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 way to hopefully cure gastric cancer, but the results are far from satisfactory in terms of global surgical treatment of gastric cancer. Gastric cancer is a common gastrointestinal malignancy in China, with a prevalence and mortality rate more than twice the world average, with 400,000 new gastric cancer cases and 300,000 deaths each year. In the past 0 years, the 5-year survival rate of patients with gastric cancer in China still hovers at 20%-30% with surgical treatment. The latest information from western countries also shows that the 5-year survival rate for resectable gastric cancer is still 10%-30%. In Japan, the 5-year survival rate 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%, and most of the patients are near the middle and late stage when first diagnosed, so they lose the chance of surgical cure. 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 systematic research data of clinical cases. 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 type 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 channels, 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 collects in the lymph nodes surrounding the three main vessels including the abdominal trunk (common hepatic artery, splenic artery and left gastric artery), the hepatoduodenal ligament and the abdominal cavernous artery. D2 surgery for gastric cancer involves the removal of the first and second station lymph nodes, the greater omentum and the omental sac, and a moderate overall resection of the part of the stomach known as the divided stomach. The clinical results obtained by referring to this surgical standard are that the 5-year survival rate of Japanese gastric cancer patients 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. In Western countries, there are different views on the clinical outcomes of this surgical standard. The Dutch trial, a randomized controlled trial of D1 and D2 radical surgery for gastric cancer, and another randomized controlled study conducted in the Commonwealth, the MRC trial, comparing the outcomes of gastrectomy alone, gastrectomy plus D1 and gastrectomy plus D2 surgery, both clinical studies concluded that D2 surgery had no significant Sasako found some problems with D2 surgery for gastric cancer in these studies, such as a very high postoperative mortality rate and a low number of cases enrolled in the study group, which are questionable findings. 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 be trained in gastrectomy and D2 lymph node dissection techniques before they can become registered surgeons 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 due to the lack of multicenter randomized controlled clinical studies. With regard to 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 second station lymph node attribution and distribution is dynamically adjusted as reflected in the Japanese gastric cancer treatment statute, and the related lymph node clearance scope of D2 surgery for gastric cancer also changes. The lymph nodes should be cleared at the same time. Professor Chen Junqing, a well-known gastric cancer expert in China, believes that there are some confusions about the concept of standard radical surgery, indications, scope of surgery and the scope of lymph node dissection in China, especially the issue of station and number of lymph node dissection, 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 radical treatment of gastric cancer 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 techniques, methods of obtaining specimen lymph nodes and sensitivity of pathological detection techniques, which directly affect the quality of pathological reports and prognostic assessment. Kodera et al. 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 lymph nodes detected can improve the accuracy of prediction, reduce staging migration effects, and help provide a basis for comprehensive multidisciplinary treatment and more accurate description of the 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 reached consensus and been incorporated into the pathological detection criteria for gastric cancer. Lymph node detection in patients undergoing surgery for gastric cancer has also been reported to be substandard in several surgical centers in North America and Europe, with Mullaney et al. reporting that only 31% of surgical patients met the criteria for lymph node evaluation. The reduced number of lymph nodes cleared means that prognostic assessment and tumor staging are difficult, and more importantly, there is a possibility of tumor residual in these patients, which 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 should not be neglected as human intervention factors, and the level of awareness of the importance of this work is very different so far, especially in primary hospitals, which requires the joint efforts of surgeons and pathologists. 2.Lymph node dissection of the third station (D3) of gastric cancer Lymph node dissection of the third station (D3) of gastric cancer has been the most controversial issue in expanding radical surgery for gastric cancer because of its large surgical trauma and many postoperative complications, especially because the clinical efficacy is not yet clear. The gastric lymphatic fluid is injected into the perigastric lymph nodes via the perigastric lymph nodes to the abdominal trunk and perigastric trunk vascular lymph nodes and then into the para-aortic lymph nodes, and finally into the body circulation by the thoracic duct. Therefore, the para-aortic lymph nodes are often considered as the last stop for surgical clearance of gastric cancer. In the case of gastric sinus cancer, for example, the rationale for D3 surgery for gastric cancer is D2 surgery plus lymph node dissection of the hepatoduodenal ligament, posterior pancreatic space, transverse colonic mesenteric vessels, and periaortic lymph nodes. Since approximately 20% to 30% of patients with progressive gastric cancer have metastases in the para-aortic lymph nodes, it is expected that long-term survival may be achieved in some patients by expanding the scope of resection. According to a prospective randomized controlled study called JCOG( 9501) in Japan, which compared the clinical outcomes of two surgical approaches for progressive gastric cancer, D3 and D2, 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) only patients who could tolerate abdominal aortic dissection, (2) patients who had undergone the surgery, and (3) patients who had undergone lymph node dissection. (2) surgical specialists who have participated in expanded lymph node dissection; (3) selection of medical centers with a high number of patients with treated gastric cancer because they have a treatment team with more reliable surgical skills and clinical experience in postoperative management; and (4) avoidance of pancreatic resection if possible, but most patients with total gastrectomy undergo splenectomy. The JCOG clinical study was concluded in 2006 and the conclusions would suggest whether D3 surgery would improve patient survival, but its findings have not yet been reported in the literature. The current clinical indications for D3 surgery are based on retrospective clinical data from studies of D2 and D3 lymph node dissection in patients with plasma surface invasion or metastatic lymph nodes in the second station of gastric cancer. It has been reported that D3 surgery does not prolong the survival of patients with metastasis in the para-aortic lymph nodes, and the 5-year survival rate is equivalent to that of D0 surgery, and 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 rate is not statistically significant. patients, may improve patient survival. Because D3 surgery may increase surgical complications and affect the function of intra-abdominal organs, and because the surgeon requires extensive surgical experience, it is not yet recommended for general practice. However, for surgeons who already have skilled experience in D2 surgery operation, careful surgical operation is possible to avoid postoperative complications of D3 surgery. 3.Gastric cancer combined with pancreaticoduodenectomy Gastric cancer combined with pancreaticoduodenectomy at the same time is often a more traumatic operation, and there are more controversies at present, but from the clinical treatment effect, some patients can obtain longer-term survival. The author has successfully performed combined pancreaticoduodenectomy for a patient with advanced gastric cancer and combined obstruction, and obtained good survival after surgery. 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. 67%), lymph node invasion in 48 cases (24%), and duodenal invasion in 6 cases (3%). 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 that only patients with direct invasion of the pancreas without lymph node metastases have a chance of long-term postoperative survival.Oyama and Yamaguchi also found that combined pancreaticoduodenectomy is clinically unsatisfactory if lymph node metastases exceed the first station. Therefore, the indications for choosing this procedure should be strictly controlled. Enlarged or super-expanded resection for progressive gastric cancer reflects the determination of today’s gastrointestinal surgeons who strive to remove the tumor and expect to improve the cure rate, but the improvement in survival is always limited. 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, and the clinical effects are in the process of continuous exploration. It includes chemotherapy, radiotherapy, radiotherapy, immunotherapy, and 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, surgical resection rates of 40% to 100% and curative resection rates of 37% to 80% have been achieved. The efficacy of this new treatment mode for gastric cancer 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, partial resection of function-preserving stomach (such as wedge resection, local resection plus adjacent lymph node resection, segmental resection, pylorus-preserving gastrectomy and proximal hemigastrectomy) and laparoscopic-assisted gastrectomy (gastric wedge resection, local resection plus adjacent lymph node resection, segmental resection, pylorus-preserving gastrectomy and proximal hemigastrectomy). resection and proximal hemigastrectomy, and subtotal distal gastrectomy with D2 lymph node dissection). In principle, each type of minimally invasive surgery has its own strict scope of indications, mainly for early gastric cancer. With the rapid development of laparoscopic surgical techniques and instruments, deeper 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 are the long-term clinical effects of laparoscopic surgery on tumor spread, postoperative recurrence and long-term clinical outcomes are still questions that surgeons should ponder before fully implementing this technology. Currently, endoscopic, laparoscopic and traditional open surgery have become the treatment options for patients with gastric cancer. Since lymph node metastasis is the main obstacle for 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 accuracy of preoperative gastric cancer staging. 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, while it is less used in Western countries due to the low prevalence of gastric cancer. In 1993, Azagra et al. performed laparoscopic gastrectomy for gastric cancer, and later on, laparoscopic surgery was successfully performed for almost all gastric procedures that could be performed by conventional surgery. In recent years, laparoscopic treatment of gastric cancer has included lymph node dissection, and the range 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, and the clinical treatment effect, operation time and postoperative complications are no different from those of traditional surgery, while the quality of survival is better than that of open surgery. With the improvement of laparoscopic lymph node dissection by experienced surgeons, 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. We are not yet widely using laparoscopy for gastric surgery, but that does not mean 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 cancer is an example. In the late 1990s, it was once considered inappropriate to perform radical surgery for colon and rectal cancer laparoscopically, but 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 minimally invasive procedure This may be related to the reduction of damage to the patient’s immune system. It has been reported that laparoscopic treatment of progressive gastric cancer is safe and reliable, and can achieve the same 5-year survival rate as traditional open surgery.