Western adjuvant trials following resection of gastric cancer have yet to demonstrate a reproducible survival advantage for treated patients. However, Japanese trials have suggested that beneficial treatments can be developed. Surgical adjuvant treatment must be based on an understanding of the routes of metastatic dissemination of stomach cancer, be designed to effectively reach each of the sites of metastasis, and offer a reasonable potential for complete destruction of residual tumor cells. The author discusses the status of Western studies and the possibility of adapting the promising new leads from Japan to Western patients.