***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : Roux-en-Y reconstruction with and without jejunal pouch was compared in a r and omized controlled trial to identify the optimal reconstruction procedure in terms of quality of life . Background Data : R and omized trials comparing techniques of reconstruction after total gastrectomy have shown controversial results . Methods : One hundred and thirty-eight patients with gastric cancer were intraoperatively r and omized for Roux-en-Y reconstruction with pouch  ( n = 71 ) or without pouch  ( n = 67 ) after gastrectomy and stratified into curative or palliative resection . Intra- and postoperative complications were recorded . Body weight and quality of life were determined every 6 months with a follow-up of up to 12 years . Results : Both groups were comparable for age , sex , incidence of concomitant disease , and staging . There were no differences in operative time , postoperative complications , and mortality . Short- and long-term weight loss was similar in both groups . In the first postoperative year , there were no benefits of pouch reconstruction in terms of quality of life , independent of the resection status . In the third , fourth , and fifth year after surgery quality of life was significantly improved for patients with a pouch . Conclusions : Roux-en-Y pouch reconstruction after gastrectomy is simple to perform and safe . Long-term survivors benefit from pouch reconstruction . Therefore , a pouch is recommended for patients with a good prognosis Background We performed a r and omized study to evaluate the differences between upper midline incision and transverse incision for gastrectomy . Methods Patients undergoing distal gastrectomy or total gastrectomy for gastric cancer were r and omly allocated to have either an upper midline incision or a transverse incision . The times taken to open and close the abdominal cavity , the number of doses of postoperative analgesics , and the incidence of postoperative pneumonia , wound infection , and intestinal obstruction were compared between the patients having the two incisions . Results Times for both opening and closing the abdominal cavity were longer with a transverse incision , in both the distal gastrectomy group and total gastrectomy group . In the patients in whom continuous epidural analgesia was used postoperatively , the number of additional doses of analgesics was smaller in the transverse-incision group after distal gastrectomy . The incidence of postoperative pneumonia was lower in the transverse-incision group after distal gastrectomy . The number of patients with postoperative intestinal obstruction was smaller in the transverse-incision group than in the midline-incision group after distal gastrectomy . In contrast to distal gastrectomy , there was no significant difference in the number of doses of postoperative analgesics , incidence of postoperative pneumonia , or incidence of postoperative intestinal obstruction between the two study groups after total gastrectomy . Conclusion A transverse incision for distal gastrectomy may be more beneficial than an upper midline incision in attenuating postoperative wound pain , decreasing the incidence of postoperative pneumonia , and preventing postoperative intestinal obstruction Quality of life ( QOL ) was studied in gastric cancer patients treated on a r and omised , controlled trial comparing D1 ( level 1 ) with D3 ( levels 1 , 2 and 3 ) lymphadenectomy . A total of 221 patients were r and omly assigned to D1 ( n=110 ) and D3 ( n=111 ) surgery .  Quality -of-life assessment s included functional outcomes ( a 14-item survey about treatment-specific symptoms ) and health perception ( Spitzer QOL Index ) was performed before and after surgery at disease-free status . Patients suffered from irrelative events such as loss of partners was excluded thereafter . Main analyses were done by intention-to-treat . Thus , 214 D1 ( 106/110=96.4 % ) and D3 ( 108/111=97.3 % ) R0 patients were assessed . Longitudinal analysis showed that functional outcomes decreased at 6 months after surgery and increased over time thereafter , while health perceptions increased over time in general . On the basis of linear mixed model analyses , patients having total gastrectomy , advanced cancer and hemipancreaticosplenectomy , but not complications had poorer QOL than those without . D1 and D3 patients showed no significant difference in QOL . The results suggest that changes of QOL were largely due to scope of gastric resection , disease status and distal pancreaticosplenectomy , rather than the extent of lymph node dissection . This indicates that nodal dissection can be performed for a potentially curable gastric cancer Background Radical surgery is the cornerstone in the treatment of resectable gastric cancer . The Intergroup 0116 and MAGIC trials have shown benefit of postoperative chemoradiation and perioperative chemotherapy , respectively . Since these trials can not be compared directly , both regimens are evaluated prospect ively in the CRITICS trial . This study aims to obtain an improved overall survival for patients treated with preoperative chemotherapy and surgery  by incorporating radiotherapy concurrently with chemotherapy postoperatively . Methods / design In this phase III multicentre study , patients with resectable gastric cancer are treated with three cycles of preoperative ECC ( epirubicin , cisplatin and capecitabine ) , followed by surgery with adequate lymph node dissection , and then either another three cycles of ECC or concurrent chemoradiation ( 45 Gy , cisplatin and capecitabine ) . Surgical , pathological , and radiotherapeutic quality control is performed . The primary endpoint is overall survival , secondary endpoints are disease-free survival ( DFS ) , toxicity , health-related quality of life ( HRQL ) , prediction of response , and recurrence risk assessed by genomic and expression profiling . Accrual for the CRITICS trial is from the Netherl and s , Sweden , and Denmark , and more countries are invited to participate . Conclusion Results of this study will demonstrate whether the combination of preoperative chemotherapy and postoperative chemoradiotherapy will improve the clinical outcome of the current European st and ard of perioperative chemotherapy , and will therefore play a key role in the future management of patients with resectable gastric cancer . Trial registration clinical trials.gov Purpose We investigated the risk factors for early postoperative complications after gastric cancer surgery . Material s and methods The data from a total of 273 patients with gastric cancer were analyzed by univariate and multivariate analysis . We applied physiological and operative severity score for the enumeration of morbidity and mortality ( POSSUM ) to compare risk-adjusted surgical outcomes among different surgical units . Results Among the preoperative variables , patient gender , chronic obstructive pulmonary disease , surgical unit , and intraoperative blood loss were independent risk factors for a higher rate of postoperative complications . There were significant differences in complication rates among different surgical units ( P = 0.001 ) . The observed-to-expected morbidity ratio ( O-to-E ratio ) ranged from 0.81 to 1.63 . Units with low surgical work volume had higher complication rates . Postoperative length of stay was significantly shorter ( P = 0.000 ) and the rate of moderate and severe complications was significantly lower ( P = 0.001 ) in specialized unit . Conclusions POSSUM is a valid system for risk-adjusted evaluation of surgical outcomes . We conclude that surgical experience and work volume greatly influence the outcome , with overall surgical outcome in specialized centers superior to that in other units . Hence , gastric cancer surgery should be performed in specialized centers . Risk factors identified in this study need further confirmation by a prospect i ve study involving a larger cohort BACKGROUND / AIMS Surgical therapy still represents the st and ard treatment for gastric carcinoma . Due to epidemiology and tumor stage , total gastrectomy is the most often required extent of gastric resection to obtain a potentially curative status . After a 30-year period we overviewed 1114 total gastrectomies  , to our knowledge one of the biggest single-institution series in the Western Hemisphere . METHODOLOGY Among 1991 cases with gastric carcinoma , treated between May 1968 and February 1998 , 1114 patients underwent total gastrectomy .  This prospect ively documented series was retrospectively analyzed with special focus on various time periods . RESULTS A constant increase of proximal gastric carcinomas was noted . R0-resections were feasible in 84.6 % of total gastrectomies . Morbidity and mortality decreased to 22.2 % and 5.5 % , respectively , in the last decade . Overall 5-years survival rate was 32.4 % . Survival was strongly influenced by tumor stage and R-classification . Overall and prognosis after R0-resection showed a significant time-dependent improvement . CONCLUSIONS Total gastrectomy requires intensive surgical skills and can be performed with acceptable morbidity and low mortality . Survival after total gastrectomy can be improved with increasing experience , and the aim of total gastrectomy for gastric carcinoma should always focus on a R0-resection To determine the clinical efficacy of Roux-en-Y reconstruction ( RY )  after distal gastrectomy , we compared postoperative outcomes of patients who underwent RY or conventional Billroth I reconstruction ( B-I ) .  A total of 50 patients were prospect ively r and omized to either B-I or RY reconstruction  , and complications , postoperative course , and nutritional status were compared . Bile reflux and inflammation in the remnant stomach and lower esophagus were evaluated by postoperative follow-up endoscopy at 6 months . Operative time and blood loss as well as postoperative nutrition did not show significant differences between the two groups . As anticipated , 5 of 24 patients with RY reconstruction  developed gastrojejunal stasis in the early postoperative period , which led to a longer postoperative hospital stay as compared with the B-I group ( mean ± S.D ; B-I ; 19.0 ± 6.2 , RY ; 31.8 ± 21.7 days ) ( P < 0.05 ) . Endoscopic examination revealed that the frequency of bile reflux ( P < 0.01 ) and degree of inflammation in the remnant stomach ( P < 0.05 ) were less in the RY group than in the B-I group . However , inflammatory findings in the lower esophagus were observed in 7 ( 27 % ) of B-I , and 8 ( 35 % ) of the RY group , suggesting that late phase esophagitis was not improved in the RY group . Roux-en-Y reconstruction was effective in preventing duodenogastric reflux and result ing gastritis , but it did not prevent esophagitis . Because RY reconstruction induces the frequent complication of Roux-en-Y stasis , causing longer postoperative hospital stay , this method has limited advantages over B-I anastomosis after distal gastrectomy AIM Laparoscopic gastrectomy ( LG ) is still not a widely accepted option for the treatment of invasive gastric cancer . This study was conducted to evaluate the results of LG for gastric adenocarcinoma in two French surgical departments . METHODS Between 2001 and 2007 , 51 patients underwent LG for gastric cancer . The results were compared to those of 79 patients who had open gastrectomy ( OG ) during the same study period . RESULTS Mean age was 61 years ( 31 - 81 ) and 66 years ( 27 - 88 ) in the LG group and in the OG group , respectively . The sex ratio was 21 women to 30 men and 25 women for 54 men in the LG group and the OG group , respectively . The mean operative duration was 260 minutes ( 90 - 420 ) and 200 ( 120 - 360 ) the LG group and the OG group , respectively ( P=0.11 ) . Estimated operative blood loss was 150 ml ( 50 - 870 ) and 240 ( 120 - 955 ) in the LG group and the OG group , respectively ( P=0.07 ) . The mean number of harvested lymph nodes was 19 ( 8 - 51 ) in the LG group and 22 ( 3 - 101 ) in the OG group , respectively ( P=0.76 ) . The overall mortality rate was 0 % and 2.5 % in the LG group and the OG group , respectively ( P=0.49 ) . The overall abdominal morbidity rate was 12 % and 16.4 % in the LG group and the OG group , respectively ( P=0.42 ) . The mean duration of hospital stay was 8.0 days ( 5 - 23 ) and 11.5 days ( 5 - 31 ) in the LG group and the OG group , respectively ( P=0.023 ) . Survival analysis at 1 , 2 , and 3 years showed no significant difference between the two groups . CONCLUSION LG for cancer is feasible and safe in patients with invasive gastric cancer . However , r and omized controlled trials are necessary to accurately define the role of laparoscopy in the treatment of gastric cancer Background Bursectomy , a procedure dissecting the peritoneal lining covering the pancreas and the anterior plane of the transverse mesocolon , has been commonly performed with radical gastrectomy for gastric cancer patients . Although possibly improving the prognosis of gastric cancers , adverse events related to bursectomy should be evaluated in prospect i ve studies . Methods This prospect i ve r and omized controlled trial was conducted by experienced surgeons in 11 Japanese institutions . Patients with T2 or T3 gastric aden 
    Output:
    
For structural measures , evidence was found for the inverse relationship between hospital volume and postoperative mortality as well as overall survival .
Regarding process measures , the most common indicators concerned surgical technique , perioperative care , and multimodality treatment .
The only outcome indicator with supporting evidence was a microscopically radical resection .