The worldwide geographical distribution of gastric carcinoma is variable. It is more common in Japan and other far eastern countries. It is the second worldwide leading cause of cancer death. In the west the incidence of distal gastric cancers has been decreasing for decades; however, cancer of esophagogastric junction and cardia is increasing. Histologically, gastric cancer can be divided into two types, intestinal type and diffuse type, according to Lauren classification. The intestinal type is more common in high-incidence countries like Japan, more likely found in the distal stomach and associated with Helicobacter pylori. The diffuse type is more common in young patients, in hereditary gastric cancer, in proximal locations, and is associated with a worse prognosis. Distal subtotal gastrectomy (50% to 75%) is the recommended surgical treatment for distal cancer of the stomach with fewer complications, shorter hospital stays, better quality of life, and no difference in overall survival compared to total gastrectomy.

The east and west remain sharply divided regarding the extent of lymph node dissection (D1, D2) for gastric adenocarcinoma. The general rules of the Japanese Research Society for Gastric Cancer divide the anatomic perigastric lymph nodes into 16 groups (Table 17.1). The anatomic location of the perigastric and extragastric lymph nodes are shown in Figure 17.1. The nodal groups are further subdivided into three regions (N1, N2, and N3), and their designations vary depending on whether the gastric cancer is located in the proximal, middle, or distal third of the stomach. The N1 and N2 lymph node groups of the distal third of the stomach are illustrated in Table 17.2. Removing only the N1 lymph nodes constitutes a D1 gastric resection while the more extended D2 resection requires the removal of both N1 and N2 lymph node groups. The current pathologic N stage is defined by the number of metastatic lymph nodes and not their anatomic location relative to the primary tumor. The American Joint Committee on Cancer recommends that retrieval of at least 15 lymph nodes is necessary to accurately stage a gastric cancer.