|Year : 2020 | Volume
| Issue : 3 | Page : 150-154
Prospective randomised study comparing Billroth II with Braun anastomosis versus Roux-en-Y reconstruction after radical distal gastrectomy for gastric cancer
Sriram Parthasarathy1, K Radhakrishna1, TC Kalawat2, BV Phaneendra3, Venkatarami Reddy Vutukuru1
1 Department of Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Nuclear Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
|Date of Submission||06-Mar-2020|
|Date of Decision||01-May-2020|
|Date of Acceptance||13-Jul-2020|
|Date of Web Publication||27-Oct-2020|
Venkatarami Reddy Vutukuru
Professor, Department of Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517 507, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Enterogastric reflux of bile is a major cause of morbidity following distal gastrectomy. Various reconstructive methods were developed to overcome this.
Methods: A prospective randomised study included all patients undergoing distal gastrectomy for gastric cancer was conducted during the period June 2012 and November 2016. After resection, they were randomized to undergo Billroth II with Braun anastomosis (BEE) (n = 28) or Roux-en-Y (RY) gastrojejunostomy (n = 26). Endoscopy and biliary scintigraphy were done at 3 months to assess the severity of gastritis and the presence of bile reflux in remnant stomach. Stomach was biopsied for histopathology. Quality of life (QOL) was assessed using gastric cancer-specific questionnaire.
Results: Demographics and nutritional status was similar. Intraoperative variables, post-operative recovery and hospital stay were not statistically different. Remnant stomach in BEE group showed more severe and extensive gastritis than RY group. The incidence of bile reflux on endoscopy was statistically significantly high in BEE (P < 0.0001). The histological findings of endoscopic biopsies were similar. The incidence of bile reflux on scintigraphy was lower in RY group (10.7% vs. 46.2%; P = 0.03). The QOL symptom score was similar.
Conclusions: The incidence of bile reflux and severity of gastritis is less in patients who underwent RY gastrojejunostomy when compared to Billroth II with Braun anastomosis without any significant difference in QOL.
Keywords: Bile reflux, Braun anastomosis, distal gastrectomy, Roux-en-Y gastrojejunostomy
|How to cite this article:|
Parthasarathy S, Radhakrishna K, Kalawat T C, Phaneendra B V, Vutukuru VR. Prospective randomised study comparing Billroth II with Braun anastomosis versus Roux-en-Y reconstruction after radical distal gastrectomy for gastric cancer. J Clin Sci Res 2020;9:150-4
|How to cite this URL:|
Parthasarathy S, Radhakrishna K, Kalawat T C, Phaneendra B V, Vutukuru VR. Prospective randomised study comparing Billroth II with Braun anastomosis versus Roux-en-Y reconstruction after radical distal gastrectomy for gastric cancer. J Clin Sci Res [serial online] 2020 [cited 2020 Nov 25];9:150-4. Available from: https://www.jcsr.co.in/text.asp?2020/9/3/150/298953
| Introduction|| |
Billroth II is the most common method of reconstruction after distal gastrectomy for gastric cancer due to its simplicity. Enterogastric reflux of bile acids is a major drawback which causes the morphologic changes and symptoms that adversely affect the quality of life (QOL). Studies have shown that enterogastric reflux alone can cause gastric adenocarcinoma in animal models and also Barrett's esophagitis and malignancy.,, Hence, surgical procedures that prevent entrogastric reflux are not only important to improve QOL but also to reduce the risk of carcinogenesis in gastric remnant and oesophagus. Therefore, various reconstructive methods to divert the bile flow away from the gastric remnant were developed. More commonly used are Roux-en-Y (RY) gastrojejunostomy and Billroth II with Braun anastomosis (BEE). Braun anastomosis added to Billroth II reconstruction may effectively decrease bile reflux. However, other studies,, reported that Braun anastomosis are not effective in preventing bile reflux and suggested that RY gastrojejunostomy was superior to BEE. However, RY gastrojejunostomy is a complex procedure and has several disadvantages such as the development of stomal ulcer, increased incidence of gallstone formation, difficulty in endoscopic approach of ampulla of Vater and the possibility of Roux stasis syndrome. Hence, a prospective randomized study was conducted to compare the incidence of bile reflux, endoscopic and histological changes in the gastric remnant and post-operative morbidity, mortality and QOL between two reconstructive methods.
| Material and Methods|| |
This prospective, randomised study conducted during the period June 2012 and November 2016, after obtaining approval from the Institutional Research and Ethics Committees. It was postulated that 5% of patients in RY reconstruction will experience poor clinical symptoms compared to 25% with BEE group. To achieve the statistical significance with 95% power and a 2-sided test of 5% for this 20% clinical difference, 80 participants for each arm were required factoring a 10% attrition rate for mortality and lost to follow-up.
The present study included all patients with histologically confirmed adenocarcinoma of the distal stomach deemed suitable for radical distal gastrectomy with curative intent. Patients who had previous gastric or small bowel surgery, additional adjacent organ resection and palliative resection were excluded. Following radical resection, patients were randomized to undergo either RY gastrojejunostomy or BEE using opaque-sealed envelope technique using blocks of 4.
In BEE group, a retrocolic loop of jejunum with afferent loop measuring 30 cm in length was used to perform side-to-side gastrojejunostomy in four layers using outer 2-0 polypropylene and inner 2-0 polyglactin continuous sutures. Then, side-to-side jejunojejunostomy was done between afferent and efferent loops 20 cm distal to gastrojejunostomy in four layers using outer 3-0 polypropylene and inner 3-0 polyglactin continuous sutures. In RY group, jejunum is divided at 25 cm from duodenojejunal flexure using linear cutting stapler. Distal transected limb is used for side-to-side gastrojejunostomy in four layers using outer 2-0 polypropylene and inner 2-0 polyglactin continuous sutures. Proximal transected end is anastomosed to distal limb 45 cm distal to gastrojejunostomy in four layers using outer 3-0 polypropylene and inner 3-0 polyglactin continuous sutures. Intraoperative parameters such as operative time and quantity of blood loss were noted. Post-operative recovery was assessed in two groups based on the amount of nasogastric aspiration, resumption of oral liquids and solids and duration of hospital stay.
Endoscopic evaluation was done on all patients at 3 months post-operatively to evaluate for residual food, degree and extent of gastritis and bile reflux. They were graded according to the Residue, Gastritis, Bile (RGB) classification of remnant stomach. Remnant stomach was biopsied at four different areas during endoscopy for the histopathological examination. Histopathological assessment of endoscopic biopsies was done by pathologist blinded to endoscopic and scintigraphic results. Updated Sydney system was used for grading of gastritis. Reflux esophagitis following gastroesophageal reflux was evaluated endoscopically and graded using the Los Angeles classification.
All patients underwent hepatobiliary scintigraphy at 3 months post-operatively to look for enterogastric reflux. If tracer bile gets localised in the left upper quadrant of the abdomen, it is considered as a positive observation for reflux. All patients were given gastric cancer specific health-related QOL questionnaire [European Organization for Research and Treatment of Cancer Quality of Life questionnaire (EORTC QLQ-ST022)]before undergoing scintigraphy and endoscopy. The outcomes measured were the incidence of bile reflux, reflux gastritis, reflux esophagitis, morbidity, mortality and QOL in two groups.
Data were collected and analysed. Mean and standard deviation were calculated for the continuous variables. Mann–Whitney U-test was used to compare the median between the two groups as sample size was small. Statistical analysis for the categorical variables was performed by computing the frequencies in each category. Frequency differences were compared using the Chi-square or Fischer's exact test when appropriate. All tests were two tailed. A P < 0.05 was considered as statistically significant.
| Results|| |
A total of 118 patients were assessed for eligibility; 38 patients were excluded from the study. Reasons for the exclusion were additional organ resection in 17 patients (colon in 9, spleen in 6 and gall bladder in 2), previous gastric resection in four patients, previous small bowel resection in eight patients and nine patients had palliative resection. After exclusion, 80 patients were randomised into two groups (40 in each group). Twelve patients in RY group and 14 patients in BEE group lost to follow-up or discontinued intervention or died on follow-up. Hence, 28 patients in RY group and 26 patients in BEE group were available for the final analysis [Figure 1].
Demographic characteristics and pre-operative nutritional status (assessed by body mass index, haemoglobin, serum total proteins and serum albumin) of patients in two groups are shown in [Table 1]. Demographics and nutritional status in two groups was similar. Intraoperative variables, post-operative recovery and duration of hospital stay in two groups are shown in [Table 2]. Operative time and blood loss were similar in two groups. Nasogastric tube drainage was higher in BEE group than in RY group, but this is not statistically significant. Post-operative recovery was similar in two groups. There was no post-operative mortality in either group.
The findings of endoscopic evaluation of remnant stomach (RGB classification) at 3 months post-operatively were compared in two groups [Table 3]. Tendency of having residual food was not different in two groups. However, remnant stomach after Billroth II with Braun anastomosis showed significantly more severe and extensive gastritis than after RY gastrojejunostomy. There was a statistically significant difference in the incidence of bile reflux on endoscopy (P < 0.0001). None of the patients with RY reconstruction showed evidence of bile reflux, whereas all except one patient showed evidence of bile reflux in BEE reconstruction. On endoscopic evaluation, none of the patients in two groups showed evidence of reflux esophagitis. There was no statistically significant difference in histological findings of endoscopic biopsies of remnant stomach in two groups [Table 4]. On assessing bile reflux with hepatobiliary scintigraphy, the frequency of bile reflux was statistically significantly lower in the RY group than in the BEE group (10.7% vs. 46.2%; P = 0.03) [Table 5]. The QOL symptom score based on EORTC QLQ-ST022 questionnaire was similar in two groups [Table 6].
| Discussion|| |
There is a lack of consensus within surgeons regarding the type of reconstruction following radical distal gastrectomy. An ideal reconstruction technique should minimize post-operative morbidity and improve QOL. Currently, Billroth II with Braun anastomosis and RY gastrojejunostomy are the two commonly used reconstructive techniques. Bile reflux is a potential carcinogenic and as well can cause gastritis in remnant stomach and also reflux oesophagitis., In RY group, there was no evidence of bile reflux on endoscopy in all patients. Similar finding was reported in another study. However, in a study bile reflux was reported ub on 21% of patients in RY group. It was probably due to small length (25 cm) of the Roux limb used in that study; whereas in the present study, we have used a Roux limb of 45 cm length. The incidence of bile reflux on biliary scintigraphy was 10.7% in RY group, which was comparable to that reported in another study 3.7 However, in some studies, there was no bile reflux in any of their patients in RY group. Whereas in BEE group, 96% had evidence of bile reflux on endoscopy and 46% on scintigraphy. Similar biliary reflux rates (47%-53%) have ben reported in other studies., Hence, above findings suggest that Billroth II with Braun anastomosis is not as effective in preventing biliary reflux into gastric remnant when compared to RY gastrojejunostomy. The tendency of having residual food in the remnant stomach was not significantly different between two groups.
Endoscopy of the remnant stomach during the early post-operative period typically reveals the signs of acute inflammation and most of these signs disappear within 3 months. Hence, endoscopy findings after 3 months were considered. Endoscopic severity of gastritis in remnant stomach showed all patients in Grade 0 and 1 in RY group, whereas only 61% of patients were in Grade 0 and 1 in BEE group. The rest 39% of patients had more severe gastritis (Grade 2). The extent of gastritis in remnant stomach on endoscopy showed none of the patients in Grade 3 in RY group, whereas 15% of patients were in Grade 3 in BEE group. Although endoscopy showed a significant difference in the degree and extent of gastritis between two groups, histological evaluation did not reveal any difference in terms of inflammation, neutrophil activity, glandular atrophy, metaplasia and dysplasia. This may be because histological assessment was done at 3 months after the surgery which is a shorter observation period. In a study there was a significant difference in the severity of inflammation and metaplasia in remnant stomach between two groups when assessed at 1 year after the surgery. There was no significant difference in the QOL symptom score between two groups despite the more frequent bile reflux in BEE group. Howeever, it is difficult to establish a relationship between patient symptoms, reflux and endoscopy findings after gastrectomy.
The incidence of bile reflux and severity of gastritis is less in patients who underwent RY gastrojejunostomy when compared to Billroth II with Braun anastomosis without any significant difference in QOL.
Financial support and sponsorship
This study was financially supported by Sri Balaji Arogya Varaprasadini Scheme of Sri Venkateswara Institute of Medical Sciences and Tirumala Tirupati Devasthanams, Tirupati.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yoshino K. History of gastric cancer surgery. J Jpn Surg Soc 2000;101:855-60.
Svensson JO. Duodenogastric reflux after gastric surgery. Scand J Gastroenterol 1983;18:729-34.
Wetscher GJ, Hinder RA, Smyrk T, Perdikis G, Adrian TE, Profanter C. Gastric acid blockade with omeprazole promotes gastric carcinogenesis induced by duodenogastric reflux. Dig Dis Sci 1999;44:1132-5.
Goldstein SR, Yang GY, Curtis SK, Reuhl KR, Liu BC, Mirvish SS, et al
. Development of esophageal metaplasia and adenocarcinoma in a rat surgical model without the use of a carcinogen. Carcinogenesis 1997;18:2265-70.
Lillemoe KD, Johnson LF, Harmon JW. Role of the components of the gastroduodenal contents in experimental acid esophagitis. Surgery 1982;92:276-84.
Chan DC, Fan YM, Lin CK, Chen CJ, Chen CY, Chao YC. Roux-en-Y reconstruction after distal gastrectomy to reduce enterogastric reflux and helocobacter pylori infection. J Gastrointest Surg 2007;11:1732-1740.
Vogel SB, Drane WE, Woodward ER. Clinical and radionuclide evaluation of bile diversion by Braun enteroenterostomy: Prevention and treatment of alkaline reflux gastritis. An alternative to Roux-en-Y diversion. Ann Surg 1994;219:458-65.
Fukuhara K, Osugi H, Takada N, Takemura M, Higashino M, Kinoshita H. Reconstructive procedure after distal gastrectomy for gastric cancer that best prevents duodenogastroesophageal reflux. World J Surg 2002;26:1452-7.
Hoya Y, Mitsumori N, Yanaga K. The advantages and disadvantages of a Roux-en-Y reconstruction after a distal gastrectomy for gastric cancer. Surg Today 2009;39:647-51.
Kubo M, Sasako M, Gotoda T, Ono H, Fujishiro M, Saito D, et al
. Endoscopic evaluation of the remnant stomach after gastrectomy: Proposal for a new classification. Gastric Cancer 2002;5:83-9.
Dixon MF, Genta RM, Yardley JH, Correa P. Classification and grading of gastritis. The updated Sydney System. International workshop on the histopathology of gastritis, Houston 1994. Am J Surg Pathol 1996;20:1161-81.
Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, et al
. Endoscopic assessment of oesophagitis: Clinical and functional correlates and further validation of the los angeles classification. Gut 1999;45:172-80.
Vickery CW, Blazeby JM, Conroy T, Arraras J, Sezer O, Koller M, et al
. EORTC Quality of Life Group. Development of an EORTC disease-specific quality of life module for use in patients with gastric cancer. Eur J Cancer 2001;37:966-71.
Piessen G, Triboulet JP, Mariette C. Reconstruction after gastrectomy: Which technique is best? J Visc Surg 2010;147:e273-83.
Osugi H, Fukuhara K, Takada N, Takemura M, Kinoshita H. Reconstructive procedure after distal gastrectomy to prevent remnant gastritis. Hepatogastroenterology 2004;51:1215-8.
Sato T, Miwa K, Sahara H, Segawa M, Hattori T. The sequential model of Barrett's esophagus and adenocarcinoma induced by duodeno-esophageal reflux without exogenous carcinogens. Anticancer Res 2002;22:39-44.
Csendes A, Burgos AM, Smok G, Burdiles P, Braghetto I, Díaz JC. Latest results (12-21 years) of a prospective randomized study comparing Billroth II and Roux-en-Y anastomosis after a partial gastrectomy plus vagotomy in patients with duodenal ulcers. Ann Surg 2009;249:189-94.
Lee MS, Ahn SH, Lee JH, Park do J, Lee HJ, Kim HH, et al
. What is the best reconstruction method after distal gastrectomy for gastric cancer? Surg Endosc 2012;26:1539-47.
Shinoto K, Ochiai T, Suzuki T, Okazumi S, Ozaki M. Effectiveness of Roux-en-Y reconstruction after distal gastrectomy based on an assessment of biliary kinetics. Surg Today 2003;33:169-77.
Kojima K, Yamada H, Inokuchi M, Kawano T, Sugihara K. A comparison of Roux-en-Y and Billroth-I reconstruction after laparoscopy-assisted distal gastrectomy. Ann Surg 2008;247:962-7.
Lindecken KD, Salm B. The effectiveness of Braun anastomosis in Billroth II surgery. The role of hepatobiliry sequence scintigraphy (HBSS) in the diagnosis of bile flow following stomach resection. Rofo 1993;159:158-60.
Johnsson F, Joelsson B, Gudmundsson K, Greiff L. Symptoms and endoscopic findings in the diagnosis of gastroesophageal reflux disease. Scand J Gastroenterol 1987;22:714-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]