BACKGROUND: National trends indicate an ongoing decline in gastric adenocarcinoma due presumably to a decreasing prevalence of H. pylori infection. Nonetheless, surgical outcomes continue to include high morbidity and mortality rates related to the advanced stage of disease encountered. HYPOTHESIS: Recent immigration patterns are responsible for a leveling off of the declining incidence of gastric cancer caused by H. pylori infection. Furthermore, advances in preoperative tumor staging and nonoperative palliation now allow better patient selection for operation and lower perioperative morbidity and mortality rates. DESIGN AND SETTING: Retrospective review of a consecutive case series at a public teaching hospital located in an area of high immigration. PATIENTS AND METHODS: All patients presenting from 1995 through 2004 with gastric adenocarcinoma. For time comparison purposes patients were divided into Early (1995-1999) and Recent (2000-2004) Periods. RESULTS: A total of 260 patients were treated over 10 years of whom 137(53%) underwent operation (Table). The operation rate decreased from the Early Period to the Recent Period as fewer advanced stage (M1) patients underwent exploratory laparotomy and were palliated by nonoperative means such as endoscopic stenting for obstruction and argon beam photocoagulation for bleeding. Of the 4 total perioperative deaths, 2 followed 11 nontherapeutic laparotomies (18% mortality), while the only 2 additional deaths followed 120 curative or palliative laparotomies (2% mortality) (p = 0.046). CONCLUSIONS: 1) In an area of high immigration there has been no decline in gastric adenocarcinoma over the past decade; 2) The H. pylori infection rate remains very high; 3) The historic male predominance has virtually disappeared; 4) Improvements in preoperative staging and nonoperative palliation have allowed a substantial reduction in the nontherapeutic laparotomy rate; 5) The marked decrease in overall perioperative mortality is primarily due to obviation of the excessive mortality attending nontherapeutic laparotomy.