes and postoperative pain trajectories between reduced-port and conventional robotic distal gastrectomy: a cumulative sum (CUSUM)-adjusted propensity score-matched analysis.” Journal of robotic surgery (2026). PMID: 42298275 ↗
L3RETROSPECTIVE_COHORTCited in: Intraoperative Considerations and Complications - [93]
Matsumoto Y, Terashima M, Fujiya K et al.. “Association between the inflow pattern of the left gastric vein and postoperative pancreatic fistula after laparoscopic gastrectomy.” Surgical endoscopy (2026). PMID: 42265294 ↗
L4COHORTCited in: Intraoperative Considerations and Complications - [94]
Fujita S, Harada H, Okuno K et al.. “Pancreas-contactless open gastrectomy for gastric cancer and postoperative pancreatic complications: A retrospective cohort study.” Surgical oncology (2026). PMID: 42250430 ↗
L3RETROSPECTIVE_COHORTCited in: Intraoperative Considerations and Complications - [95]
Sakurazawa N, Kakinuma D, Hagiwara N et al.. “Trapezoidal tunnel intracorporeal esophagogastric anastomosis technique in laparoscopic-assisted proximal gastrectomy: technical notes and preliminary experience.” World journal of surgical oncology (2026). PMID: 42219492 ↗
L4COHORTCited in: Intraoperative Considerations and Complications - [96]
Jang A, Jeong O. “Association between preoperative quality of life (QoL) and postoperative complications after gastrectomy for gastric carcinoma.” Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer (2026). PMID: 42177387 ↗
L3COHORTCited in: Intraoperative Considerations and Complications - [97]
Sanberg J, Noordman BJ, Lindblad M et al.. “Robot-assisted versus laparoscopic total gastrectomy: a western high-volume tertiary referral center experience.” Journal of robotic surgery (2026). PMID: 42156604 ↗
L3RETROSPECTIVE_COHORTCited in: Intraoperative Considerations and Complications - [98]
Takahashi K, Fujiya K, Terashima M et al.. “Comparison of long-term outcomes of robotic gastrectomy and laparoscopic gastrectomy using the modified age-adjusted Charlson Comorbidity Index.” Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association (2026). PMID: 42113328 ↗
L3COHORTCited in: Intraoperative Considerations and Complications - [99]
Yan Z, Zhao R, Ouyang J et al.. “Association between additional operation timing and perioperative outcomes after noncurative endoscopic submucosal dissection for early gastric cancer.” Surgery (2026). PMID: 42105700 ↗
L3RETROSPECTIVE_COHORTCited in: Intraoperative Considerations and Complications - [100]
Zhu C, Wang Y, Ma W et al.. “Efficacy and safety of home enteral nutritional support in postoperative gastric cancer patients: A systematic review and meta-analysis.” Clinical nutrition (Edinburgh, Scotland) (2026). PMID: 41895151 ↗
L1SR_MA_RCTCited in: Postoperative Recovery and ERAS - [101]
Datta J, McMillan MT, Shang EK et al.. “Omission of adjuvant therapy after gastric cancer resection: development of a validated risk model.” Journal of the National Comprehensive Cancer Network : JNCCN (2015). PMID: 25964639 ↗
L5OTHERCited in: Postoperative Recovery and ERAS - [102]
Hu HM, Zhou HY, Guo LL et al.. “Enhanced recovery after surgery in laparoscopic radical gastrectomy for gastric cancer: efficacy, safety, meta-analysis.” Biomedical engineering online (2026). PMID: 41664176 ↗
L1SR_MA_RCTCited in: Postoperative Recovery and ERAS - [103]
Liu W, He L, Yin C et al.. “Enhanced recovery after gastrectomy: updated Meta-analysis of 27 randomized trials (2018-2025).” BMC surgery (2025). PMID: 41354909 ↗
L1SR_MA_RCTCited in: Postoperative Recovery and ERAS - [104]
Mohajeri L, Daghayeghi R, Rostami N et al.. “Early oral feeding after laparoscopic total gastrectomy in gastric cancer patients: a meta-analysis of randomized controlled trials and cohort studies.” BMC gastroenterology (2025). PMID: 41068719 ↗
L1SR_MA_RCTCited in: Postoperative Recovery and ERAS - [105]
Shanshan W, Lian W, Lu D et al.. “Best practices for home nutritional management in postoperative gastric cancer patients: an evidence summary.” BMC cancer (2025). PMID: 40883694 ↗
L1SR_MA_RCTCited in: Postoperative Recovery and ERAS - [106]
Pan S, Wang G. “Perioperative multimodal behavioral optimization improves recovery and long-term outcomes after curative gastrectomy: a randomized controlled trial.” Surgical endoscopy (2026). PMID: 41787085 ↗
L1RCTCited in: Postoperative Recovery and ERAS - [107]
Sun Y, Tian Y, Cao S et al.. “Supervised Multimodal Prehabilitation and Clinical Outcomes in Older Patients With Frailty and Gastric Cancer: The GISSG+2201 Randomized Clinical Trial.” JAMA surgery (2026). PMID: 41604182 ↗
L1RCTCited in: Postoperative Recovery and ERAS - [108]
Lee HJ, Kim J, Koo BW et al.. “Survey of Perioperative Practices in Gastric Cancer Surgery for Establishing an Enhanced Recovery After Surgery Program Across 10 Tertiary Hospitals in South Korea.” Journal of gastric cancer (2025). PMID: 40631472 ↗
L1RCTCited in: Postoperative Recovery and ERAS - [109]
Lee HJ, Kim J, Yoon SH et al.. “Effectiveness of ERAS program on postoperative recovery after gastric cancer surgery: a randomized clinical trial.” International journal of surgery (London, England) (2025). PMID: 40072360 ↗
L1RCTCited in: Postoperative Recovery and ERAS - [110]
Tian Y, Cao S, Li L et al.. “Three-year Survival Outcomes of Patients With Enhanced Recovery After Surgery Versus Conventional Care in Laparoscopic Distal Gastrectomy: The GISSG1901 Randomized Clinical Trial.” Annals of surgery (2024). PMID: 39660451 ↗
L1RCTCited in: Postoperative Recovery and ERAS - [111]
Weindelmayer J, Mengardo V, Ascari F et al.. “Prophylactic Drain Placement and Postoperative Invasive Procedures After Gastrectomy: The Abdominal Drain After Gastrectomy (ADIGE) Randomized Clinical Trial.” JAMA surgery (2025). PMID: 39602143 ↗
L1RCTCited in: Postoperative Recovery and ERAS - [112]
Choi CI, Park JK, Chung JH et al.. “The application of enhanced recovery after surgery protocol after distal gastrectomy for patients with gastric cancer: a prospective randomized clinical trial.” Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract (2024). PMID: 38538479 ↗
L1RCTCited in: Postoperative Recovery and ERAS - [113]
Lee JS, Hu HM, Edelman AL et al.. “New Persistent Opioid Use Among Patients With Cancer After Curative-Intent Surgery.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2017). PMID: 29048972 ↗
L5OTHERCited in: Postoperative Recovery and ERAS - [114]
. “[Chinese clinical practice guideline for the laparoscopic endoscopic cooperative surgery in gastrointestinal tumor (2025 Shenzhen)].” Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery (2025). PMID: 39971545 ↗
L1GUIDELINECited in: Postoperative Recovery and ERAS - [115]
Wu J, Zhang L, Ji Y et al.. “Effects of enhanced recovery after surgery nursing combined with early enteral nutrition on Gastrointestinal function recovery after radical gastrectomy.” Langenbeck's archives of surgery (2025). PMID: 41307576 ↗
L1RCTCited in: Postoperative Recovery and ERAS - [116]
Guo S, Lin XP, Jin XR et al.. “Effect of the thumbtack needle on gastrointestinal function recovery after laparoscopic radical gastrectomy for gastric cancer with the concept of enhanced recovery after surgery: a randomized controlled trial.” Frontiers in surgery (2025). PMID: 41050349 ↗
L1RCTCited in: Postoperative Recovery and ERAS - [117]
. “RETRACTION: Effects of Enhanced Recovery After Surgery Nursing Program on the Surgical Site Wound Infection and Postoperative Complications in Patients of Gastric Cancer: A Meta-Analysis.” International wound journal (2025). PMID: 42118060 ↗
L2SR_COHORTCited in: Postoperative Recovery and ERAS - [118]
Li HY, Liu Y, Cui WX et al.. “Enhanced recovery after surgery in gastric cancer surgery: Systematic review and meta-analysis of perioperative indwelling drainage tube use.” World journal of gastrointestinal surgery (2025). PMID: 41178892 ↗
L1SR_MA_RCTCited in: Postoperative Recovery and ERAS - [119]
Chau I, Norman AR, Cunningham D et al.. “The impact of primary tumour origins in patients with advanced oesophageal, oesophago-gastric junction and gastric adenocarcinoma--individual patient data from 1775 patients in four randomised controlled trials.” Annals of oncology : official journal of the European Society for Medical Oncology (2009). PMID: 19164454 ↗
L1SR_MA_RCTCited in: Outcomes by Stage and Approach - [120]
Janjigian YY, Shitara K, Ajani JA et al.. “Nivolumab plus chemotherapy as first-line treatment for advanced gastric, gastroesophageal junction, and esophageal adenocarcinoma: 5-year follow-up results from CheckMate 649.” Annals of oncology : official journal of the European Society for Medical Oncology (2026). PMID: 41687718 ↗
L1RCTCited in: Outcomes by Stage and Approach - [121]
Liu R, Zhao J, Zhang R et al.. “Anbenitamab in previously treated HER2-positive gastric cancer (KC-WISE): prespecified interim analysis of a randomized, phase III clinical trial.” Annals of oncology : official journal of the European Society for Medical Oncology (2026). PMID: 41571045 ↗
L1RCTCited in: Outcomes by Stage and Approach - [122]
Sakai D, Kadowaki S, Kawabata R et al.. “Randomized Phase III Trial of Ramucirumab Beyond Progression Plus Irinotecan in Patients With Ramucirumab-Refractory Advanced Gastric Cancer: RINDBeRG Trial.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2025). PMID: 40408613 ↗
L1RCTCited in: Outcomes by Stage and Approach - [123]
Li J, Qin S, Xu J et al.. “Randomized, Double-Blind, Placebo-Controlled Phase III Trial of Apatinib in Patients With Chemotherapy-Refractory Advanced or Metastatic Adenocarcinoma of the Stomach or Gastroesophageal Junction.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2016). PMID: 26884585 ↗
L1RCTCited in: Outcomes by Stage and Approach - [124]
Lee CK, Kim HS, Jung M et al.. “Open-Label, Multicenter, Randomized, Biomarker-Integrated Umbrella Trial for Second-Line Treatment of Advanced Gastric Cancer: K-Umbrella Gastric Cancer Study.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2023). PMID: 37883723 ↗
L1RCTCited in: Outcomes by Stage and Approach - [125]
Kim HS, Kim HJ, Kim SY et al.. “Second-line chemotherapy versus supportive cancer treatment in advanced gastric cancer: a meta-analysis.” Annals of oncology : official journal of the European Society for Medical Oncology (2013). PMID: 23942775 ↗
L2SR_COHORTCited in: Outcomes by Stage and Approach - [126]
Singh PP, Singh S. “Statins are associated with reduced risk of gastric cancer: a systematic review and meta-analysis.” Annals of oncology : official journal of the European Society for Medical Oncology (2013). PMID: 23599253 ↗
L2SR_COHORTCited in: Outcomes by Stage and Approach - [127]
Okines AFC, Norman AR, McCloud P et al.. “Meta-analysis of the REAL-2 and ML17032 trials: evaluating capecitabine-based combination chemotherapy and infused 5-fluorouracil-based combination chemotherapy for the treatment of advanced oesophago-gastric cancer.” Annals of oncology : official journal of the European Society for Medical Oncology (2009). PMID: 19474114 ↗
L2SR_COHORTCited in: Outcomes by Stage and Approach - [128]
Pietrantonio F, Randon G, Di Bartolomeo M et al.. “Predictive role of microsatellite instability for PD-1 blockade in patients with advanced gastric cancer: a meta-analysis of randomized clinical trials.” ESMO open (2021). PMID: 33460964 ↗
L1SR_MA_RCTCited in: Outcomes by Stage and Approach - [129]
Hegewisch-Becker S, Mendez G, Chao J et al.. “First-Line Nivolumab and Relatlimab Plus Chemotherapy for Gastric or Gastroesophageal Junction Adenocarcinoma: The Phase II RELATIVITY-060 Study.” Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2024). PMID: 38723227 ↗
L2RCT_PHASE2Cited in: Outcomes by Stage and Approach