Optimal reconstruction methods after distal gastrectomy for gastric cancer: A systematic review and network meta-analysis

Zhaolun Cai, Ye Zhou, Chenxiao Wang, Yiqiong Yin, Yuan Yin, Chaoyong Shen, Xiaonan Yin, Zhixin Chen, Bo Zhang, Zhaolun Cai, Ye Zhou, Chenxiao Wang, Yiqiong Yin, Yuan Yin, Chaoyong Shen, Xiaonan Yin, Zhixin Chen, Bo Zhang

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.

Conflict of interest statement

The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Network plot of the comparisons for the Bayesian network meta-analysis. (A) Operation time; (B) intraoperative blood loss; (C) hospital stay; (D) overall postoperative morbidity; (E) delayed gastric emptying; (F) anastomotic leakage; (G) anastomotic stricture; (H) bile reflux; (I) food residual; (J) remnant gastritis; (K) reflux esophagitis.
Figure 3
Figure 3
Forest plot for comparison of surgical characteristics. (A) Operation time; (B) intraoperative blood loss; (C) hospital stay.
Figure 4
Figure 4
Forest plot for comparison of early postoperative outcomes. Odds ratio 

Figure 5

Forest plot for comparison of…

Figure 5

Forest plot for comparison of postoperative endoscopic examination. Odds ratio

Figure 5
Forest plot for comparison of postoperative endoscopic examination. Odds ratio

Figure 6

Risk of bias graph.

Figure 6

Risk of bias graph.

Figure 6
Risk of bias graph.
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Figure 5
Figure 5
Forest plot for comparison of postoperative endoscopic examination. Odds ratio

Figure 6

Risk of bias graph.

Figure 6

Risk of bias graph.

Figure 6
Risk of bias graph.
Figure 6
Figure 6
Risk of bias graph.

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