Strategies in the surgical treatment of gastric carcinoma.

Surgical therapy still represents the treatment of choice for patients with primary gastric adenocarcinoma, but surgery may have reached its limits concerning the rate of resectability, postoperative mortality and survival rates. Resectability is as high as 80%, mortality after resection ranges between 3% and 5% and the best survival data can be achieved if potentially curative tumor-free (R0-) resection including systematic lymphadenectomy can be performed. Significant prognostic benefits are to be expected in tumor stages II and IIIA. Most gastric carcinomas, however, are diagnosed in far advanced tumor stages (i.e., stage IIIB and IV) and the survival rates in these patients remain disappointing. Multimodality treatment, consisting of preoperative chemotherapy and surgery, may be an encouraging alternative strategy. By endoscopic ultrasonography and staging laparoscopy it may be possible to identify patients with locally advanced tumors, so that these patients should be subjected to multimodal therapy to improve their prognosis. Primary surgical treatment should be exclusively performed in patients with tumor stages up to IIIA and those who are not eligable for aggressive chemotherapeutic regimens, while the concept of multimodality therapy needs to be investigated in the other cases within controlled prospective clinical trials.