Trial Information

A Prospective Randomised Study Comparing Billroth II With Roux-en-Y Reconstruction After Radical Distal Subtotal Gastrectomy for Gastric Cancer

Subtotal distal gastrectomy with lymphadenectomy offers the best chance of cure either alone
or in conjunction with other modalities for patients with operable distal gastric cancer.
After a subtotal gastrectomy the gastrointestinal continuity can be restored by various
techniques. Billroth I, Billroth II and Roux-en-Y reconstruction are all acceptable
procedure with each having its merits and demerits. The choice of reconstructive procedure
varies depending on individual Surgeons preference and institutional practice. There is
geographical difference in practice with majority of surgeons in the east favoring Billroth
I, while in the west; Roux-en-Y is more commonly employed (1). Billroth I vs Roux-en-Y
reconstruction has been extensively studied with a prospective series by Sounya Nunobe et al
that reported superior symptomatic and functional outcomes of Roux-en-Y procedure (2).
However a randomised trial by Makoto Ishikawa et al found limited advantages of Roux-en-Y
over Billroth I reconstruction (3). In this study Roux-en-Y had fewer problems related to
reflux of bile but a higher incidence of stasis in the Roux limb resulting in longer
hospital stay. Another reason that some surgeon avoids doing Roux-en-Y is a triad of post
operative symptoms including abdominal pain, vomiting and nausea called Roux-en-Y loop
syndrome (4,5). Billroth II reconstruction in comparison to Roux-en-Y is a simpler operation
with only one anastomosis and faster operating time (6). This has implications while
managing gastric cancer patients who may be malnourished and a simpler procedure may have
lesser risk of complications and yield better outcomes. Billroth II has been criticized for
increased reflux associated problem like esophagitis and gastritis, also noteworthy are risk
of afferent loop and dumping syndrome. Long term nutritional outcomes are similar for both
procedures (7).