Currently, TLDG has become a hot topic among surgeons. Ikeda O et al[18] demonstrated that TLDG is associated with less invasiveness, reduced blood loss, smaller incisions, and a lower incidence of postoperative infections compared to LDG. In addition, Kanaya S et al[19] reported the application of delta anastomosis, which facilitates the Billroth I procedure in TLDG. BillrothII has also been widely performed in TLDG due to its simplicity. Although the reconstruction process of the R-Y is more complex, surgeons have made modifications to make it equally easy and safe in TLDG. Takaori K et al[20] described the use of a linear stapler in isoperistaltic anastomosis R-Y for TLDG. Okuno K et al [21] proposed β-type R-Y anastomosis, which avoids the need for laparoscopic suturing.
Ideally, GI reconstruction after LDG should preserve residual gastric function, minimize long-term complications, and enhance postoperative quality of life over the long term. The typical reconstruction involves Billroth I, Billroth II, and Roux-en-Y procedures. Billroth I has the advantage of food passage in the duodenal pathway, but the risk of anastomotic fistula may be higher when the residual stomach is small; thus, this method is suitable for early-stage gastric patients[22]. In China, progressive gastric cancer is more common, and as a result, Billroth II and Roux-en-Y are more frequently performed. Billroth II has the advantage of low tension but increases the risk of bile reflux gastritis and reflux esophagitis[23]. As a result, Braun made an anastomosis between the efferent and afferent loop at 10–15 cm from the gastrojejunal anastomosis based on Billroth II in 1892, effectively diverting partial bile and pancreatic fluid [24]. Nevertheless, this method has limitations, where studies still detected bile reflux and residual gastritis postsurgery[25]. In contrast, the Roux-en-Y method has the advantage of low-tension anastomosis. The long Roux-en-Y limb between the gastrojejunal and jejunojejunal anastomosis is beneficial for anti-bile reflux[4]. Nevertheless, previous studies indicated that RSS is often associated with nausea and vomiting postsurgery, possibly due to the disruption of intestinal electrophysiological continuity, thus affecting the patient's QoL[26].
Surgical safety is a priority for surgeons when deciding the best reconstruction method. This study's findings suggested that the R-Y group had significantly longer operative and anastomosis times compared to the BII + B group. Meanwhile, there was no significant difference in blood loss or postoperative recovery between the groups, which was consistent with studies by Chi F and Cui LH [11, 27]. R-Y mesentery separation and jejunum dissection did not increase the risk of bleeding but prolonged the operative time. In addition, Yalikun A reported no significant difference in early postoperative complications between the R-Y (14.7%) and BII + B (7.5%) procedures, which is similar to Shishegar A's findings [28, 29]. In the present study, no significant differences were observed in the incidence of early complications (R-Y: 8.8% vs. BII + B: 10.6%) or late complications (R-Y: 10.5% vs. BII + B: 12.8%) between the two groups. Therefore, the safety of both procedures was comparable for TLDG.
RSS symptoms include stomach discomfort, bloating, and vomiting and are caused by delayed emptying in nonmechanical obstruction after the Roux-en-Y procedure, with an incidence rate of 10–30%[30]. The mechanism may be related to intestinal interruption, resulting in slow waves emitted by the "Y" limb that caused the limb to move retrogradely toward gastric motility[26].
However, the advancement of anastomotic devices and the modification of the traditional R-Y by some surgeons in recent studies have significantly decreased the incidence of RSS. Gustavsson S demonstrated that an excessively long Roux-Y limb is a risk factor for RSS[12]. Motoyama K and An JY controlled the length of the "R-Y limb" to 25–30 cm, and none experienced RSS postoperatively[31, 32]. Additionally, our study utilized isoperistaltic Roux-en-Y anastomosis, which aligns more closely with human physiology and facilitates food emptying compared to antiperistaltic anastomosis[33]. Only one patient experienced RSS (1.8%), which was significantly lower than that in previous reports. Therefore, it was postulated that the 25-cm R-Y limb and the isoperistaltic gastrojejunal anastomosis potentially reduced RSS incidence.
Alkaline reflux gastritis caused by bile reflux is a significant factor that impacts the patient's postoperative life[34]. Refluxed bile damage to the residual gastric mucosa results in residual gastritis, reflux esophagitis, and an increased risk of esophageal and residual gastric cancer[35, 36]. However, the effectiveness of the R-Y and BII + B procedures in preventing bile reflux remains controversial. Lee MS and Park JY reported that endoscopic findings a year after surgery exhibited significantly higher bile reflux and a higher degree of residual gastritis in the BII + B group than in the R-Y group [37, 38]. In contrast, Yalikun A indicated that a modified BII + B with prolonged afferent and efferent loops had postoperative bile reflux and residual gastritis comparable to Roux-en-Y but may increase the risk of afferent limb torsion and internal hernia[38].
In the present study, the degree of residual gastritis and the occurrence of bile reflux were significantly lower in the endoscopic findings of R-Y than BII + B at years 1 and 3 postsurgery. The superiority of R-Y in terms of anti-reflux effects can be attributed to several factors. First, the Billroth II gastrojejunal anastomosis lacks anti-reflux properties, allowing bile from the afferent loop to flow into the residual stomach along with intestinal peristalsis. Second, even with the Braun anastomosis diverting bile, some bile may still reflux to the residual stomach since the Braun anastomosis is positioned only 10–15 cm away from the gastrojejunostomy. In contrast, R-Y anastomoses the proximal jejunum with the distal jejunum, preventing the direct flow of bile into the remaining stomach. Finally, the long and steep limb between the gastrojejunal and jejunojejunal anastomosis in R-Y makes bile reflux into the residual stomach difficult.
Chung JH's endoscopic findings at 6–32 months demonstrated that the proportion of grade 2 and 3 residual gastritis increased from 73.0–86.1% in the BII + B group, and the incidence of reflux esophagitis rose from 1–15.7%[39]. Similarly, Choi C's endoscopic findings at year 2 postoperatively showed increased bile reflux and an aggravated degree of residual gastritis in the BII + B group compared to year 1, with significantly higher reflux esophagitis compared to the R-Y group[40]. In the current study, the proportion of grade 2 and 3 residual gastritis increased in the BII + B group at year 3 postoperatively by 86.2% compared with 74.5% at year 1. Conversely, there was no significant change in the R-Y group. Furthermore, there was no significant difference in the degree of reflux esophagitis between the two groups in year 1, but in year 3, the occurrence was significantly lower in the R-Y group than in the BII + B group (P = 0.023). These findings suggest that the degree of residual gastritis and reflux esophagitis due to bile reflux may worsen over time, indicating that the R-Y group has a better long-term prognosis.
Moreover, when the residual stomach is smaller, the distance between the gastrojejunal anastomosis and the cardia is reduced. This shortened distance increases the likelihood of bile damaging the esophageal mucosa, leading to reflux esophagitis. Therefore, the Roux-en-Y method is advantageous when the patient's residual stomach is small. Additionally, the two groups had no significant differences in BMI, hemoglobin, protein, albumin to the preoperative ratio at year 3 postsurgery. Likewise, Lee Y and Park JY also reported similar results[37, 38].
The EORTC QLQ-30 and STO22 scales are frequently combined internationally to evaluate QoL in patients with gastric cancer, providing a comprehensive assessment of the physical role, social functioning, general health, and patient-specific symptoms of gastric cancer. However, long-term QoL assessments for R-Y and BII + B remain lacking. This study’s results found no significant differences in the EORTC-QLQ-30 scores. Similarly, there was no significant difference in STO22 scores between the groups, despite the lower epigastric pain score in the R-Y group. In contrast, the reflux score for R-Y was significantly lower than that for BII + B in this study. In summary, postoperative epigastric pain and reflux symptoms were reduced in the R-Y group and improved the patient's long-term QoL. However, this study has limitations, as it is a single-center retrospective study.