Role of bursectomy for advanced gastric cancer: Result of a case–control study from a large volume hospital

The short- and long-term outcomes of laparoscopic D2 lymphadenectomy plus complete mesogastrium excision for lymph node-negative gastric cancer

BACKGROUND

Patients with T1-3N0M0 gastric cancer (GC) who undergo radical gastrectomy maintain a high recurrence rate. The free cancer cells in the mesogastric adipose connective tissue (Metastasis V) maybe the reason for recurrence in these individuals. We aimed to evaluate whether D2 lymphadenectomy plus complete mesogastrium excision (D2 + CME) was superior to D2 lymphadenectomy with regard to safety and oncological efficacy for T1-3N0M0 GC.

METHODS

Patients with T1-3N0M0 GC who underwent radical resection from January 2014 to July 2018 were retrospectively analyzed; there were 323 patients, of whom 185 were in the D2 + CME group and 138 in the D2 group. The primary endpoint was 5-year disease-free survival (DFS). Secondary endpoints include the 5-year overall survival (OS), recurrence pattern, morbidity, mortality, and surgical outcomes.

RESULTS

D2 + CME was associated with less intraoperative bleeding loss, a greater number of lymph nodes harvested, and less time to first postoperative flatus, but the postoperative morbidity was similar. The 5-year DFS was 95.6% (95% CI 92.7-98.5%) and 90.4% (95% CI 85.5-95.3%) in the D2 + CME group and the D2 group, respectively, with a hazard ratio (HR) of 0.455 (95% CI 0.188-1.097; p = 0.071). In terms of recurrence patterns, local recurrence was more prone to occur in the D2 group (p = 0.031). Subgroup analysis indicated that for patients with T1b-3N0M0 GC, the 5-year DFS in the D2 + CME group was considerably greater than that in the D2 group (95.3% [95% CI 91.6-99.0%] vs. 87.6% [95% CI 80.7-94.5%], HR 0.369, 95% CI 0.138-0.983; log-rank p = 0.043).

CONCLUSION

Laparoscopic D2 + CME for T1-3N0M0 GC is safe and feasible. Furthermore, it not only reduces the local recurrence rate but also improves the 5-year DFS in cases of T1b-3N0M0 GC.

Risk Assessment and Preventive Treatment for Peritoneal Recurrence Following Radical Resection for Gastric Cancer

As the most common recurrence pattern after radical gastric cancer resection, peritoneal recurrence is a major cause of mortality, which affects the prognosis of patients to a very large extent. Peritoneal status and risk of peritoneal recurrence can be evaluated by peritoneal lavage cytology, photodynamic diagnosis, imaging examination, and pathologic analysis. Presently, there is no standard approach for preventing peritoneal recurrence after radical surgery; furthermore, controversies exist regarding the effects of some preventive methods. Among the preventive methods, there are high expectations about the potential of preoperative therapy, surgical skill improvement, hyperthermic intraperitoneal chemotherapy, and postoperative treatment to reduce the incidence of peritoneal recurrence after radical gastrectomy. This study aimed to analyze the results of previous studies on the risk assessment and preventive methods of peritoneal recurrence after radical gastrectomy in recent years. We hope to provide references for better approach to clinical diagnosis and treatment strategies for peritoneal recurrence after radical gastrectomy.

Lack of Oncological Benefit from Bursectomy in Radical Gastrectomy: A Systematic Review

BACKGROUND

Resection of the omental bursa has been suggested to reduce peritoneal recurrence and facilitate a complete oncological resection during a gastrectomy. The addition of this procedure increases technical complexity and prolongs the procedure. Published data regarding the oncological benefit of this procedure are conflicting. We hypothesized that a bursectomy during a radical gastrectomy does not improve overall survival.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline, a comprehensive literature search of 3 electronic databases (PubMed, Scopus, and Embase) was conducted to identify the clinical studies that compared bursectomy with no-bursectomy in radical gastrectomy for gastric adenocarcinoma. Qualitative and quantitative data synthesis was performed using RevMan software. A random-/fixed-effect modeling was used depending upon the heterogeneity. Bias and quality assessment tools were applied. The study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019116556).

RESULTS

Of 8 studies assessing the role of bursectomy in gastric adenocarcinoma, 6 (75%) were included - of which 2 (33%) are randomized controlled trials. Of 2,904 patients, 1,273 (%) underwent a bursectomy. There was no statistically significant difference in either overall survival (hazard ratio [HR] = 0.89, 95% CI 0.75-1.06, I2 = 14%) or disease recurrence (HR = 1.01, 95% CI 0.84-1.20, I2 = 22%) in the bursectomy group compared to the no-bursectomy group.

CONCLUSION

There is no additional oncological benefit of adding bursectomy to radical gastrectomy in all patients with gastric adenocarcinoma.

LESSONS LEARNED ANALYZING COMPLICATIONS AFTER LAPAROSCOPIC TOTAL GASTRECTOMY FOR GASTRIC CANCER

Background:

Laparoscopic surgery has been gradually accepted as an option for the surgical treatment ofgastric cancer. There are still points that are controversial or situations that are eventually associated with intra-operative difficulties or postoperative complications.

Aim:

To establish the relationship between the difficulties during the execution of total gastrectomy and the occurrence of eventual postoperative complications.

Method:

The operative protocols and postoperative evolution of 74 patients operated for gastriccancer, who were subjected to laparoscopic total gastrectomy (inclusion criteria) were reviewed. The intraoperative difficulties recorded in the operative protocol and postoperative complications of a surgical nature wereanalyzed (inclusion criteria). Postoperative medical complications were excluded (exclusion criteria). For the discussion, an extensive bibliographical review was carried out.

Results:

Intra-operative difficulties or complications reported correspond to 33/74 and of these; 18 events (54.5%) were related to postoperative complications and six were absolutely unexpected. The more frequent were leaks of the anastomosis and leaks of the duodenal stump; however, other rare complications were observed. Seven were managed with conservative measures and 17 (22.9%) required surgical re-exploration, with a postoperative mortality of two patients (2.7%).

Conclusion:

We have learned that there are infrequent and unexpected complications; the treating team must be mindful of and, in front of suspicion of complications, anappropriate decision must be done which includes early re-exploration. Finally, after the experience reported, some complications should be avoided.

The role of bursectomy in the surgical management of gastric cancer: a meta-analysis and systematic review

In order to delineate the exact role of bursectomy (BS) in gastric cancer surgery, we designed and conducted the present meta-analysis. This meta-analysis adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. A systematic literature review of the electronic databases (Medline, Scopus, Web of Science) was performed. Trial sequential analysis (TSA) was introduced for the validation of the pooled analyses. The level of evidence was attributed based on the GRADE approach. Overall, nine studies and 3599 patients were included in our meta-analysis. BS did not lead to an increase in the overall morbidity rate (OR 1.17, 95% CI 0.97-1.42, p = 0.09). Equivalence was, also, identified in all specific postoperative complications. Similarly, mortality rates were comparable (p = 0.69). Moreover, BS was related to a significantly higher operative time (p < 0.001) and perioperative blood loss (p = 0.002). Finally, resection of the omental bursa was not associated with improved R0 excision rates (p = 0.92), lymph node harvest (p = 0.1) or survival outcomes (OS p = 0.15 and DFS p = 0.97). BS displayed a suboptimal perioperative performance without any significant oncological efficacy. Due to certain limitations and the low level of evidence, further high-quality RCTs are required.

Bursectomy Versus Nonbursectomy for Gastric Adenocarcinoma: A Single-Center, Propensity-Score Matched Cohort Study in China

Background: The therapeutic value of bursectomy remains controversial for patients with gastric cancer. Therefore, the purpose of our study was to explore the safety and survival benefits of bursectomy. Materials and Methods: A total of 943 patients with gastric adenocarcinoma were included in our study, and all patients were operated on by high-quality gastrointestinal surgeons. The factors associated with overall survival (OS) were determined using the Kaplan-Meier method. In addition, patients in the bursectomy group and nonbursectomy group were matched with 1:1 propensity score matching for sex, age, tumor location, type of operation, tumor size, degree of differentiation, and pathological stage to reduce the possibility of choice bias. Results: Among the 943 eligible patients, 188 (19.9%) underwent bursectomy and 755 (80.1%) did not. In all patients, the number of retrieved lymph nodes (P = .0596), blood loss volume (P = .0896), operation time (P = .0747), number of postoperative complications (P = .626), and OS in the bursectomy group were similar to those in the nonbursectomy group. After a stratified analysis of TNM grade and T stage, it was found that bursectomy could lead to survival benefits for patients with stage T4 disease (P = .0398). Conclusions: Bursectomy does not increase the amount of blood loss, operation time, or incidence of postoperative complications. This procedure is an extended and safe surgical method for gastric adenocarcinoma. Bursectomy does not improve the survival of all patients, but for patients with stage T4 disease, bursectomy can provide survival benefits.

Gastric cancer surgery: historical background and perspective in Western countries versus Japan

Gastrectomy plus D2 lymphadenectomy plays a decisive role in the management of resectable gastric cancer in Japan. Before recent advances in chemotherapy, Japanese surgeons considered that extensive surgery involving extended lymphadenectomy with combined resection of neighboring organ(s) was required to eliminate any possible lymphatic cancer spread and improve patient survival. This approach differs radically from that in Western countries, which aim to improve survival outcomes by multidisciplinary approaches including perioperative chemotherapy and/or radiotherapy with limited lymph node dissection. However, a randomized controlled trial conducted in Japan found that more extensive lymphadenectomy including the para-aortic lymph nodes provided no survival benefit over D2 lymphadenectomy. Splenic hilum dissection with splenectomy also failed to show superiority over the procedure without splenectomy in patients with proximal gastric cancer, except in cases with tumor invasion of the greater curvature. Furthermore, bursectomy recently demonstrated similar outcomes to omentectomy alone. Although "D2 lymphadenectomy" as carried out in Japan contributes to low local recurrence rates and good survival outcomes, the results of randomized controlled trials have led to a decreased extent of surgical resection, with no apparent adverse effects on survival outcome. Notably, gastrectomy with D2 dissection has tended to become acceptable for advanced gastric cancer in Western countries, based on the latest results of the Dutch D1D2 trial. Differences in surgical practices between the West and Japan have thus lessened and procedures are becoming more standardized. Japanese D2 lymphadenectomy for advanced gastric cancer is evolving toward more minimally invasive approaches, while consistently striving to achieve the optimal surgical extent, thereby promoting consensus with Western counterparts.

Oncologic Effectiveness and Safety of Bursectomy in Patients with Advanced Gastric Cancer: A Systematic Review and Updated Meta-Analysis

Purpose/Aim: In the past few decades some researchers have questioned whether bursectomy for gastric cancer is essential from an oncological point of view and no consistent recommendations have been proposed. The aim of this systematic review with meta-analysis is to investigate the oncologic effectiveness and safety of bursectomy for the treatment of advanced gastric cancer patients.

MATERIALS AND METHODS

We planned and performed this systematic review and meta-analysis in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement and Cochrane Handbook for Systematic Reviews of Intervention.

RESULTS

Overall, four studies with a total of 1,340 patients met inclusion criteria. The pooled hazard ratio for overall survival between the bursectomy versus nonbursectomy groups was [HR = 0.85, 95% CI 0.66-1.11, p =.252]. Interestingly, the pooled HR between the two groups in serosa-positive cases subgroup, showed a significant improvement of overall survival rate in favor of bursectomy [HR = 0.72, 95% CI 0.73-0.99, p <.05].

CONCLUSIONS

Bursectomy represents a surgical procedure that might be able to improve overall survival in serosa positive gastric cancer patients. However, a definitive conclusion could not be made because of the studies' methodological limitations. This meta-analysis points to the urgent need of high quality, large-scaled, clinical trials with short- as well as long-term evaluation comparing bursectomy with non bursectomy procedures, in a controlled randomized manner, helping future researches and establishing a modern and tailored approach to gastric cancer.

Feasibility and Safety of Totally Laparoscopic Radical Gastrectomy for Advanced Gastric Cancer: Comparison with Early Gastric Cancer

Purpose

Totally laparoscopic gastrectomy (TLG) for advanced gastric cancer (AGC) is a technically and oncologically challenging procedure for surgeons. This study aimed to compare the oncologic feasibility and technical safety of TLG for AGC versus early gastric cancer (EGC).

Materials and Methods

Between 2011 and 2016, 535 patients (EGC, 375; AGC, 160) underwent curative TLG for gastric cancer. Clinicopathologic characteristics and surgical outcomes of both patient groups were analyzed and compared.

Results

Patients with AGC required a longer operation time and experienced more intraoperative blood loss than those with EGC did. However, patients from both the AGC and EGC groups demonstrated similar short-term surgical outcomes such as postoperative morbidity (14.4% vs. 13.3%, P=0.626), mortality (0% vs. 0.5%, P=0.879), time-to-first oral intake (2.7 days for both groups, P=0.830), and postoperative hospital stay (10.2 days vs. 10.1 days, P=0.886). D2 lymph node dissection could be achieved in the AGC group (95%), with an adequate number of lymph nodes being dissected (36.0±14.9). In the AGC group, the 3-year overall and disease-free survival rates were 80.5% and 73.7%, respectively.

Conclusions

TLG is as safe and effective for AGC as it is for EGC.

Bursectomy for advanced gastric cancer: an update meta-analysis

Background

The present meta-analysis was to explore the surgical and oncological outcomes of bursectomy for advanced gastric cancer (AGC).

Methods

Relevant studies that evaluated the role of bursectomy for AGC were comprehensively examined to perform a meta-analysis. The primary outcomes were overall survival (OS) and disease-free survival (DFS). The secondary outcomes were the number of harvested lymph nodes (LNs), operation time, operative bleeding, hospital stay, postoperative complication and mortality.

Results

A total of seven studies comprising 2633 cases (1176 cases in the bursectomy group and 1457 cases in the non-bursectomy group) were finally included. There was no significant difference in OS (HR 0.95, P = 0.647) and DFS (HR 0.99, P = 0.936) between the two groups. Even for patients with serosa-penetrating tumours, OS was comparable between the two groups (HR 0.87, P = 0.356). The operation time of the bursectomy group was longer (weighted mean difference, WMD 32.76 min, P = 0.002). No significant difference was found between the two groups in terms of the number of dissected LNs (WMD 5.86, P = 0.157), operative bleeding (WMD 66.99 ml, P = 0.192) and hospital stay (WMD − 0.15 days, P = 0.766). The overall postoperative complication (relative risk, RR 1.08, P = 0.421) and mortality (RR 0.44, P = 0.195) were similar between two groups.

Conclusions

This meta-analysis indicated that bursectomy is time-consuming without increasing the number of harvested LNs. Although bursectomy can be safely performed without increasing complications and mortality, it does not prolong the OS and DFS of AGC patients, including patients with serosa-penetrating tumours. Therefore, bursectomy should not be recommended as a standard procedure for AGC.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1354-1) contains supplementary material, which is available to authorized users.

Surgical anatomy of the omental bursa and the stomach based on a minimally invasive approach: different approaches and technical steps to resection and lymphadenectomy

BACKGROUND

It is imperative for surgeons to have a proper knowledge of the omental bursa in order to perform an adequate dissection during minimally invasive surgery (MIS) of the upper gastrointestinal (GI) tract. This study aimed to describe (1) the various approaches which can be used to enter the bursa and to perform a complete lymphadenectomy, (2) the boundaries and anatomical landmarks of the omental bursa as seen during MIS, and (3) whether a bursectomy should be performed for oncological reasons in upper GI cancer.

METHODS

In this observational study, videos of 20 patients undergoing different MIS procedures were reviewed, and the findings were verified prospectively in 5 patients undergoing a total gastrectomy and in a transversely sectioned cadaver. A systematic literature review (PubMed) was performed on the additive value of bursectomy during gastrectomy for cancer.

RESULTS

The omental bursa can be surgically entered through the hepatogastric ligament, gastrocolic ligament, gastrosplenic ligament or through the transverse mesocolon. Anatomical boundaries of the omental bursa could be clearly identified, and new anatomical landmarks were described (gastro-omental folds). The cranial part of the omental bursa consists of two compartments (splenic recess and superior recess), separated by the gastropancreatic fold, communicating at the level of the pancreas, and extending distally as the inferior recess. There is no clear evidence regarding beneficial effect of a bursectomy in upper GI oncology.

CONCLUSIONS

The description of the omental bursa in this study may help surgeons perform a more adequate oncological dissection during MIS. Bursectomy should not be routinely performed during oncological resections.

Changing Trends in Gastric Cancer Surgery

Gastric cancer is one of the most common causes of cancer-related death. It requires multimodal treatment and surgery is the most effective treatment modality. Radical surgery includes total or subtotal gastrectomy with lymph node dissection. The extent of lymphadenectomy still remains controversial. Eastern surgeons have performed D2 or more extended lymphadenectomy while their Western colleagues have performed more limited lymph node dissection. However, the trend has been changing in favour of D2 lymph node dissection in both hemispheres. Currently, D2 is the recommended type of lymphadenectomy in experienced centres in the west. In Japan, D2 lymph node dissection is the standard surgical approach. More extensive lymphadenectomy than D2 has not been found to be associated with improved survival and generally is not performed. Bursectomy and splenectomy are additional controversial issues in surgical performance, and trends regarding them will be discussed. The performance of bursectomy is controversial and there is no clear evidence of its clinical benefit. However, a trend toward better survival in patients with serosal invasion has been reported. Routine splenectomy as a part of lymph node dissection has largely been abandoned, although splenectomy is recommended in selected cases. Minimally invasive surgery has gained wide popularity and indications for minimally invasive procedures have been expanding due to increasing experience and improving technology. Neoadjuvant therapy has been shown to have beneficial effects and seems necessary to provide a survival benefit. Diagnostic laparoscopy should be kept in mind prior to treatment.

Bursectomy and non-bursectomy D2 gastrectomy for advanced gastric cancer, initial experience from a single institution in China

BACKGROUND

The aim of this study is to evaluate the safety and efficacy of bursectomy of D2 gastrectomy in terms of postoperative complications and short-term survival outcomes.

METHODS

From January 2012 to December 2013, data of 406 gastric cancer patients with advanced tumor stages and who underwent D2 radical gastrectomy and were grouped according to whether bursectomy was performed or not in West China Hospital, Sichuan University, were analyzed.

RESULTS

Finally, 159 patients were in bursectomy group and 247 patients in non-bursectomy group. Surgical duration was 260.1 ± 43.4 min in the bursectomy group, compared to 227.9 ± 48.6 min in the non-bursectomy group (p < 0.001). The intraoperative blood loss was comparable between the bursectomy group and the non-bursectomy group (198.9 ± 63.5 vs. 201.1 ± 53.7 ml, p = 0.729). Postoperative morbidity rate showed no significant difference between the two groups, which were 23.3 % in the bursectomy group and 17.8 % in the non-bursectomy group, p = 0.179. The overall survival outcomes of patients were compared between the two groups of all patients (p = 0.055): patients who underwent distal gastrectomy (p = 0.129) and total gastrectomy (p = 0.016) and pT2-3 stage patients (p = 0.117) and pT4a stage patients (p = 0.128). The multivariate survival analysis identified that bursectomy or not, pT stage and pN stage were independent prognostic risk factors for the overall survival.

CONCLUSIONS

The bursectomy might increase the surgical duration when the D2 gastrectomy was done. Experienced surgeons can perform it safely. However, for the survival benefits of bursectomy, long-term, large sample sized, and high-quality randomized controlled trials are expected.

Bursectomy at radical gastrectomy

Radical gastrectomy with extended lymph node dissection and prophylactic resection of the omentum, peritoneum over the posterior lesser sac, pancreas and/or spleen was advocated at the beginning of the 1960s in Japan. In time, prophylactic routine resections of the pancreas and/or spleen were abandoned because of the high incidence of postoperative complications. However, omentectomy and bursectomy continued to be standard parts of traditional radical gastrectomy. The bursa omentalis was thought to be a natural barrier against invasion of cancer cells into the posterior part of the stomach. The theoretical rationale for bursectomy was to reduce the risk of peritoneal recurrences by eliminating the peritoneum over the lesser sac, which might include free cancer cells or micrometastases. Over time, the indication for bursectomy was gradually reduced to only patients with posterior gastric wall tumors penetrating the serosa. Despite its theoretical advantages, its benefit for recurrence or survival has not been proven yet. The possible reasons for this inconsistency are discussed in this review. In conclusion, the value of bursectomy in the treatment of gastric cancer is still under debate and large-scale randomized studies are necessary. Until clear evidence of patient benefit is obtained, its routine use cannot be recommended.

Clinical application of omental bursa wash detection in gastric carcinoma

AIM: To evaluate the application value of omental bursa wash detection in gastric carcinoma.

METHODS: Omental bursa washes from 78 patients with gastric carcinoma were collected. The expression of carcino-embryonic antigen (CEA) in omental bursa washes was detected by flow cytometry (FCM). Peritoneal lavage cytology (PLC) examinations were also carried out.

RESULTS: The FCM and PLC positive rates of omental bursa washes were 37.1% (29/78) and 11.5% (9/78), respectively, which had a significant difference (P = 0.001). The positive rate of omental bursa washes correlated well with the width of tumor, location of lesion, and depth of invasion (P < 0.05). The age, gender, differentiation, vessel carcinoma embolus, and area of invasion were not relevant to omental bursa wash detection.

CONCLUSION: FCM can be well used to detect omental bursa washes. The best use of omental bursa wash detection is to assess tumor progression and to predict the emergence of gastric carcinoma micrometastases.

Long-term outcomes after prophylactic bursectomy in patients with resectable gastric cancer: Final analysis of a multicenter randomized controlled trial

BACKGROUND

Bursectomy, a traditional operative procedure to remove the peritoneal lining covering the pancreas and the anterior plane of the transverse mesocolon, has been performed for serosa-positive gastric cancer in Japan and Eastern Asia. We conducted a multicenter, randomized, controlled trial to demonstrate the noninferiority of the omission of bursectomy.

METHODS

Between July 2002 and January 2007, 210 patients with cT2-3 gastric adenocarcinoma were randomized intraoperatively to D2 gastrectomy with or without bursectomy. The primary endpoint was overall survival (OS). We provide the results of the final analysis of the complete 5-year follow-up data.

RESULTS

After the median follow-up of 80 months, 5-year OS was 77.5% for the bursectomy group and 71.3% for the nonbursectomy group (2-sided P = .16 for superiority; 1-sided P = .99 for noninferiority). The hazard ratio for death in the nonbursectomy group was 1.40 (95% CI, 0.87-2.25). The 5-year recurrence-free survivals were 73.7% and 66.6% in the bursectomy and nonbursectomy groups, respectively (2-sided P = .33 for superiority; 1-sided P = .99 for noninferiority). Cox multivariate analysis revealed that bursectomy was an independent prognostic factor of good OS (P = .033). Subgroup analysis showed a trend toward improved survival after bursectomy for tumors in the middle or lower third of the stomach and for pathologically serosa-positive tumors.

CONCLUSION

The final analysis could not demonstrate the noninferiority of the omission of bursectomy. Bursectomy should not be abandoned as a futile procedure.

Effect of gastrectomy with bursectomy on prognosis of gastric cancer: A meta-analysis

AIM: To evaluate the effect of bursectomy on overall survival, recurrence-free survival and safety of patients with gastric cancer by performing a meta-analysis.

METHODS: A literature search was performed in PubMed, EMBASE, and the Cochrane Library databases for clinical research that compared bursectomy with non-bursectomy published before October 2013. Inclusion and exclusion criteria were established and applied. Overall survival, recurrence-free survival, complications, hospital stay, operative time and blood loss were compared using hazard ratios (HRs), relative risks and weighted mean differences. Stata 12.0 software was used for statistical analysis.

RESULTS: Four studies including 1130 patients were available for the analysis (430 in the bursectomy group, 700 in the non-bursectomy group). No statistically significant difference was observed in the rate of complications between the bursectomy group and the non-bursectomy group. Bursectomy did not have a significant effect (combined HR = 1.14, 95%CI: 0.88-1.47) on overall survival, and it was not a significant factor for recurrence-free survival (combined HR = 1.06, 95%CI: 0.82-1.37).

CONCLUSION: Gastrectomy with bursectomy is not superior to non-bursectomy in terms of survival. Bursectomy is not recommended as a routine procedure for the surgical treatment of gastric cancer.

Improving the outcomes in gastric cancer surgery

Gastric cancer remains a significant health problem worldwide and surgery is currently the only potentially curative treatment option. Gastric cancer surgery is generally considered to be high risk surgery and five-year survival rates are poor, therefore a continuous strive to improve outcomes for these patients is warranted. Fortunately, in the last decades several potential advances have been introduced that intervene at various stages of the treatment process. This review provides an overview of methods implemented in pre-, intra- and postoperative stage of gastric cancer surgery to improve outcome. Better preoperative risk assessment using comorbidity index (e.g., Charlson comorbidity index), assessment of nutritional status (e.g., short nutritional assessment questionnaire, nutritional risk screening - 2002) and frailty assessment (Groningen frailty indicator, Edmonton frail scale, Hopkins frailty) was introduced. Also preoperative optimization of patients using prehabilitation has future potential. Implementation of fast-track or enhanced recovery after surgery programs is showing promising results, although future studies have to determine what the exact optimal strategy is. Introduction of laparoscopic surgery has shown improvement of results as well as optimization of lymph node dissection. Hyperthermic intraperitoneal chemotherapy has not shown to be beneficial in peritoneal metastatic disease thus far. Advances in postoperative care include optimal timing of oral diet, which has been shown to reduce hospital stay. In general, hospital volume, i.e., centralization, and clinical audits might further improve the outcome in gastric cancer surgery. In conclusion, progress has been made in improving the surgical treatment of gastric cancer. However, gastric cancer treatment is high risk surgery and many areas for future research remain.