E. Strong (ed.). Gastric cancer. Principles and practice. Springer (2015)
Methods for reconstruction
Distal gastrectomy (Fig. 12.1c) includes all procedures that leave the esophago-gastral junction intact, i.e., antrectomy, 2/3 and 4/5 gastric resections. The following reconstructions are most frequently used:
- Billroth I, characterized by a gastro-duodenal anastomosis
- Billroth II, characterized by a gastro-jejunostomy of the remaining stomach to the first jejunal loop
- Roux-en-Y, characterized by a gastro-jejunostomy of the remaining stomach to an excluded jejunal limb and an end to side jejuno-jejunostomy between the excluded jejunum to the first jejunal loop
The reconstruction according to Billroth I (BI) was first performed in 1881 and is characterized by an anastomosis between the remaining stomach and the duodenum (Fig. 12.2a) . Potential advantages of this procedure include the maintenance of a physiological gastro-duodenal passage of the food. Nevertheless, the BI reconstruction is restricted to cases with a limited resection of the distal stomach due to the restricted mobilization possibilities of the duodenum and remaining stomach to establish a tension-free anastomosis. Furthermore, a limited distal resection is contraindicated in most cases of invasive stomach cancer, thus leaving the BI reconstruction an option mainly after resection of benign lesions, noninvasive tumors, or early malignant lesions. It should be noted, that this type of reconstruction, although commonly not used in Western countries, is an often used mode of reconstruction in Asia.
Fig. 12.1. Anatomy and resection procedures of the stomach. a The four sections of the human stomach. b) Schematic drawing of proximal gastrectomy. c) Schematic drawing of distal gastrectomy. d) Schematic drawing of total gastrectomy
Fig. 12.2. Reconstruction following distal gastrectomy. a Schematic drawing of Billroth I reconstruction. b) Schematic drawing of Billroth II reconstruction. c) Schematic drawing of Roux-en-Y reconstruction
The reconstruction according to Billroth II (BII), first performed in 1885, is characterized by a gastro-jejunostomy of the remaining stomach to the first jejunal loop (Fig. 12.2b) . The advantage of this procedure in comparison to BI is the tension-free anastomosis. The main disadvantage is the un-physiological passage of the bilio-pancreatic juice through the stomach due to the missing pylorus. Some patients develop the so-called afferent loop syndrome (ALS), which is caused by an accumulation of bilio-pancreatic juice in the afferent jejunal segment due to a hampered drainage that leads to pain, nausea, and vomiting.
The Roux-en-Y (RY) reconstruction was first described by Woelfler in 1883  and later popularized by C. Roux from 1893 onwards . The Roux-en-Y reconstruction is characterized (after distal resection) by a gastro-jejunostomy of the remaining stomach to a jejunal limb (mostly the second jejunal loop), which has been excluded from the normal intestinal passage (Fig. 12.2c).
The procedure involves the blind closure of the proximal duodenum and a second anastomosis between the ascended jejunal limb and the first jejunal loop that carries the bilio-pancreatic juice. The main advantage of the procedure is the reduction of bilio-pancreatic reflux into the stomach due to the distance between the stomach and the jejuno-jejunostomy, which normally has a length of at least 40 cm. The main disadvantage is the exclusion of the duodenal segment from the normal intestinal passage. This exclusion might be the reason for the development of the so-called Roux syndrome in up to 10% of patients, characterized by a delayed emptying of the stomach into the efferent jejunal loop in the presence of a nonconstricted gastro-jejunal anastomosis.
Summary of data from clinical trials comparing reconstructions after distal gastrectomy
A meta-analysis concentrating on the comparison of BI vs. RY for reconstruction after distal gastrectomy for stomach cancer combined three RCTs . In addition, this study also performed a meta-analysis on nine observational clinical studies (OCTs). Not all parameters were available in all RCTs. A significant difference in favor of a RY reconstruction compared to BI could be detected for bile reflux (2 RCTs, 71 vs. 75 patients) and remnant gastritis (2 RCTs, 181 vs. 182 patients), while operation time and hospital stay were significantly longer after RY vs. BI (3 RCTs, 240 vs. 238 patients). Of note, reflux esophagitis showed only a tendency, but was not significantly lower after RY (3 RCTs, 227 vs. 231 patients). This trend is substantiated by a significant reduction of reflux esophagitis after RY vs. BI in the meta-analysis of OCTs (5 OCTs, 322 vs. 397 patients). The anastomotic leak rate and anastomotic stricture rate was equally high in both reconstructions (3 RCTs, 240 vs. 238 patients). Taken together, the meta-analysis demonstrated clinical benefits concerning the reduction of bile acid reflux and its consequences for a RY compared to a BI reconstruction.
A second meta-analysis comparing BI or RY including RCTs of distal gastrectomies of both nonmalignant and malignant patient cohorts is available . This meta-analysis did show no significant difference in total postoperative complications or specifically in the anastomotic leak rate in RY vs. BI (4 RCTs, 185 vs. 189 patients). A significant lower rate of reflux symptoms (5 RCTs, 381 vs. 391 patients), reflux esophagitis (6 RCTs, 340 vs. 372 patients), and gastritis (7 RCTs, 337 vs. 377 patients) was found after RY reconstruction vs. BI, while no difference for dumping syndrome was detected (5 RCTs, 361 vs. 391 patients). No significant difference for operation time was evident (3 RCTs, 106 vs. 114), patients after RY vs. BI had a significantly shorter hospital stay (2 RCTs, 91 vs. 91 patients).
The same publication also reported a metaanalysis comparing RY vs. BII reconstructions. No significant differences in total postoperative complications (2 RCTs, 65 vs. 61 patients), while dumping syndrome (2 RCTs, 83 vs. 78 patients), reflux symptoms (2 RCTs, 83 vs. 78 patients), reflux esophagitis (3 RCTs, 60 vs. 68 patients), and gastritis (6 RCTs, 114 vs. 148 patients) were significantly lower in RY vs. BII reconstructed patients.
A third meta-analysis within the same publication compared BI vs. BII reconstructions. While significantly less overall complications (4 RCTs, 738 vs. 280 patients) as well as specifically less anastomotic leaks (3 RCTs, 708 vs. 248 patients) were found in BI vs. BII reconstructed patients, the mortality rate was not significantly different (3 RCTs, 697 vs. 258 patients). Of note, the local recurrence rate was significantly higher after BI vs. BII reconstruction (2 RCTs, 71 vs. 75 patients). Concerning reflux symptoms (2 RCTs, 66 vs. 39 patients), dumping syndrome (2 RCTs, 66 vs. 39 patients), reflux esophagitis (3 RCTs, 68 vs. 67 patients), and gastritis (5 RCTs, 113 vs. 106 patients) no significant differences were found between BI and BII reconstructions.
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