Advancing gastric cancer care Insights into staging, preoperative treatment, and surgical techniques

Gastric cancer is among the most common malignancies worldwide and remains a leading cause of cancer-related mortality. In the Netherlands, approximately 1,000 patients are diagnosed each year, of whom around 400 are eligible for potentially curative treatment. Managing gastric cancer involves a series of decisions that must balance oncological outcomes with patient resilience, biological variability, safety and practical feasibility. This thesis set out to examine some of the most pressing questions in that continuum: how to stage disease more accurately, how to apply systemic therapy in older patients, and how to refine surgical techniques. In doing so, it highlights the enduring value of staging laparoscopy, but also its potential limitations, calling attention to the need for more sensitive tools, such as fluorescence-guided imaging. It examines real-world treatment allocation in older patients, revealing both the rationale and the potential risks of current clinical decision-making. It challenges the routine practice of omentectomy, arguing for evidence rather than tradition, and demonstrated that while minimally invasive subtotal gastrectomy has matured into a safe and effective approach, minimally invasive total gastrectomy may still require caution and further refinement. Taken together, this thesis offers a contribution to modern gastric cancer care: grounded in clinical reality, informed by evidence, and open to innovations.