Revisiting Laparoscopic Reconstruction for Billroth 1 Versus Billroth 2 Versus Roux-en-Y After Distal Gastrectomy: A Systematic Review and Meta-Analysis in the Modern Era

  • Min Seo Kim
  • Yeongkeun Kwon
  • Eun Pyung Park
  • Liang An
  • Haeyeon Park
  • Sungsoo ParkEmail author
Scientific Review



In this modern era, laparoscopic distal gastrectomy (LDG) has largely replaced open distal gastrectomy for the treatment of gastric cancer; however, a quantitative review of reconstruction methods applied exclusively using LDG has not yet been published. Thereafter, we compared three reconstruction methods (Billroth I, Billroth II, and Roux-en Y) using the data derived solely from LDG patients.


A systematic search was conducted using electronic bibliographic databases (Google Scholar, PubMed, and Embase), for articles that compared reconstruction methods in LDG, published within the last decade. A systematic review comparing 12 outcome parameters and sensitivity analyses were performed to increase the statistical power and minimize the inconsistency and heterogeneity of results.


Twenty-three clinical trials involving 5797 patients were included in the meta-analysis. There were no significant differences in the postoperative recovery and intraoperative parameters, except for operation time. B1 demonstrated a significantly shorter operation time when compared with B2 and RY by 21.6 min (P < 0.0001) and 44.69 min (P < 0.0001), respectively. In terms of postoperative endoscopic symptoms, RY was significantly superior to B1 and B2 for bile reflux (P < 0.001) and remnant gastritis (P < 0.001). For postoperative complications, B1 showed a significantly lower rate of postoperative morbidity than did RY and B2 (P = 0.0006 and P = 0.0005, respectively).


Our study is the first meta-analysis comparing anastomoses in LDG and introduces novel criteria for consideration when selecting reconstructions in LDG. Considering the significant differences in postoperative complications and endoscopic symptoms, these two parameters lay reasonable groundwork for guiding the surgeon’s choice of reconstruction.



Laparoscopic distal gastrectomy


Open distal gastrectomy


Billroth 1


Billroth 2





This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI) and funded by the Ministry of Health & Welfare, Republic of Korea (Grant Number: HC17C0050).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

268_2019_4943_MOESM1_ESM.docx (30 kb)
Supplementary material 1 (DOCX 30 kb)
268_2019_4943_MOESM2_ESM.tif (10.5 mb)
Supplementary Fig. 1 Forest plot comparing operation time for laparoscopic distal gastrectomy. a. Billroth I versus Roux-en Y, b. Billroth II versus Roux-en Y, and c Billroth I versus Billroth II. An inverse variance random-effects model (a, b) and fixed-effect model(c) were used for meta-analysis. (TIFF 10702 kb)
268_2019_4943_MOESM3_ESM.tif (8.1 mb)
Supplementary Fig. 2 Forest plot comparing remnant gastritis after laparoscopic distal gastrectomy. a. Billroth I versus Roux-en Y, b. Billroth II versus Roux-en Y, and c. Billroth I versus Billroth II. A Mantel–Haenszel random-effects model was used for meta-analysis. (TIFF 8311 kb)
268_2019_4943_MOESM4_ESM.tif (7.9 mb)
Supplementary Fig. 3 Forest plot comparing bile reflux after laparoscopic distal gastrectomy. a. Billroth I versus Roux-en Y, b. Billroth II versus Roux-en Y, and c. Billroth I versus Billroth II. A Mantel–Haenszel random-effects model (b) and fixed-effect model (a, c) were used for meta-analysis. (TIFF 8063 kb)
268_2019_4943_MOESM5_ESM.tif (4.7 mb)
Supplementary Fig. 4 Forest plot comparing reflux esophagitis after laparoscopic distal gastrectomy. a. Billroth I versus Roux-en Y and b. Billroth II versus Roux-en Y. A Mantel–Haenszel fixed-effect model (a) and random-effects model (b) were used for meta-analysis. (TIFF 4819 kb)
268_2019_4943_MOESM6_ESM.tif (1.7 mb)
Supplementary Fig. 5 Funnel plot for publication bias evaluation(B1 versus RY overall complications). (TIFF 1739 kb)


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Copyright information

© Société Internationale de Chirurgie 2019

Authors and Affiliations

  1. 1.Division of Upper Gastrointestinal Surgery, Department of SurgeryKorea University Anam Hospital, Korea University College of MedicineSeoulKorea
  2. 2.Department of Family MedicineKorea University College of MedicineSeoulKorea

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