Chapter 1: Historical overview of surgical treatment of gastric cancer and controversial issues Yan speed, Department of Oncology, Qinghai University Hospital When mentioning the history of gastric cancer surgery, people must not forget the names of two surgeons. One is Billroth, an Austrian physician, who removed the tumor and performed gastroduodenal anastomosis in only 90 minutes without intravenous fluids for a 43-year-old woman with gastric cancer combined with pyloric obstruction in Vienna on January 29, 1881. The patient recovered well and ate normally after surgery, and the patient died of recurrent gastric cancer on May 24 of the same year. Although he survived for only four months, the Austrian doctor pioneered the use of surgery to treat gastric cancer with success. In his honor, the direct gastroduodenal anastomosis he created is called the Billroth I anastomosis. Later, an atretic duodenal and gastrointestinal anastomosis was improved and called the Billroth II anastomosis. Another surgeon was Schlater of Switzerland, who performed the first successful total gastrectomy in 1897, pioneering the use of total gastrectomy for the treatment of gastric cancer on the basis of major gastrectomy. One of them is Borrmann from Germany, who proposed in 1923 the general classification of gastric cancer into four types according to its malignancy, which has been used until now and has become an important basis for surgeons to make surgical plans and determine the prognosis. The infiltrative growth pattern of gastric cancer proposed by our scholar Zhang Yunchang in 1964, namely mass growth, nest growth, and diffuse growth, and the two growth patterns proposed by Ming, a Chinese American, in 1977 basically established that among the many pathological factors affecting prognosis of gastric cancer, the infiltrative pattern is very important. There is also Chinese scholar Chen Junqing who started to study the clinical application of biological behavior of gastric cancer from 1980s, applied the results of the above pathological studies to clinical practice, improved and changed the traditional treatment concept, and constructed modern treatment theory and treatment plan for gastric cancer. Although in the history of gastric cancer surgical treatment, many scholars made great contributions before and after Billroth, the surgical treatment of gastric cancer has gone through a very tortuous process. In the Billroth era, the direct mortality rate of gastric cancer after surgery was very high, according to Hehere, it was 63.4% in 1881-1887, 42.8% in 1888-1894, 30%-50% in 1910-1920, and 1932 The surgical resection rate was 45%, and the 5-year survival rate was 15%. From the above data, it is clear that the surgical treatment of gastric cancer is an operation with low resection rate, low survival rate, high surgical mortality and high risk. The surgical operation was difficult to promote, so until 1940, it was basically at the level of major gastric resection in the Billroth era. During the Second World War, the treatment of a large number of casualties promoted the development and application of techniques such as blood transfusion, rehydration, anti-infection and pain relief, which ensured the safety of surgery and gradually expanded the scope of surgical resection, bringing a leap in the development of surgery. At the same time, X-ray gastrography technology was applied to clinical practice, especially in the 1950s, when Shirakabc and others perfected gastric double contrast imaging technology, which obviously improved the diagnosis of gastric cancer; in 1958, Hirschowitz began to use curved optical fiber gastroscopy to carry out intra-gastric photography, biopsy and exfoliative cytological examination, which not only improved the diagnostic technology of progressive gastric cancer, but also It became the most important diagnostic technique for early gastric cancer, and the definition of early gastric cancer has been available since then. After the improvement of gastric cancer diagnostic techniques and surgical safety no longer became a bottleneck in surgical development, from the late 1940s to the mid-1970s, the surgical treatment of gastric cancer entered a booming period, with the gradual increase of total gastrectomy and combined organ resection, however, the result was the increase of complications and surgical mortality. Could the long-term survival rate be improved? In 1969, Gilbertsen reviewed and summarized the results of 1983 cases of gastric cancer, and expanded surgery reduced the 5-year survival rate from 18% to 9% after surgery for gastric cancer. Since then, there has been a negative attitude toward expanded surgery for gastric cancer worldwide. Since the late 1960s, the surgical treatment of gastric cancer has returned to the stage of major gastrectomy plus omentectomy. In 1962, the Japanese Society for the Study of Gastric Cancer published the “Statute for the Management of Gastric Cancer”, which has been revised 13 times by 1999, stipulating the standards for the treatment and control of gastric cancer such as diagnosis, surgery, pathology, chemotherapy and radiotherapy, and carrying out standard radical surgery and extended radical surgery for gastric cancer. Although some people still disagreed with their research results, the good efficacy of D2 and D3 surgery and systematic research work had a great influence on the world’s gastric cancer research, and the Japanese “Statute for the Management of Gastric Cancer” has been recognized and promoted by most countries in the world. The surgical treatment of gastric cancer in China started in the 1950s, due to the limitation of diagnosis method, most of the patients were in advanced stage, the surgical resection rate was low and the scope of resection was small, mostly distal gastric resection and lymph node removal near the stomach, only a few hospitals carried out total gastric resection and combined organ resection. In 1978, the first national academic conference on gastric cancer was held, and the diagnosis and treatment standard of gastric cancer in China was formulated; in the early 1980s, the Japanese D2 and D3 surgeries for gastric cancer were introduced and applied nationwide, which improved the treatment level of gastric cancer in China, and the 5-year survival rate after radical gastric cancer surgery reached 40%. The 5-year survival rate after radical surgery is 63.7%, which is close to the world advanced level. With the deepening of gastric cancer research, certain views and techniques in the surgical treatment of gastric cancer are increasingly debated and have become several focal issues in the surgical treatment of gastric cancer. (1) Controversy about the scope of gastric resection: the residual rate of cancer at the cut-off end of stomach is 7.6%-16%, and there has been a debate on how to determine the scope of gastric resection for gastric cancer in different parts. However, determining the extent of gastrectomy according to the stage, general type and infiltrative growth pattern of gastric cancer has been confirmed by the results of a large number of clinical studies, and these issues will be introduced in the relevant chapters. (2) Controversy about the scope of lymph node dissection: The expanded lymph node dissection for gastric cancer proposed by Japanese scholars has aroused widespread concern and controversy among scholars all over the world. Scholars, mainly from the United States, the United Kingdom and the Netherlands, basically hold a negative attitude, believing that this type of surgery cannot improve the survival rate, but increases complications and postoperative mortality. There is no definite conclusion on how to determine the extent of lymph node dissection. The authors believe that the decision should be based on the type of surgery designed for reduced radical, standard radical, and extended radical. This book focuses on D2-centered lymph node dissection. (3) Controversies about minimally invasive surgery (EMR surgery, laparoscopic surgery) and reduction surgery for gastric cancer: What are the indications for such surgery? How to prevent cancer residue? It has been doubted by the traditional surgical treatment, and there is still no definite conclusion. (4) Controversies about combined organ resection: Should we combine splenic and pancreatic tail resection in order to remove No.10 and No.11 lymph nodes? How to choose pancreatic spleen-preserving surgery? Can combined pancreatic head duodenectomy, Appleby and other enlarged surgeries achieve the expected results? It has been doubted and concerned, and this book introduces these procedures at a large length. (5) Gastrointestinal reconstruction after total gastrectomy, there have been more than 70 types in the past 100 years, but none of them are recognized. This chapter introduces this aspect and adds the authors’ comments. (6) Prediction and blocking treatment of subclinical metastasis of gastric cancer: Subclinical metastasis of gastric cancer mainly includes peritoneal seeding, hematologic and lymphatic metastasis, and there is not yet a predictable method available. Regarding the method of killing cancer cells shed in the peritoneal cavity, it is in the experimental stage and still controversial. The intraoperative application of our self-developed 5-FU slow-release agent can be expected to hold people’s expectation. (7) Controversy about TNM staging of gastric cancer: Regarding the TNM staging method of gastric cancer, UICC, AJCC and JCC have always been controversial, and after long-term discussion and continuous improvement, TNM staging was published in 1988 for use by all countries, and was revised in 1997, stipulating that 15 lymph nodes must be detected in each case of gastric cancer, and there are still controversies and problems in its implementation. (8) Neoadjuvant chemotherapy for gastric cancer: Neoadjuvant chemotherapy for gastrointestinal cancer is being carried out at home and abroad, and the long-term efficacy has yet to be confirmed by further clinical observation. The controversial issues mentioned above have become the main development trend in the field of surgical treatment of gastric cancer, and the solutions to them are: (1) to carry out large-scale clinical collaboration. Gastric cancer is still one of the most common tumors in China. With unified standards, multi-center cooperation, the use of evidence-based medical theory, RCT method, and longer observation through large number of cases, conclusions will definitely be made on certain controversial issues. (2) Combination of clinical and basic research and multidisciplinary collaboration. Apply the results of basic research to the clinic as soon as possible, deepen the pathological biological behavior of gastric cancer into the field of molecular biology, and carry out new technologies such as molecular diagnosis, molecular margin cutting and gene therapy of gastric cancer. (3) Develop new technologies with new equipment, change the traditional treatment mode, make discoveries and innovations in minimally invasive surgery, killing cancer cells shed in the abdominal cavity, comprehensive perioperative treatment, interventional treatment, etc., so that certain destructive surgeries are replaced by certain technologies. In today’s era of rapid development of science and technology, the dreams of the past will become reality.