Overtime, surgery remained the main choice to cure locally advanced GC patients; since 1980, Eastern surgeons have adopted a D2 lymphadenectomy as the oncologically correct surgical approach [7;8].
Since then, slowly all the major European centers have adopted this surgical behavior of treatment except in the USA where, NCCN guidelines too, are currently recommending a D1+ or a modified D2 lymph node dissection for the management of a locally advanced disease .
The extent of systematic lymphadenectomy was defined as the Japanese guidelines (10) according to the type of gastrectomy conducted. In total gastrectomy D1 was defined when nodes No. 1–7 were retrieved; D2 was defined when nodes of D1 dissection plus nodes No. 8a, 9, 11p, 11d, 12a were dissected.
In Distal gastrectomy D1 was defined when nodes No. 1, 3, 4sb, 4d, 5, 6, 7 were retrieved and D2 was defined when nodes of D1 dissection plus nodes No. 8a, 9, 11p, 12a were dissected.
During the last two decades, centers have improved their learning curve for D2 lymphadenectomy. This has caused an increasing of the total number of the removed lymphonodes, a better staging of the tumor and a survival benefit.
In selected patients, oncological surgeons are now recommending an extended D3 lymphadenectomy that includes posterior lymphondal stations; this approach seems to convey survival advantages in particular in locally advanced neoplasia with serosa or/and lymphondal involvement, diffuse and proximal tumors, as the Italian Group of Gastric Cancer Research Group demonstrated .
Without an adequate screening program, similar to the one adopted in the East, patients in our region typically show at the diagnosis symptoms related to the disease and they are often affected by an advanced disease that could not benefit by an endoscopic treatment as opposed to what it happening in a high percentage of the Eastern patients.
Thus, we usually approach these patients in a multimodal manner integrating neoadjuvant treatments to surgery accompanied by an extended lymphadenectomy in selected cases.
Bencivenga M. recently demonstrated that a D3 lymphadenectomy could be addressed in T3 patients improving in a statistically way survival outcomes. This could be explained by the fact that the costs of a super-extended lymphadenectomy exceed the benefits in less advanced cancers as pT2-N0 stages but also in pT4b when cancer cells have already invaded the surrounding organs and a more aggressive nodal dissection is not sufficient to obtain a local control of the disease .
These Italian findings are confirmed by JOCG trial that also shows that a D3 lymphadenectomy might be associated with better survival in patients with tumors with subserosal invasion and not in early or more advanced disease .
In a recent paper Rovielo et al.  concluded D3 lymphadenectomy could be further explored in specialized centers for curative surgery of advanced GC, providing that an acceptable morbidity and no increase in mortality can be offered.
Considering our center, D3 lymphadenectomy has increased over the years in particular in the last five years period and in T3/T4a patients, these changes can be see also in others Western and Eastern surgical centers. Although a longer follow-up is needed, D3 seems to convey an exciting 5y-OS in patients who underwent an extended lymphadenectomy compared to D1/D2 patients (90% vs 48% vs 51%).
No major complications were noted in patients who underwent D3 surgery. Certainly we know that a D3 dissection is indisputably a more technically complicated and time consuming surgical procedure compared to D1 or D2. As a matter of fact, it requires dissection around large important vessels that are located in deep retroperitoneal space causing a major surgical stress and injury. Available data suggest that D3 can be safely performed; however data also show that high volume specialized center s adequately trained surgeons are essential .
Our study also shows an increasing use of minimal-invasive approach in the time period 2014-2018 as compared to the previous ones; the explanation might be link to an improved learning curve and to the introduction of robotic approach that makes easier and more feasible sovrapancreatic lymphadenectomy.
According to Italian and Japanese guidelines we approach only early disease in a mini invasive way. Laparoscopic surgery can be considered as an option to treat exclusively cStage I cancer that are resectable by distal gastrectomy as it is well underlined in the last published Japanese guidelines . As for more advanced cancer, there is currently no scientific evidence to address them with laparoscopic approach, since randomized trials to look at safety and long-term outcome are currently ongoing (JLSSG0901 AND KLASS02) and since their data are not clearly published.