Although genetic testing may not be necessary for the diagnosis of some hereditary GI syndromes (i.e., FAP can be diagnosed through a clinical diagnosis of polyposis), it can be beneficial for clinicians and their patients in gaging the severity of the disease (attenuated FAP vs. classic FAP) and the risk for extra-intestinal cancer, and to help identify mutation carriers in the family. Genetic testing is available for each syndrome listed in Table 2 through several commercial laboratories in the US and worldwide. Individuals presenting with DGC should be referred for CDH1 testing and if the results are negative, additional testing options may be considered. Genetic testing for individuals with intestinal type GC may be dependent on other factors in their personal and family history.

The traditional approach to genetic testing typically involves analyzing a single gene or a few related genes, such as in the case of LS, based on cancers observed in families. However, because many of these syndromes have overlapping features and because a good percentage of people (30–50%) presenting for genetic testing will not have a family history significant enough to warrant testing, this approach may not identify all mutation carriers (35). In patients with GC who do not have a family history of cancer or who have a family history that is limited, and for whom additional diagnostic procedures (colonoscopy) have been uninformative, a broader approach through a multigene panel may be beneficial and more economical. Patients should be counseled on these factors prior to testing, especially regarding the limitations of the technology, the possible implications of the test results for their personal health and their family members, the possible out-of-pocket costs, and the insurance implications.

In recent years, EUS has also emerged as an accurate staging tool in GC (46, 47). Assessment of T-stage consists of placing the EUS probe directly over the primary tumor in order to visualize its extent of invasion into the gastric wall (Figure 2). According to a Cochrane review, EUS can distinguish T1 (invasion of lamina propria, muscularis mucosae, or submucosa) from T2 (invasion of muscularis propria) lesions with a sensitivity of 85% and a specificity of 90%. Further, T1 and T2 (superficial) lesions can be differentiated from T3 and T4 (advanced) lesions with a sensitivity of 86% and a specificity of 90% (48).

To perform N-staging, EUS is used to search for nodal involvement in the paracardial, superior gastric, inferior gastric, and pancreaticoleinial regions. Lymph nodes are typically assessed according to their size and appearance, with hypoechoic, round, and well-demarcated lymph nodes typically considered to be positive. The sensitivity and specificity for identifying nodal involvement via EUS is 83 and 67%, respectively (48). While N-staging with EUS is less reliable than T-staging with EUS, it remains an informative modality that can impact treatment plans for patients with gastric adenocarcinoma (47, 48).

In the hands of an experienced endoscopist, EUS is beneficial in the locoregional staging of gastric adenocarcinoma in informing use of perioperative versus adjuvant therapy. Studies correlating EUS staging with postoperative staging indicated that EUS assessment of T- and N-stages was generally accurate and useful in guiding therapy despite some heterogeneity of the data (48).

Multidetector computed tomography (CT) is the preferred imaging modality for the diagnosis, staging, and posttreatment surveillance of gastric adenocarcinoma. Its high-resolution, thin slices, and multiplanar capabilities make it an ideal imaging modality to visualize the primary tumor and survey the chest, abdomen, and pelvis for metastatic disease. In patients with suspected or known gastric masses, the stomach should be distended with oral contrast material or water prior to performing CT. Distention of the stomach helps differentiate a collapsed gastric wall from a tumor. The normal gastric wall thickness is usually less than 5 mm in CT and should have a rugal fold pattern. There is no single CT finding that is sensitive or specific for identifying gastric malignancies. It has been shown that the combination of focal or eccentric wall thickening greater than 1 cm, and intravenous contrast enhancement is highly specific (49). The CT appearance of early and advanced gastric carcinomas reflects their macroscopic appearances as defined by the Paris classification for superficial gastric carcinomas and the Borrmann classification for advanced gastric carcinomas. Consequently, early gastric carcinomas appear as polypoid lesions, focal enhancing mucosal thickening, and ulcers. Advanced GC s may manifest as large polypoid masses, varying degrees of wall thickening, and ulcerated and excavated masses (Figure 3) (50). Loss of a normal rugal fold pattern in conjunction with focal or diffuse wall thickening of the stomach are CT features that help distinguish malignant from inflammatory wall thickening (Figures 3 and 4). Coronal and sagittal reconstructions are very helpful to display gastric anatomy and, in some cases, are the most optimal planes for visualizing the tumor. Mucinous tumors may have low attenuation on CT images and may contain calcification.

An irregular, spiculated serosal margin of the tumor is typically seen in gastric adenocarcinoma. This may represent localized desmoplasia or tumor infiltration into the perigastric fat. However, larger, poorly defined linear soft tissue or nodularity extending into or within the surrounding omental and perigastric ligaments is consistent with tumor spread (Figure 4) (51). The findings of adjacent organ invasion include the loss of a normal fat plane between the stomach and the tumor, and extension of the visible tumor into the adjacent organ. In some cases, there is focal enlargement of the adjacent organ. The addition of coronal and sagittal reconstructions improves the prediction of adjacent organ invasion (52).

The accuracy of CT for staging is 66 to 93% (52). The limitations of CT are its inability to detect subtle serosal invasion, metastatic disease in normal-sized lymph nodes, and small peritoneal deposits that may be below the resolution of CT. Positron emission tomography with 2-deoxy-w-(¹⁸F)fluoro-d-glucose (FDG PET) combined with CT (FDG PET CT) is valuable in some patients for detection of occult disease (53). Accumulation of FDG is typically low in mucinous adenocarcinoma. Combined PET CT has a higher accuracy rate in preoperative staging (68%) than PET alone (47%) or CT alone (53%) (54). Consequently, a combination of diagnostic CT in conjunction with PET or PET CT is essential when PET is obtained.

Diagnostic laparoscopy is strongly recommended as an additional staging tool to overcome some of the previously described limitations of preoperative cross-sectional imaging. In many series, DL was found to upstage 20–25% of patients and can prevent non-therapeutic laparotomies in patients with subradiographic or occult hepatic or peritoneal metastasis (55). The risk of peritoneal disease is much higher in those with linitis plastica and American Joint Committee on Cancer (AJCC) stage T3+, N+ disease; therefore, DL can change the treatment strategy of a patient with suspected stage IV disease. DL can also be utilized to re-assess disease response to systemic therapy, perform peritoneal washings to obtain cytology, or to place a preoperative feeding tube (56, 57).

In addition to performing a DL, analyzing peritoneal cytology for metastatic disease continues to be an area of controversy. Peritoneal cytology that is noted to be positive for tumor cells has been shown to be a poor prognostic marker in the absence of visible tumor spread (C1 disease) (58, 59). Studies have demonstrated that patients with C1 disease have an estimated median survival of only 20 months (57, 58). At our institution, we have a selective approach of using peritoneal cytology in scenarios such as linitis plastica, borderline performance status, or evidence of AJCC T4 disease on imaging.

Patients newly diagnosed with gastric adenocarcinoma should undergo a multidisciplinary stage-dependent treatment strategy that is tailored to the individual patient. This stage-dependent treatment approach should be informed by the following three factors: (1)

The suitability of the patient to undergo curative gastrectomy.

Many variables must be considered prior to undertaking a surgical treatment approach. Evaluation of a patient’s comorbidities and performance status are important preoperative considerations. Managing or minimizing the burden of underlying comorbidities is also important to optimize postgastrectomy recovery and outcomes. While some factors, such as frailty or performance status, may not be overtly changed, other risk factors, including nutritional reserve and electrolyte abnormalities, can be readily corrected. Ongoing investigations suggest that preoperative rehabilitation with outpatient physical therapy prior to surgical treatment may reduce the burden of frailty on operative outcomes (60, 61).

An imperative aspect of surgical planning is obtaining appropriate staging information to guide a stage-dependent treatment approach. This can be achieved through preoperative techniques of EUS, contrast-enhanced cross-sectional imaging, and DL as described in the abovementioned sections. When used in combination, these imaging modalities and techniques can be used to determine reliable staging information and allow for the potential of an R0 (margin negative) resection.

Margin-negative (R0) gastrectomy and adequate lymphadenectomy remain crucial components of operable GC therapy. Because of its additional survival benefit, multimodal therapy (i.e., systemic therapy, with or without radiotherapy) is integrated with surgical therapy. Therefore, most patients with AJCC T2+ operable GC are offered one of the following two treatment sequences: (1) surgery-first, followed by adjuvant chemotherapy and/or chemo radiotherapy or (2) perioperative systemic therapy.

At our institution, we use select patient- and tumor-related factors to inform our decision on the recommended sequence of therapy. Factors that could predict either for residual/recurrent disease after surgery and adjuvant therapy or that could predict for poor patient tolerance or completion of adjuvant therapy after surgery are considered during treatment strategy planning. For example, factors such as proximal GC, presence of linitis plastica, or borderline performance status favor perioperative therapy. Factors that suggest a more aggressive disease that may not be systemically contained well with chemotherapy, such as linitis plastica, similarly favor upfront treatment with chemotherapy as a biologic stress test, before taking the patient to a surgery that will not be beneficial in the long run. In contrast, factors including early stage GC or distal GCs (and their subsequent tumor-related events, including bleeding or obstruction) favor a surgery-first approach.

The benefit of adjuvant treatment has been established as a means to reduce the recurrence risk of GC following surgical resection. In one meta-analysis, use of any form of chemotherapy as adjuvant therapy to surgical resection of GC demonstrated an 18% overall reduction in the risk of cancer recurrence (62). While no single regimen, treatment sequence, or modality has been established as the adjuvant standard of care, the two approaches are generally considered to be standard options: either a postoperative combination of chemotherapy and radiation therapy or a perioperative use of chemotherapy alone.

Total gastrectomy is typically performed in patients with proximal GCs not involving the GEJ (i.e., cancers of the cardia or fundus). The procedure involves removing the entire stomach, GEJ, and omentum, with subsequent intestinal restoration using a Roux-en-Y reconstruction. First, the stomach is carefully dissected and mobilized free of all attachments; then, the pertinent feeding vessels are ligated (at their origin), followed by removal of the stomach. The stomach is transected slightly above the distal esophagus and duodenum, ensuring tumor-free margins, with intraoperative frozen sections confirming normal esophageal and duodenal mucosa (5, 73).

A STG is recommended for patients with mid-body or distal GCs and involves resection of approximately 80% of the stomach leaving only a small portion of the proximal stomach. Negative microscopic resection margins, with recommended resection margins greater than 4 cm from the gross tumor, are necessary to ensure an appropriate oncologic resection (43). It is essential to ligate the gastric arteries at their origins, with the exception of the short gastric vessels; these short gastric arteries should be maintained to prevent gastric remnant ischemia. A Roux-en-Y gastrojejunal reconstruction or a loop gastrojejunostomy are options for intestinal continuity. We prefer a Roux-en-Y gastrojejunal reconstruction over a loop gastrojejunostomy to avoid bile reflux to the gastric remnant (5). A hand-sewn or a stapled anastomosis is considered safe and appropriate for the reconstruction.

Level 1 evidence has shown equivalent overall and disease-free survival outcomes after total versus STG for distal GC (overall 5-year survival rate of 62.4 vs. 65.3% for TG vs. STG, respectively) (74). When compared to TG, STG has been shown to provide more favorable nutritional outcomes and quality-of-life measures (75).

Lymphadenectomy with adequate histopathological nodal evaluation are important components of staging and therapy in surgically treated GC patients (76). The extent of lymphadenectomy has been one of the most controversial areas in GC treatment. This controversy has been heavily debated in both Eastern and Western GC therapeutic studies.

There are two types of classifications of lymphadenectomy for operable GC, which are based on: (1) the topographic location of the lymph node stations and (2) the extent of nodal removal, starting within then extending away from the stomach the Japanese Research Society for Gastric Cancer described the topographic classification of histopathological and nodal evaluations. This classification is based on nodal stations within various parts of the stomach and its arterial supply, and extends to the para-aortic nodal region (77, 78). The second classification is based on the extent of nodal removal and is also known using the “D” nomenclature. There are four types of lymphadenectomy: (1) D0 denotes incomplete and is considered an inadequate nodal dissection, unless palliative gastric resection is considered, (2) D1 is defined as resection of perigastric lymph nodes, (3) D2 is referred to as D1+ resection of nodes surrounding the celiac trunk, along with a distal pancreatectomy and splenectomy, and (4) D3 includes D2+ resection of nodes along the hepatoduodenal ligament, posterior surface of the head of the pancreas, and the root of the mesentery (including the superior mesenteric artery and vein) (78, 79).

Two previous large European trials from the UK and Netherlands showed no survival differences between D1 and D2 lymphadenectomy. Both trials also showed worse operative outcomes after D2 lymphadenectomy (80–82). However, long-term results from the Dutch Gastric Cancer Group trial have confirmed a more favorable survival benefit for D2 nodal dissection. Specifically, the 15-year OS rates were 21 and 29%, respectively, for the D1 and D2 group (P = 0.34). Lower rates of local (12 vs. 22%) and regional recurrence (13 vs. 19%) were also associated with D2 lymph node dissection (82–84). Although there have been prior studies, contemporary European studies are currently evaluating survival outcomes with D2 compared to D1 lymphadenectomy in the setting of improved D2 operative outcomes (85–87).

To address the controversy around extended lymphadenectomy in Asia, JCOG9501 was a Japanese randomized controlled trial conducted to compare D2 dissection alone versus D2 with para-aortic nodal dissection (PAND) for operable T2b–T4 GC (T2b, T3, or T4). Results from JCOG9501 showed that D2 nodal dissection with PAND does not improve overall and relapse-free survival rates compared to D2 dissection alone (5-year OS rates were 70.3 and 69.2%, respectively) (88, 89). Emerging meta-analyses of D1 versus D2 trials have demonstrated that D2 dissection is associated with a significantly higher postoperative risk, but with equivalent long-term survival rates between D1 versus D2 lymphadenectomy. Additional subanalysis by T stage and spleen/pancreas preservation status detected trends for improved survival with D2 lymphadenectomy in T3/T4 patients and in those with spleen/pancreas preservation (90, 91).

Recently, a robust Cochrane review meta-analysis of over 2,500 patients enrolled in eight Asian or European lymphadenectomy (D1, D2, or D3) GC trials showed no difference in survival between D2 and D3 in Asian lymphadenectomy trials. Furthermore, no significant differences were found in overall and disease-free survival in trials of D1 versus D2 lymphadenectomy. However, D2 lymphadenectomy was associated with a significantly improved disease-specific survival rate compared to D1 lymphadenectomy, albeit with two higher operative mortality rates (92, 93). We speculate that these differences are attributable to differences in disease biology, surgical expertise, variations in where GC surgery is performed (especially in the US), and BMI in Eastern versus Western GC patients (81, 94).

In light of the above, most current Western guidelines recommend at least a D1 lymphadenectomy with a total nodal yield of 15 or more lymph nodes. A modified D2 (also known as pancreas and spleen-preserving D2 lymphadenectomy) is also recommended in expert centers. A D2 lymphadenectomy that can be done safely with a pancreas and spleen preserving technique is also considered the current recommended procedure for both total and STG in select centers (95).

Minimally invasive gastrectomy has joined the armamentarium of GC surgery. Several non-randomized and observation studies, using propensity score case-matching, have shown that MIG is associated with reductions in surgical site incision pain, length of hospital stay, use of narcotics, and postgastrectomy complication rates (96, 97). The KLASS 01 trial is a Korean prospective randomized trial of laparoscopic versus open gastrectomy for distal GC which has found that laparoscopic distal gastrectomy was associated with decreased morbidity, specifically relating to wound complications (98).

While current evidence suggests that MIG is beneficial for operable GC, several studies have included patients with smaller tumor sizes or early-stage GC. This important criterion should be noted when comparing MIG to open GC surgery, which was likely performed for larger and more advanced GCs.

Currently, there are ongoing large prospective randomized MIG versus open gastrectomy trials in Asia. One large multi-institutional phase III study was initiated in Japan to assess the OS of laparoscopic assisted distal gastrectomy compared to open distal gastrectomy in patients with early-stage GC (99, 100). At this juncture, the efficacy of MIG for GC in the US remains in its infancy and will require additional larger randomized clinical trials to generate additional traction. Furthermore, the dissemination of MIG for GC among surgeons is yet to be fully assessed.

While surgical gastrectomy has historically been the gold standard for resection of GC, ER is being used with increasing frequency in the treatment of early gastric cancer (EGC), with multiple reports and societies supporting its implementation (101–108). EGC is defined as GC confined to the mucosa or submucosa irrespective of nodal status (109). The exclusion of nodal status is based on the low likelihood of metastasis among T1a lesions (~0.4% for differentiated, ~4% for undifferentiated); however, there has been pressure to include N0 nodal status, as determined by EUS, in this definition (110). The Japanese Gastric Cancer Association currently recommends ER as an absolute indication for patients with differentiated-type T1a adenocarcinoma of ≤2 cm in diameter and without ulceration (101). More liberal indications for investigational treatment with endoscopic submucosal dissection (ESD) have also been put forth by this organization (see Table 4).

Endoscopic resection can be performed via one of the two methods: (1) endoscopic mucosal resection (EMR), where submucosal injection is used to lift the lesion with the surrounding mucosal, which is then removed by snare resection or (2) ESD, where the mucosa of the tissue surrounding the lesion is incised with a high-frequency electric knife and the submucosal layer is then dissected from the muscularis propria under direct visualization. While EMR is an acceptable technique for small lesions (<1.5 cm), ESD is the treatment of choice for most EGC lesions (102). These techniques are complex and require dedicated training to master.

Once ER has been successfully performed, standardized tissue handling and processing protocols, including pinning the specimen and marking borders, are essential to achieve accurate histologic assessment. ER is considered curative when en-bloc resection is achieved with histologic analysis revealing a differentiated-type T1a lesion, negative horizontal and vertical margins, and no evidence of lymphovascular invasion (101). When these standards are not achieved, surgical gastrectomy is recommended. While 10-year follow-up data were recently published showing no difference in all-cause mortality between patients who underwent ER and surgical resection of EGC, there remains concern for a higher rate of recurrence and metachronous cancer in ER patients (111). Despite the need for longer follow-up of these patients to fully understand the impact of ER and further refine inclusion criteria, ER is an organ-sparing, minimally invasive treatment modality that should be offered to appropriately selected patients with EGC.

Local regional failure following resection for GC is problematic, and preoperative or postoperative radiation therapy reduces the risk of recurrence in selected patients. In a series of patients who underwent a second-look laparotomy following initial curative surgery, 29% of patients had a local regional failure and 88% had a component of local regional failure (112). A more recent study of 1,172 patients who underwent R0 resection for GC identified similar patterns of failure (113). Forty-two percent of patients developed a recurrence and 26% of recurrences were local regional-only recurrences. Local recurrence was associated with a proximal tumor site and male gender.

As previously described, the INT-0116 trial is the largest randomized study to date conducted in the US to evaluate the role of postoperative chemoradiation (63, 114). The updated results of the study demonstrated a strong benefit from chemoradiation. With a median follow-up of over 10 years, chemoradiation was associated with significant improvements in OS and relapse-free survival (HR 1.32, 95% CI, 1.1 to 1.60; P < 0.0046 and HR 1.51, 95% CI, 1.25 to 1.83; P < 0.001, respectively). Fifty-two percent of patients who received chemoradiation relapsed, as compared to 76% of patients who received surgery alone. There were similar numbers of distance relapses in both arms, which suggests that improved local regional control with adjuvant chemoradiation drove the survival outcomes. Additionally, there was no difference in long-term treatment-related toxicity, including second malignancies, between the two arms. Subset analysis showed a benefit regardless of T-stage, N-stage, location of the primary, or D resection level; however, diffuse-type histology showed minimal treatment effect.

The Korean ARTIST trial tested the role of adjuvant radiation therapy in patients with D2-resected GC (115, 116). The study randomized 458 patients (stage IB–IV) to either six cycles of capecitabine and cisplatin, or two cycles of capecitabine and cisplatin, followed by chemoradiation then two cycles of capecitabine and cisplatin. At a median follow-up of 7 years, there was no significant difference in disease-free survival (HR 0.74, 95% CI, 0.520–1.050; P = 0.0922) or OS (HR 1.130, 95% CI, 0.775–1.647; P = 0.5272). Local regional failures were reduced from 13 to 7% in the chemoradiation arm. On multivariate analysis, the effect of the addition of radiation therapy on disease-free survival and OS differed by Lauren classification and lymph node ratio. There was also a significant improvement in disease-free survival with the addition of radiation in patients with node-positive disease on subgroup analysis. These findings suggests a benefit of adjuvant chemoradiation in patients with node positive or higher lymph node ratio and intestinal-type GC. The impact of radiation therapy for resectable GC was examined in a large retrospective study from seven US academic institutions (117). Using a propensity score-matched cohort, there was significant OS benefit for patients receiving chemoradiation as compared to chemotherapy alone (46.7 vs. 20.9 months; P < 0.001). Patients with N1 disease and those with lymphovascular invasion benefited the most from radiation therapy.

Based on the INT-0116 trial, postoperative chemoradiation remains the standard of care in surgically treated GC patients with T3/T4 or node-positive disease who have not received neoadjuvant therapy. The greatest benefit for adjuvant chemoradiation is with node-positive disease and intestinal-type histology. Building on some of the limitations of the INT-0116 trial, future studies will attempt to better define the role of radiation therapy for GC.

Several historical studies have shown the clinical benefits of combined chemoradiation for unresectable or partially resected GC (125, 126). Radiation therapy can also be effective for palliation of symptoms, including pain, bleeding, and dysphagia. A study of 37 patients receiving palliative radiation therapy for GC found that the majority of patients experienced symptom control or improvement following treatment, which persisted throughout their remaining life (127). The combination of palliative radiation with chemotherapy should be considered.

Given that up to 30% of patients present with locally advanced or stage IV GC, surgeons at times are asked to render an opinion about whether or not to offer palliative GC surgery (128, 129). The overarching goals of palliative GC surgery are to improve a patient’s quality of life and allow him or her to continue systemic chemo- or targeted therapy. Patients with advanced disease are typically at a higher risk for malnutrition from possible dysphagia or gastric outlet obstruction. These palliative procedures include gastrectomy or GI bypass, and are often reserved for palliation of ongoing (or pending) bleeding, perforation, or obstruction.

Secondary data analysis from The Dutch Gastric Cancer Trial investigated the impact of palliative STG versus systemic therapy alone on improvement in OS rates (83). Of the 285 patients in The Dutch Gastric Cancer Trial who were not amenable to curative resection, 129 patients did not undergo resection and had either a gastroenterostomy or an exploratory laparotomy alone, while 156 patients underwent a palliative resection. Patients in the palliative resection cohort (>70 years of age with limited metastasis to one other site) had a nearly 3-month survival benefit over patients who underwent a gastroenterostomy or exploratory laparotomy alone at the time of the initial DL for local or metastatic GC. There was, however, a higher morbidity (38 vs. 12%) and longer length of stay (15 vs. 10 days) in the palliative resection cohort, which is likely attributable to the greater extent of surgical resection.

More recent data from Asia has shown that a palliative gastrectomy leads to worse outcomes. In a prospective phase-III trial, gastrectomy followed by chemotherapy did not show any survival benefit compared with chemotherapy alone in advanced GC with a single non-curable factor. Therefore, gastrectomy could not be justified for treatment of patients with these tumors (130). The decision to undergo palliative GC surgery should be informed by the patients’ goals of care, the extent of their disease progression (and non-curable factors), their performance status, and input from the medical and radiation oncology teams.

In the West, most patients diagnosed with GC present with advanced stage disease and carry an overall 5-year survival rate of approximately 20–30% (3). Results from the US National Cancer Database indicate that up to 65% of patients with GC presented with advanced disease (T3/T4), and 85% of these patients fostered nodal metastases at the time of diagnosis (5). Patients who underwent a curative gastrectomy had a median survival rate of 24 months (5-year survival, 20–30%). However, those patients who underwent palliative versus no GC therapy had a median survival rate of 8 versus 5.4 months, respectively (5).

To inform the prognosis of surgically treated GC patients and their clinicians, externally validated patient-centered nomograms are now electronically available to estimate the survival of a patient with GC after a complete (R0) surgical resection. These nomograms are based on the patients’ age, sex, tumor location, tumor size, negative/positive lymph node status, and pathologic features/classification of the tumor(s) (131, 132).

Mortality rates after TG are noted to be very low (<2%), largely driven by a hospital’s annual surgical volume. A hospital with a higher annual surgical volume (at least 11 gastrectomies per year) was shown to have lower in-hospital mortality by approximately 3–6% when compared with lower volume centers (74, 133). With this understanding and improved surgical techniques, there has been a decline in mortality rates. Declines from 4.5 to 2.3% and from 6.9 to 4.5% have been observed in 30- and 90-day mortality rates, respectively (134, 135).

While operative mortality rates are low after TG, operative morbidity is noticeably higher, with complication rates reported to approach 30–40% (136). These complications can range from systemic (pulmonary embolism, pneumonia, myocardial infarction, deep vein thrombosis) to technically based postsurgical issues (anastomotic leak, anastomotic stricture). If these technical complications do occur, hospital readmission is almost always necessary, requiring drainage of the leaked collection, IV antibiotics, and nutritional support with either total parenteral nutrition or a feeding jejunostomy (134, 137).

Readmission after gastrectomy has been evaluated in many recent studies and estimated readmission rates range from 7 to 20%, with GI complications identified as the most common cause. It was noted that within this subset of patients, those with a higher preoperative nutritional risk and postoperative infections were found to be at the highest risk of complications requiring readmission (34, 137).

The National Comprehensive Cancer Network recommends that post-GC resection patients should be monitored every 3 to 6 months within the first 2 years of their operation. In addition, it is recommend that their follow-up should include a routine history and physical, upper GI endoscopy (for non-TG patients), cross-sectional CT imaging, and laboratory values, including a CBC, BMP, vitamin B₁₂, vitamin D, liver function tests, prealbumin, and iron levels. After 2 years of screening with no signs of recurrence, the routine surveillance intervals may be extended to every 6–12 months. In patients with a genetic predisposition, one should make note of secondary primary malignancies that may arise.