More than 100 years have passed since Billoth successfully performed the first resection of gastric sinus cancer in 1881, and the status of surgical treatment has not changed, and it is still the only effective method with hope to cure gastric cancer, but from the global situation of gastric cancer surgical treatment, the effect is far from satisfactory. Gastric cancer is a common gastrointestinal malignancy in China. The prevalence and mortality rate are more than twice the world average, with 400,000 new gastric cancer patients and 300,000 deaths each year. In the past 30 years. The 5-year survival rate of patients with gastric cancer in China still hovers at 20%-30% after surgery. The latest information from western countries also shows that the 5-year survival rate of resectable gastric cancer is still 10% 30% Ell. 5-year survival rate in Japan is about 60%, which is remarkable compared with China and western countries. From the current situation of gastric cancer treatment in China, the following factors are worth considering: (1) Due to the lagging level of understanding of early diagnosis of gastric cancer and census methods, the diagnosis rate of early gastric cancer is less than 10%. This is one of the reasons why the 5-year survival rate of gastric cancer patients in China lags far behind that of Japan: (2) irregular surgical methods and non-rational application directly affect the effect of surgical treatment; (3) the clinical effect of comprehensive treatment of gastric cancer is still not as certain as that of colon and rectal cancer, and there is still a lack of credible multicenter studies of large clinical cases. Systematic research data are still lacking. This article reviews the progress and hot issues in the surgical treatment of gastric cancer in recent years. Gastrectomy plus second-station lymph node dissection Gastrectomy plus second-station lymph node dissection (i.e. D2 curative surgery for gastric cancer) is the standard procedure for the treatment of progressive gastric cancer. The principle of the operation is that the stomach has many lymphatic circulation pathways, and these gastric lymphatic fluid first flows to the lymph nodes distributed along the large and small curves of the stomach (i.e. perigastric or first-station lymph nodes), and then converges to the lymph nodes adjacent to the three main vessels including the abdominal trunk (common hepatic artery, splenic artery and left gastric artery), the lymph nodes within the hepatoduodenal ligament and the perigastric artery. D2 surgery for gastric cancer is a moderate overall resection including the first and second station lymph nodes, the greater omentum and omental sac and part of the stomach. The clinical results obtained by referring to this surgical standard are that the 5-year survival rate of Japanese gastric cancer patients has increased from 41.2% to 63.8%. The standardized radical gastric cancer surgery in China was also developed according to this standard and promoted nationwide. There are different views on the clinical outcomes of this surgical standard in Western countries. A randomized controlled trial called the Dutch trial, which compared the outcomes of both D1 and D2 radical surgery for gastric cancer, and another randomized controlled study conducted in the Commonwealth, the MRC trial, which compared the outcomes of gastrectomy alone, gastrectomy plus D1 and gastrectomy plus D2 surgery, both concluded that D Sasako found some problems with D2 surgery for gastric cancer in these studies, such as a very high postoperative morbidity and mortality rate in the study group and a low number of enrolled cases, with questionable conclusions. In any case, the superiority of D2. surgery has been confirmed by retrospective non-randomized controlled, clinical studies with good clinical outcomes reported. It is now generally accepted that D2 radical gastric cancer surgery improves the 5-year survival rate of patients with gastric cancer. In Japan, general surgeons must first be trained in gastrectomy and D2 lymph node dissection techniques-/)ml and qualified before becoming registered physicians qualified to perform this procedure. Although D2 radical surgery for gastric cancer has been considered as the standard radical surgery in Japan with good clinical outcomes, more reliable clinical evidence is expected on this point due to the lack of multicenter randomized controlled clinical studies. Regarding the concept of D2 surgery for gastric cancer, we should also pay attention to changes in the continuity and effectiveness of gastric cancer research, changes in biological behavior, or updates in research techniques. For example, the attribution and distribution of lymph nodes in the second station as reflected in the Japanese gastric cancer treatment statute is dynamically adjusted, and the related lymph node clearance range for D2 surgery for gastric cancer also changes, so if we do not pay attention to this in our clinical work, surgical irregularities may occur, for example, the lymph nodes in the 14th group of gastric sinus For example, the original group 14 lymph nodes of gastric sinus cancer (superior mesenteric arteriovenous parietal lymph nodes) are the third station, but now they are adjusted to the second station, and the radical treatment of D2 gastric sinus cancer should be cleared at the same time. Professor Chen Junqing, a well-known gastric cancer expert in China, believes that there is some confusion in China about the concept of standard radical surgery, indications, scope of surgery and the scope of lymph node clearance, especially the issue of station and number of lymph node clearance, which directly hinders the standardized treatment of gastric cancer in China and deserves attention. The number of lymph node dissection is another important index reflecting the level of gastric cancer eradication and affecting patients’ prognosis, but the quality control intervention factors for the number of specimen lymph nodes and metastasis degree (number of metastatic lymph nodes/number of examined lymph nodes) are standardized surgical dissection technique, specimen lymph node acquisition method and sensitivity of pathological detection technique, which directly affect the quality of pathological report and prognosis assessment. kodera et al. conducted a study on 493 cases receiving Kodera et al. evaluated 493 patients who underwent radical surgery for D2 and D3 gastric cancer using the 1997 version of the International Union Against Cancer TNM staging method for gastric cancer and found that the number of lymph nodes involved was a more sensitive indicator of prognosis compared with different site staging. Increasing the number of detected lymph nodes can improve the accuracy of prediction, reduce the staging migration effect, and help provide a basis for multidisciplinary comprehensive treatment and more accurate description of patient’s tumor load.Karpeh et al. concluded that for accurate tumor staging, more than 15 lymph nodes must be detected in each gastric cancer patient, and this recommendation has been agreed and incorporated into the pathological detection criteria for gastric cancer. It has been reported that. Mullaney et al. reported that only 31% of patients undergoing surgery met the criteria for lymph node evaluation. The reduced number of cleared lymph nodes implies difficulties in prognostic assessment and tumor staging, and more importantly, the possibility of residual tumor in these patients, on the other hand, indicates that surgical lymph node clearance is not standardized and the extent of surgery is not adequate, and such surgery will affect patient prognosis. In addition. It is also worth mentioning that the technique of lymph node acquisition for resected specimens and the professional level of the extraction technicians as human intervention factors cannot be ignored, and the level of awareness of the importance of this work so far is very different. Especially in primary hospitals. This requires the joint efforts of surgeons and pathologists. 2.Lymph node dissection in the third station (D3) of gastric cancer Lymph node dissection in the third station (D3) of gastric cancer. D3 lymph node dissection refers to the removal of lymph nodes adjacent to the abdominal aorta. Gastric lymphatic fluid is injected via perigastric lymph nodes to the abdominal trunk and perigastric trunk vascular lymph nodes then into the abdominal para-aortic lymph nodes. Finally, it enters the body circulation through the thoracic duct. Therefore, the para-aortic lymph nodes are often considered as the last stop of surgical debulking for gastric cancer. In the case of gastric sinus cancer, for example, the principle of D3 surgery for gastric cancer is D2 surgery plus lymph node dissection of the hepatoduodenal ligament, posterior pancreatic space, transverse colonic mesenteric vessels and peri-abdominal aorta. Since approximately 2O% 3O% of patients with progressive gastric cancer present with metastasis to the para-aortic lymph nodes, it is expected that some patients may achieve long-term survival through extended resection surgery. According to a prospective randomized controlled study called JCOG (9501) in Japan, which compared the clinical outcomes of both D3 and D2 surgical approaches for progressive gastric cancer, it was shown that expanded periaortic lymph node dissection did not increase complications or morbidity and mortality in hospitalized patients, but the conditions of the study included (1) selecting only patients who could tolerate abdominal aortic dissection; (2) selecting only patients who could tolerate abdominal aortic lymph node dissection; and (3) selecting patients who could tolerate abdominal aortic lymph node dissection. The JCOG clinical study was concluded in 2006 and the conclusions will suggest whether D3 surgery will improve patient survival. However, the findings have not yet been reported in the literature. The current clinical indications for D3 surgery are based on retrospective clinical data studying D2 and D3 lymph node dissection in patients with gastric cancer with plasma surface invasion or metastasis in the second station lymph nodes. It has been reported that D3 surgery does not prolong the survival of patients with metastasis in the para-aortic lymph nodes. 5-year survival rates are equivalent to DO surgery, and it is believed that D3 surgery may be beneficial only for patients with gastric cancer with tumors ≥ T3 or (and) lymph nodes ≥ N2, while there is no metastasis in the para-aortic lymph nodes, but the difference in survival rates is not statistically significant. d3 surgery as a prophylactic lymph node dissection for patients without para-aortic lymph nodes D3 surgery as a prophylactic lymph node dissection in patients without paraaortic lymph node metastasis. It may improve the survival rate of patients. Because D3 surgery may increase surgical complications and affect the function of intra-abdominal organs. Moreover, the surgeon needs extensive surgical experience, and it is not yet advocated for universal implementation. However, for surgeons who are already skilled in D2 surgery operation. Careful surgical operation. It is possible to avoid the postoperative complications of D3 surgery. 3.Gastric cancer combined with pancreaticoduodenectomy Gastric cancer combined with pancreaticoduodenectomy at the same time is often more traumatic, and there are many controversies at present, but from the clinical treatment effect, some patients can get longer-term survival. The author has performed a case of advanced gastric cancer for a patient who was considered to be advanced. I have successfully performed a combined pancreaticoduodenectomy for gastric cancer in a patient with fork and obstruction. After the operation, he achieved good survival. However, the indications for surgery must be strictly controlled. The following pathological features should be considered for combined pancreaticoduodenectomy: (1) lymph node metastasis to the third station; (2) duodenal invasion of more than 3 cm: (3) direct invasion of the pancreas; (4) tumor invasion found in the duodenal plasma membrane; (5) sometimes transverse colon invasion. oyama and yamaguchi [.] reported gastric cancer combined with pancreaticoduodenectomy in 202 patients. There were 136 cases (67%) of direct invasion, 48 cases (24%) of lymph node invasion, and 6 cases (3%) of duodenal invasion. Their clinical findings were that the clinical outcome of combined pancreaticoduodenectomy was limited and most patients eventually died of extensive peritoneal metastases, liver and distant lymph node metastases. Clinical experience suggests. Only patients with direct invasion of the pancreas without lymph node metastasis. Oyama and Yamaguchi also found that if the lymph node metastasis exceeds the first station, the patient has a chance of long-term postoperative survival. If the lymph node metastasis exceeds the first station, the clinical result of combined pancreaticoduodenectomy is not satisfactory. Therefore. The indications for this surgery should be strictly controlled. Enlarged or super enlarged resection for progressive gastric cancer reflects the determination of today’s gastrointestinal surgeons to remove the tumor in the hope of improving the cure rate. However, the improvement of survival rate is always limited. The surgical treatment for patients with gastric cancer should be selected rationally based on evidence-based medicine. Comprehensive adjuvant therapy is another new and fast-developing treatment pathway for progressive gastric cancer. Clinical effects are also in the process of continuous exploration. It includes chemotherapy, radiotherapy, radiotherapy, immunotherapy, neoadjuvant therapy alone or in combination, applied to patients with locally progressive tumors or seemingly surgically resectable but at high risk of recurrence. Through tumor downstaging. To achieve a surgical resection rate of 40% to 100%. The curative resection rate reaches 37% 80%. The efficacy of this new mode of gastric cancer treatment needs further clinical observation. 4.Minimally invasive surgical treatment for gastric cancer Minimally invasive surgical treatment for gastric cancer actually includes three types of techniques: endoscopic gastric mucosal or submucosal resection, functional gastric partial resection (such as wedge resection, local resection plus adjacent lymph node resection, segmental resection, pylorus preserving gastric resection and proximal hemigastric resection) and laparoscopic assisted gastric resection (gastric wedge resection, local resection plus adjacent lymph node resection, segmental resection, pylorus preserving gastric resection and proximal hemigastric resection). resection and proximal hemigastrectomy, and subtotal distal gastrectomy with D2 lymph node dissection). Each minimally invasive surgical procedure has its own strict range of indications in principle. It is mainly for early gastric cancer. With the rapid development of laparoscopic surgical techniques and instruments, in-depth understanding of gastric physiological functions and more knowledge of biological characteristics of gastric cancer, minimally invasive treatment of partially progressive gastric cancer has started to appear. However, what is the effect of laparoscopic surgical treatment on tumor spread, postoperative recurrence and long-term clinical effect are still questions that surgeons should ponder before fully implementing this technology. At present, endoscopic, laparoscopic and traditional open surgery have become the treatment options available to patients with gastric cancer. Since lymph node metastasis is the main obstacle to the development of minimally invasive surgery. Accurate preoperative gastric cancer staging has become an important basis for choosing minimally invasive techniques. The development of diagnostic techniques such as endoscopic ultrasound, cT, MRI, and PET.cT has significantly improved the preoperative staging of gastric cancer. have significantly improved the accuracy of preoperative staging of gastric cancer. The diagnosis rate of early gastric cancer is 20% in the West, 40% in Korea, and more than 50% in Japan, so minimally invasive treatment is widely carried out in Korea and Japan. Goh et al. completed the first laparoscopic Bi-II gastrectomy in 1992; in 1993, Azagra et al [131 completed laparoscopic gastrectomy for gastric cancer, and later laparoscopy was successfully used to perform almost all gastric surgeries that could be done by conventional surgery in the past. In recent years, laparoscopic treatment of gastric cancer has included lymph node dissection, and the scope of indications for surgery has gradually expanded. Globally, the countries with the most cases of laparoscopic gastric cancer treatment are still Korea and Japan, and the main indications are early gastric cancer. The quality of survival is better than that of open surgery. With the improvement of laparoscopic lymph node dissection by experienced surgeons, the scope of laparoscopic surgery has been expanded to include the treatment of perigastric lymph nodes. The treatment of laparoscopic surgery has been extended to progressive gastric cancer, and from the limited clinical reports, the prognosis of these patients is acceptable. As with the maturation process of other surgical techniques, the clinical outcome of laparoscopic surgery is closely related to the surgeon’s level of operative skill and requires a learning curve process. The fact that laparoscopy is not yet widely used for gastric surgery does not mean that we deny this technology. As experienced laparoscopic surgeons gradually deepen their mastery of this procedure under the guidance of education and training and clinical practice, we believe that the era of widespread application of this new technology of laparoscopic gastrectomy for gastric cancer will soon come. The successful laparoscopic treatment of colon and rectal cancers is an example of how laparoscopic radical surgery for colon and rectal cancers was once considered inappropriate in the late 1990s. Today, the results of a randomized controlled clinical study clearly show that laparoscopic radical surgery for colon and rectal cancer can achieve the same efficacy as open surgery, and for stage III patients the efficacy is even better than that of traditional open surgery, probably because of the reduced damage to the patient’s immune system associated with minimally invasive surgery. It has been reported that… Laparoscopic treatment of progressive gastric cancer is reported to be safe and reliable and can achieve the same 5-year survival rate as that of traditional open surgery.