Roux-en-Y versus Billroth-I reconstruction after distal gastrectomy for gastric cancer

Daisuke Nishizaki, Riki Ganeko, Nobuaki Hoshino, Koya Hida, Kazutaka Obama, Toshi A Furukawa, Yoshiharu Sakai, Norio Watanabe, Daisuke Nishizaki, Riki Ganeko, Nobuaki Hoshino, Koya Hida, Kazutaka Obama, Toshi A Furukawa, Yoshiharu Sakai, Norio Watanabe

Abstract

Background: Gastric cancer is the fifth most common cancer diagnosed worldwide. Due to improved early detection rates of gastric cancer and technological advances in treatments, a significant improvement in survival rates has been achieved in people with cancer undergoing gastrectomy. Subsequently, there has been increasing emphasis on postgastrectomy syndrome (e.g. fullness, delayed emptying, and cold sweat, amongst others) and quality of life postsurgery. However, it is uncertain which types of reconstruction result in better outcomes postsurgery.

Objectives: To assess the evidence on health-related quality of life and safety outcomes of Roux-en-Y and Billroth-I reconstructions after distal gastrectomy for people with gastric cancer.

Search methods: We searched the Cochrane Library and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 4 May 2021. We checked the reference lists of the included studies and contacted manufacturers and professionals in the field. There were no language restrictions.

Selection criteria: Randomised controlled trials (RCTs) allocating participants to Roux-en-Y reconstruction or Billroth-I reconstruction after distal gastrectomy for gastric cancer.

Data collection and analysis: Two review authors independently screened studies identified by the search for eligibility and extracted data. The primary outcomes were health-related quality of life after surgery and incidence of anastomotic leakage. The secondary outcomes included body weight loss, incidence of bile reflux, length of hospital stay, and overall morbidity. We used a random-effects model to conduct meta-analyses. We assessed risk of bias of the included studies in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and the certainty of the evidence using the GRADE approach.

Main results: We included eight RCTs (942 participants) in the review. One study included both cancer patients and benign disease patients such as stomach ulcers. Two studies compared Roux-en-Y, Billroth-I, and Billroth-II reconstructions, whilst the other studies compared Roux-en-Y and Billroth-I directly. For the primary outcomes, the evidence suggests that there may be little to no difference in health-related quality of life between Roux-en-Y and Billroth-I reconstruction (standardised mean difference 0.04, 95% confidence interval (CI) -0.11 to 0.18; I² = 0%; 6 studies; 695 participants; low-certainty evidence due to study limitations and imprecision). The evidence for the effect of Roux-en-Y versus Billroth-I reconstruction on the incidence of anastomotic leakage is very uncertain (risk ratio (RR) 0.63, 95% CI 0.16 to 2.53; I² = 0%; 5 studies; 711 participants; very low-certainty evidence). The incidence of anastomotic leakage was 0.6% and 1.4% in the Roux-en-Y and Billroth-I groups, respectively. For the secondary outcomes, the evidence suggests that Billroth-I reconstruction may result in little to no difference in loss of body weight compared to Roux-en-Y reconstruction (mean difference (MD) 0.41, 95% CI -0.77 to 1.59; I² = 0%; 4 studies; 541 participants; low-certainty evidence). Roux-en-Y reconstruction probably reduces the incidence of bile reflux compared to Billroth-I reconstruction (RR 0.40, 95% CI 0.25 to 0.63; I² = 22%; 4 studies; 399 participants; moderate-certainty evidence). Billroth-I reconstruction may shorten postoperative hospital stay, but the evidence for this outcome is very uncertain (MD 0.96, 95% CI 0.16 to 1.76; I² = 56%; 7 studies; 894 participants; very low-certainty evidence). Billroth-I reconstruction may reduce postoperative overall morbidity compared to Roux-en-Y reconstruction (RR 1.47, 95% CI 1.02 to 2.11; I² = 0%; 7 studies; 891 participants; low-certainty evidence).

Authors' conclusions: The evidence suggests that there is little to no difference between Roux-en-Y and Billroth-I reconstruction for the outcome health-related quality of life. The evidence for the effect of Roux-en-Y versus Billroth-I reconstruction on the incidence of anastomotic leakage is very uncertain as the incidence of this outcome was low. Although the certainty of evidence was low, we found some possibly clinically meaningful differences between Roux-en-Y and Billroth-I reconstruction for short-term outcomes. Roux-en-Y reconstruction probably reduces the incidence of bile reflux into the remnant stomach compared to Billroth-I reconstruction. Billroth-I reconstruction may shorten postoperative hospital stay compared to Roux-en-Y reconstruction, but the evidence is very uncertain. Billroth-I reconstruction may reduce postoperative overall morbidity compared to Roux-en-Y reconstruction. Future trials should include long-term follow-up of health-related quality of life and body weight loss.

Trial registration: ClinicalTrials.gov NCT01375738 NCT01142271 NCT01065688.

Conflict of interest statement

DN: none known.

RG: none known.

NH has received writing fees from Igaku‐Shoin and Kanehara publishers.

KH has received grants for research from JSPS KAKENHI, Mitsubishi Foundation, Senko Medical, Kondo Memorial Foundation, and Japan Society of Laparoscopic Colorectal Surgery outside the submitted work. He has received lecture fees from Johnson & Johnson, Medtronic, and Otsuka Pharmaceutical Company outside the submitted work.

KO has received grants or research support from the Japan Agency for Medical Research and Development and the Japan Society for the Promotion of Science (JSPS KAKENHI). He has received grants from Taiho Pharmaceuticals, consultant fee from Ethicon, Stryker, Olympus, Medicaroid, Medtronic, and Intuitive Surgical, and payment for lectures from Ethicon, Covidien Japan, Intuitive Surgical, Taiho Pharmaceuticals, Chugai Pharmaceuticals, Tsumura Pharmaceuticals, Miyarisan Pharmaceuticals, EA Pharma, Otsuka Pharmaceuticals, Kaken Pharmaceuticals, Gunze Medical Japan, Medicon, Ono Pharmaceuticals, and Olympus.

TAF has received lecture fees from Eli Lilly, Janssen, Meiji, Mitsubishi‐Tanabe, MSD, and Pfizer and consultancy fees from Takeda Science Foundation, Mitsubishi‐Tanabe, Shionogi and SONY. He has received royalties from Igaku‐Shoin and Nihon Bunka Kagaku‐sha publishers. He has received research support from Mochida and Mitsubishi‐Tanabe and Shionogi. He has a patent 2020‐548587 concerning smartphone CBT apps pending, and intellectual properties for Kokoro‐app licensed to Mitsubishi‐Tanabe.

YS has received grants from Chugai, Taiho, Tsumura, Daiichi‐Sankyo, Yakult, Otsuka, Shionogi, and Sanofi, and payment for lectures from Chugai, Taiho, Tsumura, Johnson & Johnson, Covidien Japan, Striker Japan, Olympus, Takeda, and Terumo, outside the submitted work.

NW has received research funds from the Japanese Ministry of Health Labor and Welfare and the Japanese Ministry of Education, Science, and Technology. He has also received royalties from Sogensha and advantage Risk Management for writings. The results in the review are completely independent of the intention of these grants.

Affiliations of all members involved in this review have been unchanged for the past three years.

Nobody involved in this review is an investigator of a study that might be included in the review.