Site	Grade I recommendations	Grade II recommendations	Grade III recommendations
Local recurrence	To treat as recurrent/metastatic gastric cancer or encourage participation in clinical trials	Surgery combined with drug therapya (Evidence 2B) Radiotherapy combined with drug therapyb (Evidence 2A)
Recurrence at the remnant stomach or anastomotic region c	ESD Total remnant gastrectomy + lymph node dissection ± combined organ resection	Palliative surgery	Endoscopic stent placement Bypass surgery Jejunal nutrition tube placement

Abbreviations: ESD, endoscopic submucosal dissection.

Notes

^a Local recurrence is defined as the re‐occurrence of tumor at the resection site after radical gastrectomy and regional lymph node metastasis. Most studies regarding local recurrence of gastric cancer are retrospective and single‐institution studies, and there is a lack of large‐scale prospective studies. Findings from one study suggested that surgery may be an important prognostic factor for survival as the mOS of patients who underwent surgery was significantly better than unresectable patients (25.8 vs. 6.0 months) [224]. Although some local recurrent diseases can be surgically treated, the indications for surgical intervention must be strictly followed.

^b For patients with local recurrence who did not receive any previous radiotherapy, concurrent chemoradiotherapy has been associated with survival benefits. A retrospective study showed that concurrent chemoradiotherapy in gastric cancer patients with local recurrence at the anastomic site or regional lymph nodes was associated with an ORR of 61.9% and mOS of 35 months [225]. Compared with chemotherapy alone, concurrent chemoradiotherapy resulted in a higher ORR (87.8% vs. 63.0%, P = 0.01), longer mOS (13.4 vs. 5.4 months, P = 0.06), and better control of symptoms such as pain, bleeding, and obstruction (85.0% vs. 55.9%, P = 0.06) [226, 227].

^c Recurrence in the remnant stomach after radical gastrectomy usually occurs within 10 years after surgery [228], and the possibility of resection is high. ESD can be performed for early gastric remnant recurrence without lymph node metastasis. The en bloc resection rate and complete resection rate were reported to be 91%‐100% and 74%‐94% [229]. The resection of advanced‐stage recurrent remnant gastric cancer should include total gastrectomy, lymph node dissection, and combined resection of invaded organs. The regional lymph nodes that were not resected at initial surgery should be resected. Of note, the metastasis rate of the jejunal mesentery and root lymph nodes near the anastomotic stoma of Billroth II anastomosis is high and should be included in the field for lymph node dissection [230]. For patients with unresectable tumors who are symptomatic, palliative resection, bypass surgery, stent implantation, or jejunal nutrition tube implantation can be considered.