Published online Jun 27, 2022. doi: 10.4240/wjgs.v14.i6.594
Peer-review started: November 22, 2021
First decision: December 27, 2021
Revised: January 9, 2022
Accepted: May 13, 2022
Article in press: May 13, 2022
Published online: June 27, 2022
Processing time: 216 Days and 20 Hours
Gastric cancer (GC) patients have a poor prognosis and high mortality. The efficacy and safety of uncut Roux-en-Y (URY) anastomosis after laparoscopic distal gastrectomy (LDG) are still controversial.
The URY gastrojejunostomy reduces these complications by blocking the entry of bile and pancreatic juice into the residual stomach and preserves the impulse originating from the duodenum, while BII combined Braun (BB) anastomosis reduces the postoperative biliary reflux without Roux-Y stasis syndrome. Therefore, the purpose of this study was to compare the efficacy and safety of laparoscopic URY with BB anastomosis in patients with GC who underwent radical distal gastrectomy.
The purpose of this study was to perform a systematic review and meta-analysis to evaluate the application value of URY anastomosis in LDG.
PubMed, Embase, Web of science, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang, Chinese Biomedical Database, and VIP Database for Chinese Technical Periodicals (VIP) were used to search relevant studies published from January 1994 to August 18, 2021. The following databases were also used in our search: Clinicaltrials.gov (https://clinicaltrials.gov), Data Archiving and Networked Services, the World Health Organization International Clinical Trials Registry Platform Search Portal (https://www.who.int/clinical-trials-registry-platform/the-ictrp-search-portal), and the reference lists of articles and relevant conference proceedings in August 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com). We cited high-quality references using its results analysis functionality. The methodological quality of the eligible randomized clinical trials (RCTs) was evaluated using the Cochrane Risk of Bias Tool, and the non-RCTs were evaluated using the Newcastle-Ottawa scale. Statistical analyses were performed using Review Manager (Version 5.4).
Eight studies involving 704 patients were included in this meta-analysis. The incidence of reflux gastritis [odds ratio = 0.07, 95% confidence interval (CI): 0.03-0.19, P < 0.00001) was significantly lower in the URY group than in the BB group. The pH of the postoperative gastric fluid was lower in the URY group than in the BB group at 1 d [mean difference (MD) = -2.03, 95%CI: (-2.73)-(-1.32), P < 0.00001] and 3 d [MD = -2.03, 95%CI: (-2.57)-(-2.03), P < 0.00001] after the operation. However, no significant difference in all the intraoperative outcomes was found between the two groups.
This work demonstrated that URY is superior to BB in patients with GC when the postoperative outcome is considered. Therefore, this evidence supports the recommendation of URY gastrojejunostomy for gastrointestinal reconstruction after LDG.
Several limitations were present in this study. First, most of the included studies were conducted in tertiary centers, and the recruited patients were carefully selected and had relatively low morbidity and low body mass index, which might result in a limited generalization of these findings. Second, the included studies are mostly observational ones, thus, with a potential selection bias. Third, the included RCTs has a certain bias in the implementation of blinding. This is inevitable because the surgeon cannot perform the procedure without knowing the assigned procedure. Therefore, a large sample size and a rigorously designed RCTs are needed for confirming our results. Finally, all the LDG procedures were performed in China, probably because the incidence of GC is higher in East Asia than in most Western countries and distal tumors are more common in Eastern countries. Moreover, our hope is that this topic can attract the attention of surgeons in more countries.