Resection margin strategy and surgical practices in gastric cancer surgery: the European REMARCS (Resection MARgin for cancer of the stomach) survey

Background: The appropriate distance to the resection margin in gastric cancer surgery remains debated and is often based on limited or outdated evidence. With evolving perioperative strategies, this study aimed to assess current resection margin practices across European centers. Method: A web-based survey consisting of 45 questions was developed by a panel of 13 international experts including surgeons, pathologists, and oncologists. It covered center demographics, resection margin strategies, and postoperative care. Distributed from January to June 2022, the survey targeted Upper Gastrointestinal (UGI) surgeons via mailing lists and social media platforms of various UGI and visceral surgical societies. Results: Responses were received from 172 surgeons at 154 centers across 19 countries. Of these respondents, 54% were from university hospitals, 39% from general hospitals, and 8% from private hospitals. Surgeons had on average 20.8 (SD ± 9.4) years of surgical experience and managed an average of 23.2 (SD ± 21.8) cases per year. For intestinal-type tumors, 77% of surgeons reported using a proximal margin of at least 5 cm, with 64% selecting exactly 5 cm. For diffuse type gastric cancer, 63% of surgeons recommended a minimum of 8 cm. There was no difference with respect to the recommended distance to the resection margin between low, medium and high-volume surgeons or between university, general and private hospitals. Routine macroscopic inspection of the specimen was performed by 64% of respondents. Conclusion: This survey reveals a heterogeneity in applying the current guidelines for resection margin lengths across European centers. Further prospective studies are essential to evaluate the feasibility and oncological safety of future organ-sparing strategies.