Optimal reconstruction methods after distal gastrectomy for gastric cancer

Abstract

Background:The choice of anastomosis methods including Billroth I, Billroth II, and Roux-en-Y after a distal gastrectomy is still controversial. The conventional meta-analyses assessing 2 alternative treatments were not powered to compare differences in clinical outcomes. To guide treatment decisions in patients with gastric cancer (GC) after distal gastrectomy, we did a systematic review and network meta-analysis to identify the best reconstruction method.Methods:We systematically searched PubMed, EMBASE, the Cochrane Library for randomized controlled trials comparing the outcomes of Billroth I, Billroth II, or Roux-en-Y reconstruction after distal subtotal gastrectomy for patients with GC, then we performed a direct meta-analysis and Bayesian network meta-analysis to pooled odds ratios (OR) or weighted mean differences (WMD) with 95% credible intervals (CrI) with random effects model. The node-splitting method was used to assess the inconsistency. We estimated the potential ranking probability of treatments by calculating the surface under the cumulative ranking curve for each intervention.Results:Nine studies involving 1161 patient were included in the network meta-analysis. Statistical significance was reached for the comparisons of Roux-en-Y versus Billroth I reconstruction (WMD 37, 95% Crl: 22–51) and Billroth II versus Billroth I reconstruction (WMD 25, 95% Crl: 5.8–43) for operation time; and Roux-en-Y versus Billroth I reconstruction (WMD 26, 95% Crl: 2.1–68) for intraoperative blood loss; and Roux-en-Y versus Billroth I reconstruction (OR 3.4, 95% Crl: 1.1–13) for delayed gastric emptying. Roux-en-Y reconstruction was superior to Billroth I and Billroth II reconstruction in terms of frequency of bile reflux (OR 0.095, 95% Crl: 0.010–0.63; OR 0.064, 95% Crl: 0.0037–0.84, respectively) and the incidence of remnant gastritis (OR 0.33, 95% Crl: 0.16–0.58; OR 0.40, 95% Crl: 0.17–0.92, respectively).Conclusion:Roux-en-Y reconstruction is superior to Billroth I and Billroth II reconstruction in terms of preventing bile reflux and remnant gastritis, Billroth I and Billroth II anastomosis could be considered as the substitute in consideration of technical simplicity. As for postoperative morbidity and the advantage of physiological food passage, Billroth I method is the choice.

Korean Practice Guideline for Gastric Cancer 2018: an Evidence-based, Multi-disciplinary Approach

“…Roux-en-Y reconstruction is superior to Billroth I and Billroth II reconstruction in terms of preventing bile reflux (OR, 0.095; 95% CI, 0.010–0.63 and OR, 0.064; 95% CI, 0.0037–0.84, respectively) and remnant gastritis (OR, 0.33; 95% CI, 0.16–0.58 and OR, 0.40; 95% CI, 0.17–0.92, respectively). Meanwhile, Roux-en-Y gastric anastomosis resulted in more frequent delayed gastric emptying than did Billroth I (OR, 3.4; 95% CI, 1.1–13) [85]. However, there was no difference in patient quality of life according to the type of reconstruction (P=0.290–0.994) [86].…”

Gastric cancer in the remnant stomach after pancreaticoduodenectomy: A case series

“…Older retrospective cohort studies of patients who underwent gastrectomy for ulcer diseases showed that B‐II reconstruction was accompanied by two to three times higher incidence of GC in the remnant stomach than B‐I reconstruction, consistent with the idea that bile reflux plays a role in carcinogenesis. A recent meta‐analysis of randomized controlled trials showed that B‐I and B‐II reconstruction were accompanied by higher incidence of bile reflux and remnant gastritis than Roux‐en‐Y reconstruction . For these reasons, Roux‐en‐Y reconstruction is commonly performed among gastric surgeons.…”

Clinical Outcome of Novel Reconstruction of Double Shouldering Technique after Proximal Gastrectomy

“…17 Cai et al reviewed the reconstruction method after distal gastrectomy, and LA classification was used in 3 of 8 papers, and 4 of 8 papers reported results according to RGB classification. [23][24][25][26][27][28] Again, only one in eight papers reported results for all three: LA classification, RGB classification, and ref lux symptom. 26 The limitations of this study are that it is a retrospective observational study, that only three surgeons in a single center participated, and there was a small sample size as an observational study.…”