Is Roux-en-Y or Billroth-II reconstruction the preferred choice for gastric cancer patients undergoing distal gastrectomy when Billroth I reconstruction is not applicable? A meta-analysis

BACKGROUND: Although Billroth II and Roux-en-Y procedures are the two most commonly performed types of reconstruction techniques following distal stomach resection, there is yet no consensus on which reconstruction is the best choice. This meta-analysis aims to compare the perioperative safety and long-term complications of Billroth-II and Roux-en-Y reconstruction. METHOD: We searched the databases of the PubMed, the Cochrane Library, Web of Science, EMBASE, and the Chinese Biomedicine Database from January 2000 to January 2018 and included studies that compared Roux-en-Y with Billroth-II reconstruction after distal gastrectomy for gastric cancer. The meta-analyses were performed using RevMan 5.0 software. RESULT: Four randomized controlled trials (RCTs) and eight non-randomized observational clinical studies (OCS) were included. Billroth-II anastomosis was more beneficial than Roux-en-Y in reducing the operation time (OR = 34.14, 95%CI = 24.19-44.08, P < .00001, I(2) = 54%) and intraoperative blood loss (OR = 54.32, 95%CI = 50.29-58.36, P < .00001, I(2) = 36%). However, Roux-en-Y anastomosis was more beneficial than Billroth-II in reducing the incidence of remnant gastritis (OR = 0.12; 95% CI = 0.08-0.17; P < .00001; I(2) = 8%), reflux esophagitis (OR = 0.26; 95%CI = 0.15-0.44; P < .00001; I(2) = 0%), dumping symptoms (OR = 0.31; 95%CI = 0.13-0.73; P = .008; I(2) = 0%), reflux symptoms (OR = 0.20; 95% CI = 0.10-0.42; P < .0001; I(2) = 0%). No differences were found between the two groups with respect to anastomotic leakage (OR = 1.56, 95%CI = 0.66-3.64, P = .59, I(2) = 0%); postoperative mortality (OR = 1.15, 95%CI = 0.38-3.51, P = .80, I(2) = 0%); overall postoperative morbidity (OR = 0.92, 95%CI = 0.6-1.42, P = .72, I(2) = 0%); and delayed gastric emptying (OR = 0.84, 95%CI = 0.40-1.77, P = .65, I(2) = 0%). CONCLUSION: Roux-en-Y reconstruction does not carry greater postoperative complications than the Billroth II reconstruction. Additionally, it can improve the postoperative quality of life owing to less remnant gastritis, reflux esophagitis, dumping symptoms, and reflux symptoms. Considering the long-term postoperative outcomes, Roux-en-Y reconstruction appears to be a better choice following distal stomach resection.