Randomized controlled trial of uncut Roux-en-Y vs Billroth II reconstruction after distal gastrectomy for gastric cancer: Which technique is better for avoiding biliary reflux and gastritis?

Abstract

Aim: To identify which technique is better for avoiding biliary reflux and gastritis between uncut Roux-en-Y and Billroth II reconstruction.

Methods: A total of 158 patients who underwent laparoscopy-assisted distal gastrectomy for gastric cancer at the First Hospital of Jilin University (Changchun, China) between February 2015 and February 2016 were randomized into two groups: uncut Roux-en-Y (group U) and Billroth II group (group B). Postoperative complications and relevant clinical data were compared between the two groups.

Results: According to the randomization table, each group included 79 patients. There was no significant difference in postoperative complications between groups U and B (7.6% vs 10.1%, P = 0.576). During the postoperative period, group U stomach pH values were lower than 7 and group B pH values were higher than 7. After 1 year of follow-up, group B presented a higher incidence of biliary reflux and alkaline gastritis. However, histopathology did not show a significant difference in gastritis diagnosis (P = 0.278), and the amount of residual food and gain of weight between the groups were also not significantly different. At 3 mo there was no evidence of partial recanalization of uncut staple line, but at 1 year the incidence was 13%.

Conclusion: Compared with Billroth II reconstruction, uncut Roux-en-Y reconstruction is secure and feasible, and can effectively reduce the incidence of alkaline reflux, residual gastritis, and heartburn. Despite the incidence of recanalization, uncut Roux-en-Y should be widely applied.

Keywords: Alkaline gastritis; Bile reflux; Billroth II; Gastric cancer; Uncut Roux-en-Y.

Figure 1

Two kinds of reconstruction after laparoscopy-assisted distal gastrectomy. A: Uncut Roux-en-Y reconstruction; B: Billroth II reconstruction. All included patients underwent LADG with D2 lymphadenectomy, which was performed by the same surgical team. Then, two groups underwent different reconstructions as shown.

Figure 2

Bile reflux grades. During the endoscopic examination, a modified biliary reflux classification in three grades was applied. A: grade 0, absence of bile (Figure 2A); B: grade 1, small amount of bile located in the bottom of residual stomach without overflow (Figure 2B); C: grade 2, bile spilled into the jejunum with tidal rhythm (Figure 2C).

Figure 3

Biopsy for gastritis. Gastric tissue biopsies were taken to compare the degree of gastritis: A: grade 0 [hematoxylin and eosin (HE) staining, × 200], normal mucosa with small amount of lymphocytes and transparent microscopic field; B: grade 1 (HE, × 200), intermediate between grades 0 and 2 with a moderate amount of lymphocytes or other kinds of inflammatory cells; C: grade 2 (HE, × 400), acute inflammation with fully infiltrated tissue by lymphocytes or other kinds of inflammatory cells.

Figure 4

Perioperative potential of hydrogen (pH) in the stomach of the patients. Change of potential of hydrogen (pH) in the remnant stomach was recorded at 8:00 am on the day before surgery as well as 1-5 d after surgery. During the postoperative period, all stomach pH values of group U patients were below 7.00. Conversely, all stomach pH values of group B patients were higher than 7.00.