Brief Article Open Access
Copyright ©2010 Baishideng. All rights reserved.
World J Gastroenterol. Jan 7, 2010; 16(1): 98-103
Published online Jan 7, 2010. doi: 10.3748/wjg.v16.i1.98
Reoperation for early postoperative complications after gastric cancer surgery in a Chinese hospital
Birendra Kumar Sah, Ming-Min Chen, Min Yan, Zheng-Gang Zhu, Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai Institute of Digestive Surgery, Shanghai 200025, China
Author contributions: Sah BK designed the study, collected the data, and drafted the manuscript; Chen MM and Yan M assisted in interpretation of data and assisted in drafting the manuscript; Zhu ZG participated in the design and final approval of the study and critical revision of the article.
Correspondence to: Zheng-Gang Zhu, Professor, Department of General Surgery, Ruijin Hospital, 197 Ruijin Er Road, Shanghai 200025, China.
Telephone: +86-21-64370045 Fax: +86-21-53821171
Received: October 24, 2009
Revised: November 21, 2009
Accepted: November 28, 2009
Published online: January 7, 2010


AIM: To investigate the occurrence of postoperative complications of gastric cancer surgery, and analyze the potential causes of reoperation for early postoperative complications.

METHODS: A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer were included in the study. The study endpoint was the analysis of postoperative complications in inpatients.

RESULTS: About 31% of patients had early postoperative complications, and complications of infection occurred most frequently. Intra-abdominal hemorrhage and anastomotic leak were the main causes of reoperation, which accounted for about 2.2%. Mortality was 11.1% in the reoperation group, but was only 0.8% in other patients. The duration of postoperative stay in hospital was significantly longer and the total expenditure was markedly higher in the patients who underwent reoperation (P < 0.001). There was no significant association of any available factors in this study with the high rate of reoperation.

CONCLUSION: Reoperation significantly increases the mortality rate and raises the burden of the surgical unit. More prospective studies are required to explore the potential risk factors.

Key Words: Reoperation, Gastric cancer, Surgery, Postoperative complications


Though the occurrence of postoperative complications and mortality rate after surgery for gastric cancer have significantly decreased over the past years, they are still considered high[1,2]. Radical gastrectomy with D2 lymph node dissection is widely accepted, but the extent of lymph node dissection is controversial among different centers[3-10]. It is well accepted that the extent of surgery (particularly aggressive dissection of the lymph nodes) does not extend the overall survival, and postoperative complications were significantly related to the extent of surgery, particularly the extent of lymph node dissection. This was proved by Japanese surgeons who conducted several clinical randomized controlled trials (RCTs)[3,9-11]. Sasako et al[9] conducted a RCT in 24 hospitals in Japan to compare D2 lymphadenectomy alone with D2 lymphadenectomy plus para-aortic nodal dissection (PAND) in patients undergoing gastrectomy for curable gastric cancer. They concluded that compared with D2 lymphadenectomy alone, D2 lymphadenectomy plus PAND does not improve the survival in curable gastric cancer; extended D2 lymphadenectomy plus PAND should not be performed to treat curable stage T2b, T3, or T4 gastric cancer; and that D2 gastrectomy is associated with the low mortality and reasonable survival of the patients.

Many researchers at leading centers for gastric cancer, including those in Korea and China, have indicated that combined resection of other organs is not of long-term benefit and it significantly increased the prevalence of postoperative complications and mortality[3,4,11-13]. The occurrence rates of postoperative complications in the spleen-preservation group and splenectomy group were 11.6% and 29.3%, respectively. There was a higher frequency of pleural effusion, intra-abdominal abscess, and pancreatitis in splenectomized patients. A higher recurrence was observed in the splenectomy group (40.4%) compared with the spleen-preservation group (25.1%). The mean survival time was 72.0 mo in the spleen-preservation group compared with 56.7 mo in the splenectomy group[13]. Investigation of early postoperative complications would therefore be beneficial to optimize the extent of gastric cancer surgery.

Reoperation after routine surgery, particularly after gastric cancer surgery, increases the overall burden for both the the surgical ward and the patients. We therefore investigated the factors causing reoperation and their effects on the recovery of patients who undergo surgery for gastric cancer.


A total of 1639 patients who underwent radical or palliative gastrectomies for gastric cancer in five consecutive years were included in the study (Table 1). Data were collected directly by comprehensive review of the original records of all patients. Sixty-seven patients with missing data and 13 patients who underwent emergency surgery were excluded from the analysis. Exclusion criteria were disease other than gastric cancer, and any type of palliative surgery (including exploratory laparotomy and gastrojejunal anastomosis) other than gastrectomy. The median age of the patients was 59 years (range, 17-93 years). The ratio of male and female patients was approximately 7:3.

Table 1 Demographic data of the patients.
ItemsPercentage (%)
Age group (yr)
≤ 6054.1
≥ 7120.7
Primary gastric cancer97.4
Gastric stump cancer12.6
Site of tumor
Large or multiple25.6
No. of procedures
Partial gastrectomy76.0
Total gastrectomy24.0
Type of resection
Radical gastrectomy91.6
Palliative gastrectomy8.4
Combined resection
Type of anastomosis
Billroth I47.6
Billroth II13.9
Billroth reverse213.4
Roux-en-Y (P-shape)3.0
TNM stage

Patients with early and resectable advanced gastric cancer underwent radical surgery (gastrectomies with D2 lymphadenectomy). Patients with late-stage gastric cancer underwent palliative gastrectomy. Most patients were diagnosed to be in stage III. The tumor invaded the serosa or adjacent structures in 38.1% of patients which was classified as pT3, and in 11.4% of patients classified as pT4 (Table 1). With respect to combined organ resection, 19 splenectomies, 14 partial pancreatectomies with splenectomy, 14 partial colectomies, two partial colectomies with splenectomy, seven partial hepatectomies (lobectomy), one total hysterectomy and one partial pancreatectomy were carried out in 58 patients (Table 1). About 25% of the patients underwent total gastrectomy. Billroth I, typical Roux-en-Y, and Billroth reverse (esophagogastric anastomosis) were the preferred methods for anastomosis after distal gastrectomy, total gastrectomy and proximal partial gastrectomy. Above 85% patients underwent surgery by senior surgeons with experience of 20-30 years. The minimal working experience of the surgeons was > 15 years. No surgical fellow or surgeons-in-training was allowed to perform the surgery independently. All the patients were managed by senior attendants under direct supervision of the surgeons.

The endpoint was analysis of postoperative complications and postoperative mortality in inpatients. Complications were recorded according to the definitions stated in the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM)[14]. As there are many complications that are not covered by its definitions, an undefined complication was therefore recorded as “innominate” and the details were provided in separate tables. Severities of all complications were stratified according to Rui Jin Hospital Classification of Complications[15].

We also audited the overall expenditure in US dollars ($) of patients during their stay in hospital and compared it between the reoperation group and non-reoperation group.

Statistical analysis

The statistical analysis was done using the Statistical Package for Social Science (SPSS) version 13.0 for Windows (SPSS, Incorporated, Chicago, IL, USA). Non-parametric methods were used to test the data without normal distribution. P < 0.05 was considered significant.


About 31% of patients had different types of complications according to POSSUM criteria. The prevalence of individual complications was not equal to the total number of complications. Multiple complications were possible in a single patient (Table 2). Postoperative infection was the most common complication. The occurrence of anastomotic leak was about 2%, and postoperative mortality was only 1%.

Table 2 Details of complications.
ComplicationsFrequencyPercentage (%)
Wound dehiscence
Anastomotic leak382.3
Pyrexia of unknown origin25315.4
Urinary tract infection201.2
System failure
Deep venous thrombosis40.2

There were numerous innominate complications (Table 3), most of which were accompanied by complications described in POSSUM. Most patients had pleural effusion or/and seroperitoneum, most of which were accompanied by low fever but pathological diagnosis of infection could not be confirmed. A substantial number of patients had persistent fever or recurring fever of unknown origin. About 5% of patients had persistent nausea or vomiting caused by gastroplegia or enteroplegia, anastomosis edema, or ileus. Some patients were clinically suspected to have a minor leak but there was no sufficient objective evidence to support this finding. Although these patients were managed by conservative treatment (mainly NPO, intravenous antibiotics, and total parenteral nutrition), they still increased the burden on the surgical ward. Complications were rare such as pancreatic fistula, chyle leak, and bleeding at the anastomosis site.

Table 3 Innominate complications.
ComplicationsFrequencyPercentage (%)
Pleural effusion21313
Continuous or relapsing pyrexia of unknown origin17010.4
Gastro or enteroplegia, anastomosis edema, ileus754.6
Suspicious or sub-clinical anastomotic leak573.5
Central vein catheter infection140.9
Anastomosis site or upper GI bleeding100.6
Chyle leak80.5
Pancreatic fistula60.4

Innominate complications were recorded empirically and merged to calculate different levels of complication type according to the Rui Jin Hospital Classification of Complications[15]. Most complications were minor (11.0%) or moderate (15.2%), only 8.3 % of patients had severe complications.

Patients were categorized into three levels according to the length of postoperative stay in hospital. About 75% of patients were discharged in good condition in less than 15 d after uneventful recovery and removal of sutures, 19.7% of patients discharged within 16-30 d and only 6% of patients stayed in hospital for more than a month.

There was a significant difference in the occurrence rate of overall complications between partial and total gastrectomy with radical lymphadenectomy, but no significant difference between partial and total gastrectomy with palliative lymphadenectomy was observed (Table 4). The occurrence of complications of infection (including deep infection, pulmonary infection), system failure, and mortality was significantly higher in total gastrectomy with radical lymphadenectomy. After stratification of patients into partial and total gastrectomy groups, we noted no significant difference in complication occurrence between radical lymphadenectomy and palliative lymphadenectomy (Table 5).

Table 4 Difference of complication rate between partial and total gastrectomy.
LN dissection
Overall308 (26.7)142 (40.9)< 0.00132 (34.8)24 (52.2)NS
Reoperation  23 (2.0)12 (3.5)NS1 (1.1)0NS
Wound1 (0.1) 0NS 00
Deep 11 (1.0)4 (1.2)NS1 (1.1)0NS
Wound dehiscence
Superficial7 (0.6) 1 (0.3)NS1 (1.1)0NS
Deep4 (0.3) 1 (0.3)NS 00
Leak 22 (1.9)12 (3.5)NS1 (1.1)3 (6.5)NS
Wound8 (0.7) 6 (1.7)NS1 (1.1)0NS
Deep 42 (3.6)30 (8.6)< 0.0015 (5.4)3 (6.5)NS
PUO165 (14.3)65 (18.7)0.04413 (14.1)10 (21.7)NS
Septicemia1 (0.1)6 (1.7)< 0.001 00
Chest 86 (7.5)61 (17.6)< 0.00114 (15.2)11 (23.9)NS
UTI 13 (1.1)6 (1.7)NS1 (1.1)0NS
System failure
Renal 15 (1.3)12 (3.5)0.0081 (1.1)0NS
Respiratory 12 (1.0)7 (2.0)NS3 (3.3)0NS
Cardiac5 (0.4)6 (1.7)0.0342 (2.2)0NS
Hypotension8 (0.7)6 (1.7)NS2 (2.2)0NS
DVT1 (0.1)3 (0.9)NS1 (1.1)0NS
Death6 (0.5)8 (2.3)0.0072 (2.2)1 (2.2)NS
Table 5 Difference of complications rate between radical and palliative LN dissection.
LN dissection
Overall308 (26.7)32 (34.8)NS142 (40.9)24 (52.2)NS
Reoperation  23 (2.0)1 (1.1)NS12 (3.5)0NS
Wound1 (0.1) 0NS 00NS
Deep 11 (1.0)1 (1.1)NS4 (1.2)0NS
Wound dehiscence
Superficial7 (0.6)1 (1.1)NS1 (0.3)0NS
Deep4 (0.3) 0NS1 (0.3)0NS
Leak 22 (1.9)1 (1.1)NS 12 (3.5)3 (6.5)NS
Wound8 (0.7)1 (1.1)NS6 (1.7)0NS
Deep 42 (3.6)5 (5.4)NS 30 (8.6)3 (6.5)NS
PUO165 (14.3)13 (14.1)NS65 (18.7)10 (21.7)NS
Septicemia1 (0.1) 0NS6 (1.7)0NS
Chest 86 (7.5)14 (15.2)0.00861 (17.6)11 (23.9)NS
UTI 13 (1.1)1 (1.1)NS6 (1.7)0NS
System failure
Renal 15 (1.3)1 (1.1)NS 12 (3.5)0NS
Respiratory 12 (1.0)3 (3.3)NS7 (2.0)0NS
Cardiac5 (0.4)2 (2.2)NS6 (1.7)0NS
Hypotension8 (0.7)2 (2.2)NS6 (1.7)NS
DVT1 (0.1)1 (1.1)NS3 (0.9)0NS
Death6 (0.5)2 (2.2)NS8 (2.3)1 (2.2)NS

Thirty-six patients underwent reoperation for different causes, with. intra-abdominal hemorrhage and anastomotic leak as the main causes (Table 6). There was no significant difference in physiological score (PS; P = 0.382) and operative severity score (OSS; P = 0.849) between patients in the reoperation group and the non-reoperation group. Median values of PS and OSS in the reoperation group were 14.5 (range, 12-25) and 18 (range, 16-24) respectively, whereas they were 15 (range, 12-38) and 18 (range, 11-28) in the non-reoperation group. Mortality was significantly higher in patients who underwent reoperation (P < 0.001), being 11.1% in the reoperation group but only 0.8% in other patients (Table 7). In the reoperation group, the mortality rate of patients with radical lymphadenectomy was higher than that of patients who underwent palliative lymphadenectomy. Mortality rate was higher in patients who underwent total gastrectomy than in those who underwent partial gastrectomy (Table 7).

Table 6 Causes of reoperation.
CausesSurgical managementFrequency
Intra-abdominal hemorrhage1Simple hemostasis16
Anastomotic leakRepair and placement of drainage10
Deep wound dehiscenceClosure of abdominal wall4
Abdominal infectionDebridement and placement of drainage3
IleusAdhesiolysis of small intestine2
Anastomotic obstructionReconstruction1
Table 7 Potential causes of death.
ComplicationsReoperation n (%)
Yes (n = 36)No (n = 1603)
Death4 (11.11)13 (0.81)
Extent of surgery
LN dissection
Radical4 (11.11)10 (0.62)
Palliative03 (0.18)
Partial1 (0.03)7 (0.44)
Total3 (8.33)6 (0.37)
Intra abdominal hemorrhage1 (0.03)0
Anastomotic leak2 (5.55)0
Deep1 (0.03)2 (0.12)
Pyrexia of unknown origin03 (0.18)
Septicemia01 (0.06)
Chest3 (8.33)7 (0.44)
Urinary tract2 (5.55)0
System failure
Renal3 (8.33)8 (0.49)
Respiratory4 (11.11)10 (0.62)
Cardiac2 (5.55)9 (0.56)
Hypotension1 (0.03)9 (0.56)
Deep venous thrombosis03 (0.18)
Pancreatitis01 (0.06)
Anastomosis site bleeding01 (0.06)

Except for four patients with wound dehiscence who were discharged within one month, the other 32 patients were treated in hospital for more than one month. The length of postoperative stay was significantly longer in patients who underwent reoperation (P < 0.001). The mean duration of postoperative stay was 44.6 d (standard deviation, SD = 29.41 d) in patients with reoperation, but was only 14.6 d (SD = 8.09 d) in other patients.

Reoperation caused a significant economic burden for patients. There was a significant difference in the total expenditure between groups of patients with or without reoperation (P < 0.001). The median expenditure in patients with reoperation was 7946.36 $ (SD = 8930.38 $) but it was only 3238.32 $ (SD = 4404.63 $) in other patients.

Univariate analysis of the data revealed no significant association of any available factors in this study with the higher rate of reoperation, including age, hypertension, anemia, hypoalbuminemia, hyperglycemia, type of gastrectomy, combined organ resection, type of anastomosis, surgeon’s experience (number of operations performed), tumor stage.


In the surgical approach for early and selective advanced gastric cancer, gastrectomy with D2 lymphadenectomy is justified[6,16-19]. The procedure of surgery, particularly the extent of lymphadenectomy for gastric cancer, varies among individual centers. The occurrence of postoperative complications was higher in inexperienced hands, and there was a considerable difference in early surgical outcomes among centers[3,20]. Postoperative complications were inversely correlated with the number of patients undergoing treatment in a surgical unit[21]; similar results were published for patients undergoing surgery for gastric cancer[15]. Overall survival rate was higher at specialized centers. It was therefore stressed in many articles that gastric cancer surgery was safe at specialized centers[3,6,22,23].

The postoperative complications at our institution were in the acceptable range because most patients had a smooth recovery and postoperative mortality was not high. Overall surgical outcome was acceptable because of the occurrence rate of complications was below the moderate level. Postoperative infection was the commonest complication. There are several complications (e.g. gastroplegia or enteroplegia, suspicious anastomotic leak, pleural effusion) which are not covered by POSSUM. These complications cannot be ignored because they have a big impact on the overall burden (patient-related and economic) of our hospital. A substantial number of patients had persistent fever without a clear diagnosis; appropriate investigation was necessary to find the cause. Further investigation was required to classify or define the diagnosis of sub-clinical anastomotic leak. The Ruijin Hospital Classification of Complication, stratifies complications to different levels according to the severity of the disease, and is a validated classification[2,15]. We suggest that other hospitals use this classification for assessment of surgical outcome.

Reoperation was in the acceptable range as compared with a recent report from the Korean Institute, and the mortality caused by reoperation was low[24]. Most reoperations were carried out for intra-abdominal hemorrhage, which may be related to the experience of surgeons and necessitates additional efforts to examine the easily missed bleeding sites (particularly anastomosis sites). The four cases of rupture of the abdominal wall may be attributed to the poor surgical technique because these patients had their linea alba closed by an interrupted silk suture. We did not observe this complication in patients with linea alba closed by a continuous absorbable suture. Anastomotic leak was followed by intra-abdominal infection which often caused peripancreatic abscess, and eventually pancreatic fistulas in some cases. Improvement of surgical technique is therefore crucial to lower the occurrence of intra-abdominal hemorrhage and anastomotic leak.

In conclusion, although the overall occurrence of postoperative complications was high after gastric cancer surgery, the occurrence rate of severe complications and mortality were low. Reoperation after gastric cancer surgery significantly increases the mortality and overall burden of the surgical unit. As the gastric cancer surgery is considered as a routine surgery, it is important to control the postoperative complications. Univariate analysis of the data revealed no significant association of any available factors in this study with the high rate of reoperation; however, more prospective studies are required to explore the potential risk factors for the higher rate of reoperation after gastric cancer surgery.


Though the occurrence of postoperative complications and mortality after surgery for gastric cancer have significantly decreased over the past years, they are still considered high. It was well accepted that the extent of surgery does not extend the overall survival and that postoperative complications were significantly related to the extent of surgery. Therefore, surgical extent should be seriously considered and postoperative complications should not be ignored.

Innovations and breakthroughs

The postoperative complication is highly variable among different centers. However, surprisingly there are very few reports on this issue, especially from Chinese surgical centers. This study was conducted at a leading center for gastric cancer surgery in China, and analyzed a large cohort of patients for a long period. It provides the details on the occurrence of postoperative complications and analyzed its impact on patients and surgical ward. The finding of this study certainly provides very useful reference to the surgeons working in this field.


The better understanding about the occurrence of different types of the postoperative complications and its underlying causes may help surgeons reduce the postoperative complications and upgrade the quality of surgical treatment.


“POSSUM” is an internationally accepted scoring system which is applied for the evaluation of surgical treatment. “Rui Jin Hospital Classification of the complications” is a novel system which stratifies all the complications in three different levels and provides objective idea about the severity of complications.

Peer review

The article has some very good information and is worthy of publication.


Peer reviewers: AM El-Tawil, PhD, Department of Surgery, University Hospital of Birmingham, Edgbaston, B15 2TH, United Kingdom; Michael Leitman, MD, FACS, Chief of General Surgery, Beth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003, United States

S- Editor Wang JL L- Editor Ma JY E- Editor Lin YP

1.  Hyung WJ, Kim SS, Choi WH, Cheong JH, Choi SH, Kim CB, Noh SH. Changes in treatment outcomes of gastric cancer surgery over 45 years at a single institution. Yonsei Med J. 2008;49:409-415.  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Sah BK, Zhu ZG, Chen MM, Yan M, Yin HR, Zhen LY. Gastric cancer surgery and its hazards: post operative infection is the most important complication. Hepatogastroenterology. 2008;55:2259-2263.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  McCulloch P, Niita ME, Kazi H, Gama-Rodrigues JJ. Gastrectomy with extended lymphadenectomy for primary treatment of gastric cancer. Br J Surg. 2005;92:5-13.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Hartgrink HH, van de Velde CJ, Putter H, Bonenkamp JJ, Klein Kranenbarg E, Songun I, Welvaart K, van Krieken JH, Meijer S, Plukker JT. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial. J Clin Oncol. 2004;22:2069-2077.  [PubMed]  [DOI]  [Cited in This Article: ]
5.  Ichikura T, Chochi K, Sugasawa H, Mochizuki H. Modified radical lymphadenectomy (D1.5) for T2-3 gastric cancer. Langenbecks Arch Surg. 2005;390:397-402.  [PubMed]  [DOI]  [Cited in This Article: ]
6.  Sano T, Sasako M, Yamamoto S, Nashimoto A, Kurita A, Hiratsuka M, Tsujinaka T, Kinoshita T, Arai K, Yamamura Y. Gastric cancer surgery: morbidity and mortality results from a prospective randomized controlled trial comparing D2 and extended para-aortic lymphadenectomy--Japan Clinical Oncology Group study 9501. J Clin Oncol. 2004;22:2767-2773.  [PubMed]  [DOI]  [Cited in This Article: ]
7.  Bali C, Ziogas D, Fatouros E, Fatouros M. Is there a role for surgery in recurrent gastric cancer. Ann Surg Oncol. 2009;16:1074-1075; author reply 1076.  [PubMed]  [DOI]  [Cited in This Article: ]
8.  Kulig J, Popiela T, Kolodziejczyk P, Sierzega M, Szczepanik A. Standard D2 versus extended D2 (D2+) lymphadenectomy for gastric cancer: an interim safety analysis of a multicenter, randomized, clinical trial. Am J Surg. 2007;193:10-15.  [PubMed]  [DOI]  [Cited in This Article: ]
9.  Sasako M, Sano T, Yamamoto S, Kurokawa Y, Nashimoto A, Kurita A, Hiratsuka M, Tsujinaka T, Kinoshita T, Arai K. D2 lymphadenectomy alone or with para-aortic nodal dissection for gastric cancer. N Engl J Med. 2008;359:453-462.  [PubMed]  [DOI]  [Cited in This Article: ]
10.  Bonenkamp JJ, Hermans J, Sasako M, van de Velde CJ, Welvaart K, Songun I, Meyer S, Plukker JT, Van Elk P, Obertop H. Extended lymph-node dissection for gastric cancer. N Engl J Med. 1999;340:908-914.  [PubMed]  [DOI]  [Cited in This Article: ]
11.  Wu CW, Chang IS, Lo SS, Hsieh MC, Chen JH, Lui WY, Whang-Peng J. Complications following D3 gastrectomy: post hoc analysis of a randomized trial. World J Surg. 2006;30:12-16.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Zhang CH, Zhan WH, He YL, Chen CQ, Huang MJ, Cai SR. Spleen preservation in radical surgery for gastric cardia cancer. Ann Surg Oncol. 2007;14:1312-1319.  [PubMed]  [DOI]  [Cited in This Article: ]
13.  Oh SJ, Hyung WJ, Li C, Song J, Kang W, Rha SY, Chung HC, Choi SH, Noh SH. The effect of spleen-preserving lymphadenectomy on surgical outcomes of locally advanced proximal gastric cancer. J Surg Oncol. 2009;99:275-280.  [PubMed]  [DOI]  [Cited in This Article: ]
14.  Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg. 1991;78:355-360.  [PubMed]  [DOI]  [Cited in This Article: ]
15.  Sah BK, Zhu ZG, Chen MM, Xiang M, Chen J, Yan M, Lin YZ. Effect of surgical work volume on postoperative complication: superiority of specialized center in gastric cancer treatment. Langenbecks Arch Surg. 2009;394:41-47.  [PubMed]  [DOI]  [Cited in This Article: ]
16.  Swan R, Miner TJ. Current role of surgical therapy in gastric cancer. World J Gastroenterol. 2006;12:372-379.  [PubMed]  [DOI]  [Cited in This Article: ]
17.  Kodera Y. The beginning of a new era: East meets West more comfortably regarding lymphadenectomy for gastric cancer. Japan will finally drop the surgery-alone arm in its pursuit of a multimodal treatment strategy. Gastric Cancer. 2007;10:69-74.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Roviello F, Marrelli D, Morgagni P, de Manzoni G, Di Leo A, Vindigni C, Saragoni L, Tomezzoli A, Kurihara H. Survival benefit of extended D2 lymphadenectomy in gastric cancer with involvement of second level lymph nodes: a longitudinal multicenter study. Ann Surg Oncol. 2002;9:894-900.  [PubMed]  [DOI]  [Cited in This Article: ]
19.  Biffi R, Chiappa A, Luca F, Pozzi S, Lo Faso F, Cenciarelli S, Andreoni B. Extended lymph node dissection without routine spleno-pancreatectomy for treatment of gastric cancer: low morbidity and mortality rates in a single center series of 250 patients. J Surg Oncol. 2006;93:394-400.  [PubMed]  [DOI]  [Cited in This Article: ]
20.  Pedrazzani C, Marrelli D, Rampone B, De Stefano A, Corso G, Fotia G, Pinto E, Roviello F. Postoperative complications and functional results after subtotal gastrectomy with Billroth II reconstruction for primary gastric cancer. Dig Dis Sci. 2007;52:1757-1763.  [PubMed]  [DOI]  [Cited in This Article: ]
21.  Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128-1137.  [PubMed]  [DOI]  [Cited in This Article: ]
22.  Smith DL, Elting LS, Learn PA, Raut CP, Mansfield PF. Factors influencing the volume-outcome relationship in gastrectomies: a population-based study. Ann Surg Oncol. 2007;14:1846-1852.  [PubMed]  [DOI]  [Cited in This Article: ]
23.  Smith JK, McPhee JT, Hill JS, Whalen GF, Sullivan ME, Litwin DE, Anderson FA, Tseng JF. National outcomes after gastric resection for neoplasm. Arch Surg. 2007;142:387-393.  [PubMed]  [DOI]  [Cited in This Article: ]
24.  Oh SJ, Choi WB, Song J, Hyung WJ, Choi SH, Noh SH. Complications requiring reoperation after gastrectomy for gastric cancer: 17 years experience in a single institute. J Gastrointest Surg. 2009;13:239-245.  [PubMed]  [DOI]  [Cited in This Article: ]