Key messages
‐ Comparing uncut Roux‐en‐Y reconstruction with Billroth II reconstruction, the two treatments may be similar in terms of major postoperative complications, incidence of anastomotic leakage, and changes in body weight, but we are very uncertain about the majority of these results. The uncut Roux‐en‐Y reconstruction may reduce the occurrence of bile reflux, but may make little to no difference to the occurrence of remnant gastritis.
‐ Comparing uncut Roux‐en‐Y reconstruction with Roux-en-Y reconstruction, uncut Roux-en-Y reconstruction may have little or no effect on major postoperative complications and incidence of anastomotic leakage. It may increase the occurrence of bile reflux, but may make little to no difference to the occurrence of remnant gastritis and oesophagitis. We are very uncertain about the above results.
What is gastric cancer, and how can it be treated?
Gastric cancer, also known as stomach cancer, ranks among the most common types of cancer worldwide. When this cancer is found in the lower part of the stomach, a common treatment is to remove that part of the stomach. This surgery is known as a distal gastrectomy. After removing part of the stomach, surgeons need to perform another surgery to connect the remaining part of the stomach to the small intestine, ensuring the digestive system still works.
This reconnecting surgery is crucial for the patient's recovery and long-term health. One specific method, called the uncut Roux-en-Y technique, is designed to reduce complications after surgery. However, there is ongoing debate among medical professionals about whether this method offers more benefits and is safer compared to other surgical techniques.
What did we want to find out?
We wanted to know if the uncut Roux-en-Y reconstruction after a distal gastrectomy for stomach cancer was better than other reconstruction methods in improving:
‐ Health-related quality of life, measured at least six months after surgery
‐ Major postoperative complications within 30 days after surgery
‐ Incidence of anastomotic leakage (a situation where the place where the surgeon joined or reconnected different parts of your digestive system, called an anastomosis, starts to leak) within 30 days after surgery
‐ Changes in body weight from the initial weight, measured at least six months after surgery
‐ The occurrence of bile reflux, inflammation in the remaining part of the stomach, or oesophagus inflammation, measured at least six months after surgery
What did we do?
We looked for studies that compared the uncut Roux-en-Y reconstruction with other types of reconstruction (Billroth I, Billroth II, and regular Roux-en-Y) after a distal gastrectomy for stomach cancer. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found 10 studies involving 1365 people, conducted in China and South Korea. Of these, eight studies, which included 1167 participants, contributed data to our analyses.
In our comparison of uncut Roux-en-Y and Billroth II reconstructions, uncut Roux-en-Y reconstruction may make little to no difference to major postoperative complications, incidence of anastomotic leakage, and the occurrence of remnant gastritis, but we are very uncertain about these results. It may make little to no difference to changes in body weight, but may reduce the occurrence of bile reflux.
In our comparison of uncut Roux-en-Y with Roux-en-Y reconstruction, uncut Roux-en-Y reconstruction may have little or no effect on major postoperative complications and incidence of anastomotic leakage. It may increase the occurrence of bile reflux, but may make little to no difference to the occurrence of remnant gastritis and oesophagitis. We are very uncertain about the above results.
What are the limitations of the evidence?
We have little confidence in the evidence because the studies were small and results varied widely. Moreover, very few studies reported our main outcomes. It is likely that future research could change our understanding of this topic. More comprehensive studies are needed to provide clearer, more reliable answers.
How up-to-date is this evidence?
This evidence is up-to-date to November 2023.
Given the predominance of low- to very low-certainty evidence, this Cochrane review faces challenges in providing definitive clinical guidance. We found the majority of critical outcomes may be comparable between the uncut Roux-en-Y reconstruction and other methods, but we are very uncertain about most of these results. Nevertheless, it indicates that uncut Roux-en-Y reconstruction may reduce the incidence of bile reflux compared to Billroth-II reconstruction, albeit with low certainty. In contrast, compared to Roux-en-Y reconstruction, uncut Roux-en-Y may increase bile reflux incidence, based on very low-certainty evidence.
To strengthen the evidence base, further rigorous and long-term trials are needed. Additionally, these studies should explore variations in surgical procedures, particularly regarding uncut devices and methods to prevent recanalisation. Future research may potentially alter the conclusions of this review.
Choosing an optimal reconstruction method is pivotal for patients with gastric cancer undergoing distal gastrectomy. The uncut Roux-en-Y reconstruction, a variant of the conventional Roux-en-Y approach (or variant of the Billroth II reconstruction), employs uncut devices to occlude the afferent loop of the jejunum. This modification is designed to mitigate postgastrectomy syndrome and enhance long-term functional outcomes. However, the comparative benefits and potential harms of this approach compared to other reconstruction techniques remain a topic of debate.
To assess the benefits and harms of uncut Roux-en-Y reconstruction after distal gastrectomy in patients with gastric cancer.
We searched CENTRAL, PubMed, Embase, WanFang Data, China National Knowledge Infrastructure, and clinical trial registries for published and unpublished trials up to November 2023. We also manually reviewed references from relevant systematic reviews identified by our search. We did not impose any language restrictions.
We included randomised controlled trials (RCTs) and quasi‐RCTs comparing uncut Roux-en-Y reconstruction versus other reconstructions after distal gastrectomy for gastric cancer. The comparison groups encompassed other reconstructions such as Billroth I, Billroth II (with or without Braun anastomosis), and Roux-en-Y reconstruction.
We used standard Cochrane methodological procedures. The critical outcomes included health-related quality of life at least six months after surgery, major postoperative complications within 30 days after surgery according to the Clavien-Dindo Classification (grades III to V), anastomotic leakage within 30 days, changes in body weight (kg) at least six months after surgery, and incidence of bile reflux, remnant gastritis, and oesophagitis at least six months after surgery. We used the GRADE approach to evaluate the certainty of the evidence.
We identified eight trials, including 1167 participants, which contributed data to our meta-analyses. These trials were exclusively conducted in East Asian countries, predominantly in China. The studies varied in the types of uncut devices used, ranging from 2- to 6-row linear staplers to suture lines. The follow-up periods for long-term outcomes spanned from 3 months to 42 months, with most studies focusing on a 6- to 12-month range. We rated the certainty of evidence from low to very low.
Uncut Roux-en-Y reconstruction versus Billroth II reconstruction
In the realm of surgical complications, very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Billroth II reconstruction may make little to no difference to major postoperative complications (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.24 to 4.05; I² = 0%; risk difference (RD) 0.00, 95% CI -0.04 to 0.04; I² = 0%; 2 studies, 282 participants; very low-certainty evidence) and incidence of anastomotic leakage (RR 0.64, 95% CI 0.29 to 1.44; I² not applicable; RD -0.00, 95% CI -0.03 to 0.02; I² = 32%; 3 studies, 615 participants; very low-certainty evidence). We are very uncertain about these results.
Focusing on long-term outcomes, low- to very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Billroth II reconstruction may make little to no difference to changes in body weight (mean difference (MD) 0.04 kg, 95% CI -0.84 to 0.92 kg; I² = 0%; 2 studies, 233 participants; low-certainty evidence), may reduce the incidence of bile reflux into the remnant stomach (RR 0.67, 95% CI 0.55 to 0.83; RD -0.29, 95% CI -0.43 to -0.16; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 3 to 7; 1 study, 141 participants; low-certainty evidence), and may have little or no effect on the incidence of remnant gastritis (RR 0.27, 95% CI 0.01 to 5.06; I2 = 78%; RD -0.15, 95% CI -0.23 to -0.07; I2 = 0%; NNTB 7, 95% CI 5 to 15; 2 studies, 265 participants; very low-certainty evidence).
No studies reported on quality of life or the incidence of oesophagitis.
Uncut Roux-en-Y reconstruction versus Roux-en-Y reconstruction
In the realm of surgical complications, very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Roux-en-Y reconstruction may make little to no difference to major postoperative complications (RR 4.74, 95% CI 0.23 to 97.08; I² not applicable; RD 0.01, 95% CI -0.02 to 0.04; I² = 0%; 2 studies, 256 participants; very low-certainty evidence) and incidence of anastomotic leakage (RR 0.34, 95% CI 0.05 to 2.08; I² = 0%; RD -0.02, 95% CI -0.06 to 0.02; I² = 0%; 2 studies, 213 participants; very low-certainty evidence). We are very uncertain about these results.
Focusing on long-term outcomes, very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Roux-en-Y reconstruction may increase the incidence of bile reflux into the remnant stomach (RR 10.74, 95% CI 3.52 to 32.76; RD 0.57, 95% CI 0.43 to 0.71; NNT for an additional harmful outcome (NNTH) 2, 95% CI 2 to 3; 1 study, 108 participants; very low-certainty evidence) and may make little to no difference to the incidence of remnant gastritis (RR 1.18, 95% CI 0.69 to 2.01; I² = 60%; RD 0.03, 95% CI -0.03 to 0.08; I² = 0%; 3 studies, 361 participants; very low-certainty evidence) and incidence of oesophagitis (RR 0.82, 95% CI 0.53 to 1.26; I² = 0%; RD -0.02, 95% CI -0.07 to 0.03; I² = 0%; 3 studies, 361 participants; very low-certainty evidence). We are very uncertain about these results.
Data were insufficient to assess the impact on quality of life and changes in body weight.