Review question
We reviewed the evidence for the effect of Roux-en-Y compared to Billroth-I reconstruction after surgery for gastric cancer. We found eight studies.
Background
Gastric (stomach) cancer is one of the most common cancers worldwide. Recently, early detection rates of gastric cancer and treatment technology have improved. As a result, people can survive longer after surgery, and the importance of quality of life after surgery has been discussed. Billroth-I and Roux-en-Y are both options for reconstruction of continuity of the gastrointestinal system after distal gastrectomy (removal of the lower part of the stomach).
However, there are no standards on which reconstructive procedure to select; guidelines do not describe which procedure should be a priority. It was therefore important to perform a review of the available evidence to aid decision making for people undergoing surgery, surgeons, physicians, medical staff, and policymakers.
Study characteristics
The evidence is current to 4 May 2021.
We identified eight trials including 942 participants with gastric cancer who underwent distal gastrectomy. The studies were conducted in four countries. One study included both cancer patients and patients with other diseases (such as stomach ulcers). Two studies compared Roux-en-Y, Billroth-I, and Billroth-II reconstruction, whilst the other studies compared Roux-en-Y and Billroth-I directly. As for surgical approaches, open or laparoscopic (key-hole) surgery, or both, were used in all studies; robotic surgery was not used. Six different scales were used to measure quality of life.
Key results
The evidence suggests that Roux-en-Y reconstruction may result in little to no difference in quality of life 12 months after surgery. However, these findings must be interpreted with caution because the study investigators measured quality of life in different ways. The evidence is very uncertain for the effect of the interventions on leakage through the reconstructed connection (anastomotic leakage).
Billroth-I reconstruction may result in little to no difference in loss of body weight; probably increases bile reflux into the remnant stomach; and may reduce overall complications after surgery compared to Roux-en-Y reconstruction. The evidence is very uncertain for the effect of the procedures on length of hospital stay.
Certainty of the evidence
The certainty of the evidence for quality of life was low due to limitations in how the studies were designed and conducted, and because there are not enough studies to be certain about the results for this outcome. The certainty of the evidence for the other outcomes ranged from very low to moderate. Further research is needed to look at the effects of reconstruction methods over a longer time period.
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.
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.
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.
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.
Randomised controlled trials (RCTs) allocating participants to Roux-en-Y reconstruction or Billroth-I reconstruction after distal gastrectomy for gastric cancer.
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.
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).