"The Japanese Gastric Cancer Society recommends conservative surgery for patients with early gastric cancer.  However, there are many conservative surgical options, including ordinary open surgery, laparoscopic-assisted gastrectomy, laparoscopic intragastric surgery, pylorus-preserving gastrectomy, and hand-assisted laparoscopic surgery.  Guidelines for choosing among these options have yet to be established.

For advanced gastric cancer, the standard operation in Japan is D2 dissection.  However, this procedure has a high postoperative mortality and morbidity, which has led some surgeons to favor D1 dissection plus alpha or D1 dissection plus adjuvant radio-chemotherapy.

For patients with nodal involvement, D4 dissection has been used in Japan, and the efficacy of D4 dissection is now the subject of two randomized trials.

For T4 tumors, gastro-pancreato-splenectomy is considered mandatory.  However, the use of pancreato-splenectomy to yield a complete clearance of the No. 10 and 11 lymph node stations is controversial, because of the high postoperative incidence of pancreatic fistula, anastomotic insufficiency, and abscess.  Though omentectomy is routinely performed, there are no prospective studies confirming its efficacy.  Advanced gastric cancer with serosal invasion less than 2.5 cm in diameter has less risk of peritoneal recurrence, so it may be valuable to undertake a randomized study comparing gastrectomy plus omentectomy to omentum-preserving gastrectomy.

In patients with peritoneal dissemination, intraperitoneal chemo-hyperthermia plus peritonectomy has improved prognoses, and prospective studies should be undertaken to compare this treatment with systemic chemotherapy.  The effect of neoadjuvant chemotherapy on cytoreduction with R0 resection should also be prospectively studied."