Difficulties and challenges of laparoscopic radical gastrectomy after neoadjuvant therapy_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

WUQIKUN·Hairula ¹ , ZHANG Wei ² , ZHANG Weihan ¹ , CHEN Xiaolong ¹ , HU Jiankun ¹ ,  YANG Kun ¹

1. Gastric Cancer Center, Gastric Cancer Research Laboratory, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
2. Department of Gastrointestinal Surgery, Fushun County People’s Hospital, Fushun, Sichuan 643200, P. R. China;

Corresponding?author：

YANG Kun, Email: yangkun068@163.com

Keywords：

gastric cancer; neoadjuvant therapy; laparoscopic surgery; lymph node dissection; digestive tract reconstruction; perioperative management

DOI：

10.7507/1007-9424.202604077

Video：

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Neoadjuvant therapy has become a key component of perioperative management for locally advanced gastric cancer. By inducing tumor downstaging and downgrading, it increases the likelihood of R0 resection, facilitates early control of micrometastatic disease, and informs subsequent adjuvant treatment strategies. However, treatment-induced changes, including tissue edema, adhesions, fibrosis, and disruption of anatomical planes, increase the technical complexity of laparoscopic radical gastrectomy and pose greater challenges to lymph node dissection, margin assessment, gastrointestinal reconstruction, and perioperative management. In the era of neoadjuvant therapy, the goal of gastric cancer surgery has evolved from achieving radical resection alone to balancing oncological efficacy with surgical safety. Standardized laparoscopic techniques, optimized perioperative care, and multidisciplinary management are essential to improve surgical quality and reduce perioperative risks. Future efforts should focus on refining patient selection, optimizing preoperative evaluation and surgical decision-making, and advancing perioperative strategies, thereby promoting a more precise and individualized approach to minimally invasive surgery for gastric cancer.

Citation： WUQIKUN·Hairula, ZHANG Wei, ZHANG Weihan, CHEN Xiaolong, HU Jiankun, YANG Kun. Difficulties and challenges of laparoscopic radical gastrectomy after neoadjuvant therapy. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2026, 33(5): 610-616. doi: 10.7507/1007-9424.202604077 Copy

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3.	Yang H, Zhang WH, Ge R, et al. Application of gross tissue response system in gastric cancer after neoadjuvant chemotherapy: a primary report of a prospective cohort study. Front Oncol, 2021, 11: 585006. doi: 10.3389/fonc.2021.585006.
4.	Bracale U, Corcione F, Pignata G, et al. Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: a multi-institutional propensity score-matched study. J Surg Oncol, 2021, 124(8): 1338-1346.
5.	Japanese Gastric Cancer Association. Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer, 2023, 26(1): 1-25.
6.	Wang FH, Zhang XT, Tang L, et al. The Chinese Society of Clinical Oncology (CSCO): clinical guidelines for the diagnosis and treatment of gastric cancer, 2023. Cancer Commun (Lond), 2024, 44(1): 127-172.
7.	Wu ZM, Teng RY, Shen JG, et al. Reduced lymph node harvest after neoadjuvant chemotherapy in gastric cancer. J Int Med Res, 2011, 39(6): 2086-2095.
8.	Yu JH, Wang ZZ, Fan YC, et al. Comparison of neoadjuvant chemotherapy followed by surgery vs. surgery alone for locally advanced gastric cancer: a meta-analysis. Chin Med J (Engl), 2021, 134(14): 1669-1680.
9.	Shannon AB, Straker RJ 3rd, Keele L, et al. Lymph node evaluation after neoadjuvant chemotherapy for patients with gastric cancer. Ann Surg Oncol, 2022, 29(2): 1242-1253.
10.	van der Wielen N, Daams F, Rosati R, et al. Three-year survival and distribution of lymph node metastases in gastric cancer following neoadjuvant chemotherapy: results from a European randomized clinical trial. Surg Endosc, 2023, 37(9): 7317-7324.
11.	Haskins IN, Kroh MD, Amdur RL, et al. The effect of neoadjuvant chemoradiation on anastomotic leak and additional 30-day morbidity and mortality in patients undergoing total gastrectomy for gastric cancer. J Gastrointest Surg, 2017, 21(10): 1577-1583.
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13.	Liao XL, Liang XW, Pang HY, et al. Safety and efficacy of laparoscopic versus open gastrectomy in patients with advanced gastric cancer following neoadjuvant chemotherapy: a meta-analysis. Front Oncol, 2021, 11: 704244. doi: 10.3389/fonc.2021.704244.
14.	Yang H, Zhang WH, Liu K, et al. Application of clockwise modularized laparoscopic lymphadenectomy in the suprapancreatic area, a propensity score matching study and comparison with open gastrectomy. Surg Endosc, 2021, 35(3): 1465-1475.
15.	熊方麗, 賀育華, 蔣曉蓮. 加速康復外科模式下胃癌患者術后早期下床活動現狀及影響因素分析. 中國普外基礎與臨床雜志, 2022, 29(12): 1618-1622.
16.	陳使功, 俞鴻瑋, 車生富, 等. 胃癌營養不良影響因素以及對臨床的影響及其治療策略研究進展. 中國普外基礎與臨床雜志, 2025, 32(3): 381-388.
17.	Mortensen K, Nilsson M, Slim K, et al. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS^?) Society recommendations. Br J Surg, 2014, 101(10): 1209-1229.
18.	中國抗癌協會胃癌專業委員會機器人手術臨床研究協作組. 胃癌患者新輔助治療圍手術期加速康復外科管理熱點問題專家共識 (2026版). 中華胃腸外科雜志, 2026, 29(3): 243-257.
19.	Mueller TC, Schirren R, Kehl V, et al. Parenteral nutrition during neoadjuvant chemotherapy for patients with non-metastatic gastric or esophago-gastric cancer to reduce postoperative morbidity (PERCOG): study protocol for a randomized controlled trial. Trials, 2017, 18(1): 621. doi: 10.1186/s13063-017-2388-3.
20.	Weimann A, Bezmarevic M, Braga M, et al. ESPEN guideline on clinical nutrition in surgery - update 2025. Clin Nutr, 2025, 53: 222-261.
21.	Li Q, Chen C, Wang X. Perioperative nutritional interventions for gastric cancer patients: a meta-analysis of surgical outcomes. Front Nutr, 2025, 12: 1680833. doi: 10.3389/fnut.2025.1680833.
22.	He FJ, Wang MJ, Yang K, et al. Effects of preoperative oral nutritional supplements on improving postoperative early enteral feeding intolerance and short-term prognosis for gastric cancer: a prospective, single-center, single-blind, randomized controlled trial. Nutrients, 2022, 14(7): 1472. doi: 10.3390/nu14071472.
23.	史明輝, 吳舟橋, 董軍, 等. 新輔助免疫治療時代胃癌圍手術期安全的新挑戰: 免疫相關不良事件與術后并發癥的鑒別. 中華胃腸外科雜志, 2026, 29(2): 155-162.
24.	Haanen J, Obeid M, Spain L, et al. Management of toxicities from immunotherapy: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol, 2022, 33(12): 1217-1238.
25.	Schneider BJ, Naidoo J, Santomasso BD, et al. Management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: ASCO guideline update. J Clin Oncol, 2021, 39(36): 4073-4126.
26.	Brahmer JR, Abu-Sbeih H, Ascierto PA, et al. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune checkpoint inhibitor-related adverse events. J Immunother Cancer, 2021, 9(6): e002435. doi: 10.1136/jitc-2021-002435.
27.	Wang J, Tong T, Zhang G, et al. Evaluation of neoadjuvant immunotherapy in resectable gastric/gastroesophageal junction tumors: a meta-analysis and systematic review. Front Immunol, 2024, 15: 1339757. doi: 10.3389/fimmu.2024.1339757.
28.	van der Wielen N, Straatman J, Daams F, et al. Open versus minimally invasive total gastrectomy after neoadjuvant chemotherapy: results of a European randomized trial. Gastric Cancer, 2021, 24(1): 258-271.

1. 赫捷, 陳萬青, 李兆申, 等. 中國胃癌篩查與早診早治指南 (2022, 北京). 中華消化外科雜志, 2022, 21(7): 827-851.
2. 李茁鈺, 劉凱, 張維漢, 等. 全球及中國胃癌的流行病學特點及趨勢: 2018–2022《全球癌癥統計報告》解讀. 中國普外基礎與臨床雜志, 2024, 31(10): 1236-1245.
3. Yang H, Zhang WH, Ge R, et al. Application of gross tissue response system in gastric cancer after neoadjuvant chemotherapy: a primary report of a prospective cohort study. Front Oncol, 2021, 11: 585006. doi: 10.3389/fonc.2021.585006.
4. Bracale U, Corcione F, Pignata G, et al. Impact of neoadjuvant therapy followed by laparoscopic radical gastrectomy with D2 lymph node dissection in Western population: a multi-institutional propensity score-matched study. J Surg Oncol, 2021, 124(8): 1338-1346.
5. Japanese Gastric Cancer Association. Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer, 2023, 26(1): 1-25.
6. Wang FH, Zhang XT, Tang L, et al. The Chinese Society of Clinical Oncology (CSCO): clinical guidelines for the diagnosis and treatment of gastric cancer, 2023. Cancer Commun (Lond), 2024, 44(1): 127-172.
7. Wu ZM, Teng RY, Shen JG, et al. Reduced lymph node harvest after neoadjuvant chemotherapy in gastric cancer. J Int Med Res, 2011, 39(6): 2086-2095.
8. Yu JH, Wang ZZ, Fan YC, et al. Comparison of neoadjuvant chemotherapy followed by surgery vs. surgery alone for locally advanced gastric cancer: a meta-analysis. Chin Med J (Engl), 2021, 134(14): 1669-1680.
9. Shannon AB, Straker RJ 3rd, Keele L, et al. Lymph node evaluation after neoadjuvant chemotherapy for patients with gastric cancer. Ann Surg Oncol, 2022, 29(2): 1242-1253.
10. van der Wielen N, Daams F, Rosati R, et al. Three-year survival and distribution of lymph node metastases in gastric cancer following neoadjuvant chemotherapy: results from a European randomized clinical trial. Surg Endosc, 2023, 37(9): 7317-7324.
11. Haskins IN, Kroh MD, Amdur RL, et al. The effect of neoadjuvant chemoradiation on anastomotic leak and additional 30-day morbidity and mortality in patients undergoing total gastrectomy for gastric cancer. J Gastrointest Surg, 2017, 21(10): 1577-1583.
12. 劉凱, 楊玉賞, 楊昆, 等. 食管胃結合部腺癌外科治療中國專家共識 (2024年版). 消化腫瘤雜志 (電子版), 2024, 16(2): 133-152.
13. Liao XL, Liang XW, Pang HY, et al. Safety and efficacy of laparoscopic versus open gastrectomy in patients with advanced gastric cancer following neoadjuvant chemotherapy: a meta-analysis. Front Oncol, 2021, 11: 704244. doi: 10.3389/fonc.2021.704244.
14. Yang H, Zhang WH, Liu K, et al. Application of clockwise modularized laparoscopic lymphadenectomy in the suprapancreatic area, a propensity score matching study and comparison with open gastrectomy. Surg Endosc, 2021, 35(3): 1465-1475.
15. 熊方麗, 賀育華, 蔣曉蓮. 加速康復外科模式下胃癌患者術后早期下床活動現狀及影響因素分析. 中國普外基礎與臨床雜志, 2022, 29(12): 1618-1622.
16. 陳使功, 俞鴻瑋, 車生富, 等. 胃癌營養不良影響因素以及對臨床的影響及其治療策略研究進展. 中國普外基礎與臨床雜志, 2025, 32(3): 381-388.
17. Mortensen K, Nilsson M, Slim K, et al. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS^?) Society recommendations. Br J Surg, 2014, 101(10): 1209-1229.
18. 中國抗癌協會胃癌專業委員會機器人手術臨床研究協作組. 胃癌患者新輔助治療圍手術期加速康復外科管理熱點問題專家共識 (2026版). 中華胃腸外科雜志, 2026, 29(3): 243-257.
19. Mueller TC, Schirren R, Kehl V, et al. Parenteral nutrition during neoadjuvant chemotherapy for patients with non-metastatic gastric or esophago-gastric cancer to reduce postoperative morbidity (PERCOG): study protocol for a randomized controlled trial. Trials, 2017, 18(1): 621. doi: 10.1186/s13063-017-2388-3.
20. Weimann A, Bezmarevic M, Braga M, et al. ESPEN guideline on clinical nutrition in surgery - update 2025. Clin Nutr, 2025, 53: 222-261.
21. Li Q, Chen C, Wang X. Perioperative nutritional interventions for gastric cancer patients: a meta-analysis of surgical outcomes. Front Nutr, 2025, 12: 1680833. doi: 10.3389/fnut.2025.1680833.
22. He FJ, Wang MJ, Yang K, et al. Effects of preoperative oral nutritional supplements on improving postoperative early enteral feeding intolerance and short-term prognosis for gastric cancer: a prospective, single-center, single-blind, randomized controlled trial. Nutrients, 2022, 14(7): 1472. doi: 10.3390/nu14071472.
23. 史明輝, 吳舟橋, 董軍, 等. 新輔助免疫治療時代胃癌圍手術期安全的新挑戰: 免疫相關不良事件與術后并發癥的鑒別. 中華胃腸外科雜志, 2026, 29(2): 155-162.
24. Haanen J, Obeid M, Spain L, et al. Management of toxicities from immunotherapy: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol, 2022, 33(12): 1217-1238.
25. Schneider BJ, Naidoo J, Santomasso BD, et al. Management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: ASCO guideline update. J Clin Oncol, 2021, 39(36): 4073-4126.
26. Brahmer JR, Abu-Sbeih H, Ascierto PA, et al. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immune checkpoint inhibitor-related adverse events. J Immunother Cancer, 2021, 9(6): e002435. doi: 10.1136/jitc-2021-002435.
27. Wang J, Tong T, Zhang G, et al. Evaluation of neoadjuvant immunotherapy in resectable gastric/gastroesophageal junction tumors: a meta-analysis and systematic review. Front Immunol, 2024, 15: 1339757. doi: 10.3389/fimmu.2024.1339757.
28. van der Wielen N, Straatman J, Daams F, et al. Open versus minimally invasive total gastrectomy after neoadjuvant chemotherapy: results of a European randomized trial. Gastric Cancer, 2021, 24(1): 258-271.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Difficulties and challenges of laparoscopic radical gastrectomy after neoadjuvant therapy

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