Clinical Study Of Reconstruction Methods After Laparoscopic Radical Distal Gastrectomy For Gastric Cancer

Objective: The aim of this study was to compare the short-term and long-term outcomes of different reconstruction after laparoscopic distal gastrectomy(LDG),to identify the risk factors which influence the prognosis and quality of life and provide some reference for the selection of reconstruction.Methods: We retrospectively collected data of patients who underwent LDG for operative gastric cancer between April 2015 and December 2019 in the Department of General Surgery,Tianjin Medical University General Hospital.The patients were classified into four groups according to the reconstruction methods: Billroth-Ⅰ(BⅠ),Billroth-Ⅱ+Braun(BⅡ+Braun),Roux-en-Y(RY),and Uncut Roux-en-Y(Uncut RY).The parameter that we evaluated,includes clinicopathological characteristics,perioperative outcomes,postoperative complications and prognosis.Univariate and multivariate analyses were done to find the independent risk factors for prognosis and quality of life.Results: A total of 165 patients were investigated,BⅠ,BⅡ+Braun,RY,and Uncut RY were performed in 50,70,17,and 27 patients,respectively.(1)There were no significant difference in gender,BMI,ASA classification,smoking and drinking history,past medical history and tumor differentiation among the four groups(P > 0.05).Compared to other groups,the patients in BⅠ group were significantly younger(60±9.8y,P=0.004),the tumor size was significantly smaller(P(27)0.001),and the TNM stage was significantly earlier(P=0.004),the tumor was mainly located in the gastric antrum in BⅠ(86.0%,P(27)0.001).(2)The proportion of TLDG was significantly higher in BⅠ as well as the proportion of LADG in RY patients(P(27)0.001).Operation time was significantly shorter in BⅠ compared to the others(216.2±25.8min,P(27)0.001).There were no significant difference in intraoperative blood loss,the number of harvested lymph node,time to first flatus,time to first liguid diet,postoperative hospitalization and complications among the four groups(P > 0.05).(3)The overall survival rate was not significantly different among groups(P =0.060),the two-year overall survival rate of BⅠ,BⅡ+Braun,RY and Uncut RY were 96.4%,80.0%,78.6%,88.9% respectively(P =0.105).The disease-free survival rate was significantly different among groups(P=0.002),the two-year disease-free survival rate BⅠ,BⅡ+Braun,RY and Uncut RY were 88.2%,61.6%,67.7%,90.9% respectively(P =0.008).(4)Endoscopic findings confirmed that reflux esophagitis,gastritis and bile reflux were significantly lower in RY and Uncut RY patients(P(27)0.001)1 year after surgery.Although the roux stasis syndrome(RSS)was slightly higher in the RY group,there were no statistically significant differences(15.3% VS 5.9%,P =0.565).None of the patients experienced afferent recanalization in Uncut RY.The weight loss rate for BⅡ+Braun was greater than others(32.1%,P =0.032),and the albumin and prognostic nutritional index(PNI)were significantly lower in BⅡ+Braun group than BⅠ,RY,and Uncut RY groups during follow-up(P =0.016).(5)The multivariate analysis showed that BⅠ and BⅡ+Braun were independent risk factors for reflux esophagitis,gastritis(HR=0.295,95%CI 0.136-0.638,P =0.001)and bile reflux(HR=0.271,95%CI 0.089-0.824,P =0.021).Advanced age(HR=1.112,95%CI 1.015-1.218,P=0.021),low hemoglobin(HR=0.933,95%CI 0.889-0.979,P =0.005),low PNI(HR=24.68,95%CI 2.283-266.90,P =0.008),high N stage(HR=1.963,95%CI 1.833-4.628,P=0.022)and bile reflux(HR=274.32,95%CI 14.34-544.43,P(27)0.001)were found to be independent risk factors for mortality.Conclusion: 1.The four reconstruction methods after LDG are both feasible and safe with the same treatment effects.2.BⅠ gastroduodenostomy takes less time to operate and RY is more complex with the longest operation time.BⅠ is more commonly performed in the early gastric carcinoma located at antrum.BⅡ+Braun is the most frequently adopted reconstruction and is more suitable for the larger locally advanced tumors.3.RY and Uncut RY reconstruction are equally superior to BⅠ and BⅡ+Braun in terms of reflux esophagitis,gastritis bile reflux and postoperative nutritional status.It is beneficial to improve the quality of life after operation.4.Uncut RY shows benefits in term of better quality of life compared to BI and BII+Braun.Although the lower RSS rate didn’t show any significance statistically in comparison to RY,Uncut RY still remains a better choice for reconstruction.