Clinical Study About Uncut Roux-en-Y And Billroth Ⅱ With Braun Anastomosis In Laparoscopic Distal Gastrectomy For Gastric Cancer

Research backgroundGastric cancer has been always threatening the life and health of people in China,which providing a severe situation during the prevention and treatment of the disease.By now,surgery is still an important method in the treatment of gastric cancer.With the development of science and technology and the application of novel medical instruments,laparoscopic technology has become more and more prevalent in the treatment of gastric cancer and won the favor of the majority of surgeons.In recent years,a number of prospective studies from China and foreign countries also confirmed that laparoscopic surgery not only has a safe and reliable effect in the treatment of early gastric cancer,but also become suitable for the treatment with advanced gastric cancer,and has equivalent short-term and long-term clinical efficacy compared with traditional laparotomy,so its application has been gradually popularized.The majority of Chinese patients with gastric cancer are diagnosed as advanced gastric cancer and have bad clinical stage,most of lesion are located in the distal stomach.Therefore,laparoscopic distal gastrectomy with D2 lymphadenectomy has become the standard surgical method for distal gastric cancer.The methods of digestive tract reconstruction after laparoscopic distal gastrectomy can be divided into Billroth Ⅰ anastomosis,Billroth Ⅱanastomosis,Billroth Ⅱ with Braun anastomosis,Roux-en-Y anastomosis,uncut Roux-en-Y anastomosis and so on.At present,which way is better is still unknown.As the treatment of gastric cancer becomes more and more standardized and accurate,the survival time of patients with gastric cancer is gradually prolonged,patients now begin to focus on a better quality of life.Surgeons are always looking forward to finding out an ideal digestive tract reconstruction method which not only have a safe and radical effect but also improve the quality of life and survival rate.Alkaline reflux gastritis is a common postoperative complication after surgery,which is often seen after Billroth Ⅱ anastomosis,and affects the quality of life of patients after surgery.In 1892,Braun modified the Billroth II anastomosis and increased a side-to-side anastomosis between afferent and efferent jejunal loop,which can prevent the digestive fluid reflux into the remnant stomach and reduce the incidences of alkaline reflux gastritis;Vogel first used radionuclide biliary scanning in 1994 to prove the diversion effect of Braun anastomosis,which provides a theoretical basis for Braun anastomosis to prevent alkaline reflux gastritis.However,relevant studies have shown that the anti-reflux effect of Braun anastomosis is limited,and the incidence of alkaline reflux gastritis is still high.Roux-en-Y anastomosis can effectively alleviate the occurrence of alkaline reflux gastritis,but patients with this anastomosis may suffer from Roux stasis syndrome(RSS),the symptoms include nausea、vomiting、abdominal pain and other discomfort,which may affects the quality of life after surgery.In order to prevent the occurrence of RSS syndrome,Van stiegmann and Goff reported the modified Roux-en-Y anastomosis in 1988,called uncut Roux-en-Y anastomosis,which was performed on the basis of Billroth Ⅱ with Braun anastomosis.The afferent jejunal loop was blocked without cutting it off to alleviate the occurrence of alkaline reflux gastritis.In 2005,Uyama et al.first reported the uncut Roux-en-Y anastomosis in the laparoscopic distal gastrectomy for gastric cancer,which showed the effectiveness of this anastomosis.The uncut Roux-en-Y anastomosis is similar with Billroth Ⅱ with Braun anastomosis.There is still controversy about whether it is necessary to block without cutting the jejunal input loop and which way is reliable to block the loop.There is no reliable clinical evidence about which has a better postoperative quality of life between the two groups.Therefore,a retrospective study was conducted to explore the clinical efficacy and postoperative quality of life between uncut Roux-en-Y anastomosis and Billroth Ⅱ with Braun anastomosis in laparoscopic distal gastrectomy for gastric cancer and provide better evidence for future clinical practice.MethodThe clinical data of patients who underwent laparoscopic distal gastrectomy in the Department of general surgery of the First Affiliated Hospital of the Army Medical University from January 2016 to December 2019 were collected and analyzed,finally,the information from 200 patients were collected,which including 108 patients with uncut Roux-en-Y anastomosis and 92 patients with Billroth Ⅱ with Braun anastomosis.The general data and perioperative conditions of the two groups were compared.Patients were followed up and the outcome of gastroscopy was evaluated and compared one year after the surgery,and the quality of life of cancer patients was assessed by using the Chinese version of the Quality of Life Questionnaire-Core 30(QLQ-C30)and the Quality of Life Questionnaire-Stomach 22(QLQSTO22)designed by the European Organization for Research and Treatment(EORTC).ResultThere was no significant difference in baseline data between the uncut Roux-en-Y anastomosis group and Billroth Ⅱ with Braun anastomosis group(all P > 0.05).There was no significant difference in the perioperative conditions and the incidence of postoperative complications between the two groups(all P > 0.05).Endoscopic evaluation was performed one year later,the uncut Roux-en-Y anastomosis group and Billroth Ⅱ with Braun anastomosis group had significant differences in gastric stasis(19.8% VS 37%,χ~2=11.199,P=0.024),gastritis(11.6% VS 34.2%,χ~2=20.892,P < 0.001),bile reflux(1.2% VS 28.8%,χ~2=25.237,P<0.001).No recanalization occurred in the uncut Roux-en-Y group.There was no significant difference in nutritional changes between the two groups before the surgery and one year after surgery.(all P > 0.05)One year after the surgery,the EORTC-QLQ-C30 scale was used,there was no significant difference between the uncut Roux-en-Y group and Billroth Ⅱ with Braun group in the scores of the overall health status;there were also no significant difference in the scores of physical function,role function,emotional function,cognitive function and social function and the scores of fatigue,nausea and vomiting,pain,dyspnea,insomnia,decreased appetite,constipation,diarrhea and economic difficulties(all P > 0.05).EORTC-QLQ-STO22 scale was used one year after operation.There was no significant difference in the scores of dysphagia,eating restriction,anxiety,dry mouth,taste,body image and hair loss between the two groups(all P > 0.05);while there was significant difference in the scores of pain and reflux symptoms between the uncut Roux-en-Y anastomosis group and Billroth Ⅱ with Braun anastomosis group(8.3 vs 16.7,Z=-2.342,P = 0.019;0 vs 5.6,Z =-2.284,P = 0.022).ConclusionThe uncut Roux-en-Y anastomosis is safe and reliable in laparoscopic distal gastrectomy and should be popularized.Compared with Billroth Ⅱ with Braun anastomosis,the uncut Rouxen-Y anastomosis has obvious advantages in reducing the incidences of gastric stasis,gastritis and bile reflux,and better quality of life of patients after surgery.