The landscape of gastro-oesophageal adenocarcinoma (GEA) management has undergone substantial transformation over the past decade owing to shifts in epidemiology, evolving treatment paradigms and the integration of new therapeutic strategies. The global burden of GEA continues to rise, with differing patterns observed in Asia compared with Western countries. Important insights gleaned from recent high-profile clinical trials - both successful and negative - have considerably reshaped perioperative treatment strategies, redefining the roles of chemotherapy, radiotherapy, immune checkpoint inhibitors and targeted therapies. Although still investigational, organ-preserving approaches and circulating tumour DNA (ctDNA)-based patient stratification are shaping the direction of future GEA management. By consolidating these developments, this Review aims to provide clinicians and researchers with a comprehensive and structured guide to the state-of-the-art perioperative management of GEA, emphasizing the underlying biology, clinical implications and future directions.