Maintenance of resection margins in gastrectomy for cancer: simple in procedure, influential in survival-current status and literature review on optimal lengths and positive margins.

Abstract

Purpose: The prognostic significance of the proximal margin length (PML) and positive resection margins (PRMs) in gastric cancer (GC) remains controversial. International guidelines for PML differ widely, reflecting a lack of consensus on optimal surgical margins. While positive RMs are associated with poor survival, their impact varies according to the tumor stage and nodal involvement.

Methods: A comprehensive review of the relevant literature was conducted to evaluate guideline recommendations on PML, factors influencing pathological negativity, the prognostic impact of PMLs and PRMs, and treatment strategies for cases with PRMs, including incidence, additional resection, and adjuvant therapy.

Results: A tumor-specific approach is essential for determining the optimal PML. When achieving the recommended PML is challenging, an intraoperative frozen section (IFS) analysis helps to ensure negative margins while minimizing unnecessary resection. PRMs are associated with poor survival, particularly in early stage GC, whereas their impact in advanced-stage GC is often overshadowed by systemic disease progression. Additional resection may benefit the selection of patients with early stage GC; however, its role in advanced-stage GC remains uncertain.

Conclusion: Further research should refine surgical decision-making, optimize PML thresholds, and evaluate the role of multimodal treatment strategies, including molecular profiling and intraoperative imaging techniques. Effective management of PRMs requires balancing oncological safety with functional preservation.