Received: 28 March 2023 | Revised: 24 July 2023 | Accepted: 24 July 2023

DOI: 10.1002/mog2.48

ORIGINAL ARTICLE

Comparison of Billroth II with Braun and Roux‐en‐Y

reconstructions after distal gastrectomy for gastric
cancer: A meta‐analysis

Defei Chen | Chenglin Tang | Fan He | Fuyu Yang | Saed Woraikat |

Kun Qian

Department of Gastrointestinal Surgery,

The First Affiliated Hospital of
Chongqing Medical University,
Chongqing, China
Correspondence
Kun Qian, Department of
Gastrointestinal Surgery, the First
Affiliated Hospital of Chongqing Medical
University, Chongqing 400016, China.
Email: Hxjsqk@hotmail.com
Funding information
Chongqing Medical Scientific Research
Project (Joint project of Chongqing
Health Commission and Science and
Technology Bureau),
Grant/Award Number: 2021MSXM096
Abstract
Roux‐en‐Y (RY) and Billroth II with Braun (BB) reconstruction are two similar
methods of reconstruction after distal gastrectomy (DG). Currently, it is unclear
which method is superior. This meta‐analysis was performed to compare the safety
and efficacy of BB and RY reconstruction after DG for gastric cancer. A literature
search of Pubmed, Embase, Web of Science, and Cochrane Library was conducted
to identify studies comparing BB with RY after DG for gastric cancer until the
end of October 2022. Main outcomes assessed were perioperative outcomes,
postoperative complications, functional findings, and nutritional status. Meta‐
analyses were performed using RevMan 5.4 software. Finally, eight studies with a
total of 910 patients were considered for the meta‐analysis. The meta‐analysis
results revealed that operation time, anastomosis time, incidence of total
complications, and delayed gastric emptying were reduced, and the incidence of
bile reflux was increased in patients undergoing BB compared to RY reconstruction.
In conclusion, BB has the advantage of reducing operative time, anastomotic time,
intraoperative blood loss, overall postoperative complications, and delayed gastric
emptying. RY has the advantage of preventing bile reflux and gastritis after surgery.

KEYWORDS
Billroth II Braun, distal gastrectomy, gastric cancer, meta‐analysis, reconstruction,
Roux‐en‐Y

1 | INTRODUCTION respectively.1 Radiotherapy as well as chemotherapy and

immunotherapy may improve the outcomes, but surgical
Globally, gastric cancer is one of the most prevalent resection with proper lymph node dissection remains the
malignant tumors of the digestive tract. Among malignant primary option for curable gastric cancer.2 Distal gastrec-
tumors, its morbidity and mortality rank fifth and fourth, tomy (DG) with sufficient resection margin is the indicated

Defei Chen, Chenglin Tang, and Fan He contributed equally to this study.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2023 The Authors. MedComm – Oncology published by John Wiley & Sons Australia, Ltd on behalf of Sichuan International Medical Exchange & Promotion Association
(SCIMEA).

MedComm – Oncology. 2023;2:e48. wileyonlinelibrary.com/journal/mog2 | 1 of 13

https://doi.org/10.1002/mog2.48

2 of 13 | CHEN
treatment for cancer located in the distal stomach.
Reconstruction of the digestive tract after gastrectomy is
one of the most important aspects of surgery. The goal of
optimal reconstruction is maintenance of satisfactory
nutritional status and quality of life, with the simplest
techniques available while reducing postoperative morbidity
as much as possible.
The main reconstruction methods for DG include
Billroth I (BI) reconstruction,3 Billroth II (BII) reconstruc-
tion,4 Billroth II Braun (BB) reconstruction,5 Roux‐en‐Y (RY)
reconstruction,6 and uncut RY (URY) reconstruction,7 BI
reconstruction has specific requirements in terms of gastric
cancer location while the other reconstructions have broader
indications. BI and BII retain intestinal continuity and are
easier to perform while other reconstructions are technically
challenging and alter the intestinal anatomy, however, the
chronic bile reflux into the stomach may cause remnant
gastritis with a potential risk for gastric metaplasia.8,9 BB
reconstruction was designed specifically to reduce the flow of
bile into the stomach and URY is a modification of the BB
anastomosis in which a jejunal occlusion is fashioned.5,7,10
RY reconstruction addresses the problem of alkaline
bile reflux in BI and BII reconstruction but it leaves the
patient prone to RSS.11,12 URY reconstruction can effectively
prevent reflux gastritis and is superior to RY in preventing
RSS after DG,10,13 however, it is more complex and expen-
sive compared with BB and RY. Compared with BII
reconstruction, BB reconstruction has a supplementary
Braun anastomosis, through which the bile can flow into
distal jejunum directly, so it can reduce the bile reflux
theoretically.4,5 Everything considered, BB and RY seem to
be the preferred reconstruction method after DG.
BB and RY reconstruction are similar anatomically, both
of them have an anastomosis of stomach and jejunum plus
an anastomosis of jejunum and jejunum, but which one is
superior remains controversial. Therefore, we performed this
meta‐analysis to compare the safety and efficacy of BB and
RY reconstruction after DG for gastric cancer. Finally, eight
studies with a total of 910 patients were considered for the
meta‐analysis and we found that BB has the advantage of
reducing operative time, anastomotic time, intraoperative
blood loss, overall postoperative complications, and delayed
gastric emptying. RY has the advantage of preventing bile
reflux and gastritis after surgery.
2 | RESUL TS
2.1 | Studies with sufficient quality
were selected for meta‐analysis
To search for all eligible studies for the meta‐analysis,
125 publications were selected during the initial
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ET AL.
search. After reviewing the publications, the full text
of 11 studies was further assessed. Of these, three
papers did not meet the criteria and were excluded.
Finally, one randomized controlled trial (RCT) 14 and
seven nonrandomized observational clinical studies
(OCS) 15–21 with a total of 910 patients were consid-
ered for the meta‐analysis (Figure 1). The population
characteristics of each study are shown in Table 1. A
total of 518 and 392 patients were included in the BB
and RY groups, respectively. Studies were conducted
in South Korea (four studies)14–17 and China (four
studies). 18–21 Quality scores of each included article
were between 6 and 9, indicating sufficient study
quality (Table 1).
2.2 | Comparison of perioperative
outcomes between BB and RY
To compare the feasibility of BB and RY, perioperative
outcomes including operation time, anastomosis
time, intraoperative blood loss, harvested lymph
nodes, length of hospital stay, and time to first flatus
or defecation were evaluated (Table 2). Eight
studies 14–21 reported operation time and the meta‐
analysis showed operation time was lower in the
BB group (weighted mean difference [WMD],
−21.06 min; 95% confidence interval [CI], −31.50
to −10.63; p < 0.0001; Figure 2A). Among the two
studies reporting anastomosis time18,20 anastomosis
time was lower in the BB group (WMD, −8.65 min;
95% CI, −9.20 to −8.10; p < 0.00001; Figure 2B).
Eight studies 14–21 reported intraoperative blood
loss and the meta‐analysis revealed the value was
similar in the two groups (WMD, −13.44 mL;
95% CI, −28.67 to 1.78; p = 0.08; Figure 2C). The
number of harvested lymph nodes was reported in
seven studies 15–21 and was similar between the two
groups (WMD, 0.50; 95% CI, −1.71 to 2.71; p = 0.66;
Figure 2D). No significant difference was observed
between the two groups in terms of hospital stay
(WMD, −0.02; 95% CI, −0.19 to 0.14; p = 0.77;
Figure 2E) and time to first flatus or defecation
(WMD, −0.09; 95% CI, −0.27 to 0.09; p = 0.35;
Supporting Information: Figure S1A).
2.3 | Comparison of postoperative
complications between BB and RY
To compare the safety of BB and RY, postoperative
complications were evaluated (Table 2). The overall
postoperative complications were reported in eight

CHEN ET AL.
F I G U R E 1 PRISMA flow diagram of
studies selected for meta‐analysis; PRISMA:
Preferred Reporting Items for Systematic
Reviews and Meta‐Analyses.
studies.14–21 There was no significant difference in the
risk of total complications (odds ratio [OR], 0.68; 95%
CI, 0.46 to 1.00; p = 0.05; Figure 3A). Four stud-
ies 15,17,20,21 reported postoperative complications ac-
cording to the Clavien–Dindo classification22 and risk
of total complications (OR, 0.63; 95% CI, 0.40 to 0.99;
p = 0.04; Supporting Information: Figure S2A) was a
lower in the BB group. However, subgroups of grade
Grades I–II (OR, 0.66; 95% CI, 0.40 to 1.09; p = 0.11;
Supporting Information: Figure S2B) and Grades
III–IV (OR, 0.61; 95% CI, 0.24 to 1.58; p = 0.31;
Supporting Information: Figure S2C) did not differ
between groups. Delayed gastric emptying was re-
ported in five studies 16,17,19–21 and the BB group had a
lower risk (OR, 0.40; 95% CI, 0.18 to 0.89; p = 0.02;
Figure 3B). The risk of other complications, including
anastomotic leakage (OR, 0.48; 95% CI, 0.09 to 2.58;
p = 0.39; Figure 3C), ileus (OR, 0.58; 95% CI, 0.19 to
1.84; p = 0.36; Figure 3D), postoperative pancreatitis
(OR, 4.33; 95% CI, 0.96 to 19.49; p = 0.06; Figure 3E),
duodenal stump leakage (OR, 0.96; 95% CI, 0.25 to
3.76; p = 0.95; Supporting Information: Figure S2D),
intra‐abdominal abscess (OR, 1.06; 95% CI, 0.24 to
4.59; p = 0.94; Supporting Information: Figure S2E),
wound problem (OR, 1.18; 95% CI, 0.45 to 3.12;
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| 3 of 13
p = 0.74; Supporting Information: Figure S2F) was
similar between the BB and RY groups.
2.4 | Comparison of postoperative
functional findings and nutritional status
between BB and RY
To compare the efficacy of BB and RY, postoperative
functional findings and nutritional status were
assessed. Three studies 15,16,20 reported postoperative
functional findings including residual food, gastritis,
and bile reflux; the results of the meta‐analysis are
shown in Table 2. No difference was found in the risk
of residual food (OR, 0.68; 95% CI, 0.39 to 1.16;
p = 0.16; Figure 4A) and gastritis (OR, 4.63; 95% CI,
0.92 to 23.29; p = 0.06; Figure 4B) between BB and RY
groups. Risk of bile reflux was significantly lower in
the RY group (OR, 4.77; 95% CI, 1.23 to 18.53;
p = 0.02; Figure 4C). Postoperative nutritional status
1 year after surgery was reported in two studies
(Table 2).15,19 No significant between‐group differ-
ences were observed in body weight (WMD, 1.64; 95%
CI, −0.52 to 3.80; p = 0.14; Figure 4D), hemoglobin
(WMD, 2.01; 95% CI, −1.29 to 5.31; p = 0.23;
 | 4 of 13

TABLE 1 Characteristics of the included studies.

Quality Study Operation Surgical Sample Sex BMI Mean ASA score TNM stage
Author Country Design score period type group size male/female (kg/m2) age (yr) (I/II/III) (I/II/III/IV)
Lee et al.14 South RCT 6 2006–2007 LA/open BB 52 42/10 NA 59.7 ± 10.9 NA NA
Korea RY 47 28/19 NA 58.5 ± 10.7 NA NA
15
Park and Kim South Retro 7 2005–2013 LA/TL BB 76 N/A NA NA NA NA
Korea RY 55 N/A NA NA NA NA
16
Choi et al. South Retro 7 2010–2012 LA BB 26 18/8 23.4 ± 2.0 59.7 ± 9.1 4/22/0 22/3/1/0
Korea RY 40 28/12 23.7 ± 2.4 57.2 ± 10.7 18/20/2 38/2/0/0
17
Cui et al. South Retro 7 2013–2015 TL BB 26 15/11 NA 60.1 ± 13.3 13/13/0 12/7/7/0
Korea RY 30 22/8 NA 57.6 ± 12.6 18/12/0 23/5/2/0
18
Chi et al. China Retro 7 2019–2020 TL BB 54 39/15 21.8 ± 2.4 65.3 ± 9.8 24/24/6 7/19/28/0
RY 51 31/20 22.0 ± 2.6 67.3 ± 7.9 25/21/5 8/18/25/0
Jun et al.19 China Retro 7 2017–2019 LA/Open BB 36 18/18 22.47 ± 2.61 65.64 ± 8.59 9/20/7 0/14/19/3
RY 36 22/14 21.00 ± 3.39 63.86 ± 9.22 8/23/5 0/11/23/2
20
Yalikun et al. China Retro 7 2016–2019 TL BB 145 97/48 23.4 ± 5.8 62 61/72/12 44/35/62/4
RY 102 72/30 22.8 ± 6.2 63 45/42/15 21/22/56/3
21
Yan et al. China Retro 7 2015–2020 LA/TL BB 103 75/28 23.3 ± 3.5 68.0 ± 9.3 29/68/6 24/26/53/0
RY 31 20/11 22.5 ± 2.9 62.4 ± 10.6 11/19/1 10/9/12/0
Note: Data are presented as mean ± standard deviation, median or n corresponding to groups.
Abbreviations: ASA, American Society of Anesthesiologists; BB, Billroth II with Braun; BMI, body mass index; LA, laparoscopy‐assisted; NA, not available; RCT, randomized controlled trial; RY, Roux‐en‐Y;
TL, totally laparoscopic.
CHEN
ET AL.

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CHEN ET AL. | 5 of 13

TABLE 2 Meta‐analysis of outcomes of interest.

Outcome of interest Studies Patients (n) OR/WMD 95% CI I² (%) p‐value
Perioperative outcomes
Operation time 8 910 −21.06 −31.50, −10.63 75 <0.0001
Anastomosis time 2 352 −8.65 −9.20, −8.10 89 <0.00001
Intraoperative blood loss 8 910 −13.44 −28.67, 1.78 73 0.08
Harvested lymph nodes 7 811 0.50 −1.71, 2.71 66 0.66
Hospital stay 8 910 −0.02 −0.19, 0.14 0 0.77
Time to first flatus or defecation 4 410 −0.09 −0.27, 0.09 43 0.35
Postoperative complications
Total complications 8 910 0.68 0.46, 1.00 0 0.05
Clavien‐Dindo classification 4 568 0.63 0.40, 0.99 0 0.04
Grades I–II 4 568 0.66 0.40, 1.09 1 0.11
Grades III–IV 4 568 0.61 0.24, 1.58 0 0.31
Anastomotic leakage 4 536 0.48 0.09, 2.58 0 0.39
Delayed gastric emptying 5 650 0.40 0.18, 0.89 20 0.02
Ileus 5 579 0.58 0.19, 1.84 0 0.36
Postoperative pancreatitis 3 276 4.33 0.96, 19.49 0 0.06
Duodenal stump leakage 2 381 0.96 0.25, 3.76 0 0.95
Intra‐abdominal abscess 3 270 1.06 0.24, 4.59 21 0.94
Wound problem 6 713 1.18 0.45, 3.12 0 0.74
RGB classification
Residual food 3 424 0.68 0.39, 1.16 0 0.16
Gastritis 3 424 4.63 0.92, 23.29 86 0.06
Bile reflux 3 424 4.77 1.23, 18.53 82 0.02
Postoperative nutritional status
Body weight 2 187 1.64 −0.52, 3.80 0 0.14
Hemoglobin 2 187 2.01 −1.29, 5.31 46 0.23
Albumin 2 187 0.27 −0.68, 1.23 36 0.58
Abbreviations: CI, confidence interval; OR, odds ratio; RGB, residue, gastritis, bile; WMD, weighted mean difference.

Figure 4E), or albumin (WMD, 0.27; 95% CI, −0.68 to
1.23; p = 0.58; Figure 4F).
2.5 | Sensitivity analyses of outcomes
with high heterogeneity
To explore the source of heterogeneity, sensitivity
analyses were performed. The results of the meta‐
analysis revealed significant heterogeneity in some
outcomes, such as operative time (I² = 75%; p < 0.0001),
anastomosis time (I2 = 89%; p < 0.00001), intraoperative
blood loss (I² = 73%; p = 0.08), harvested lymph nodes
(I2 = 66%; p = 0.66), and incidence of gastritis (I² = 86%;
p = 0.06) and bile reflux (I² = 82%; p = 0.02). Sensitivity
analysis of intraoperative blood loss showed heterogene-
ity was reduced to 44% after excluding the study by
Yalikun et al.,20 but the difference was not significant
(p = 0.58) (Supporting Information: Table S1). Sensitivity
analysis of incidence of gastritis and bile reflux indicated
the heterogeneity was decreased to 8% and 0% respec-
tively after excluding the study by Yalikun et al.,20
moreover, a significantly lower risk of incidence of
gastritis (p < 0.00001) and bile reflux (p < 0.00001) was
found in BB group after excluding the aforementioned
study (Supporting Information: Table S1). However, a
thorough review of this study revealed no reason for
exclusion.
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6 of 13 | CHEN ET AL.

F I G U R E 2 Meta‐analysis of surgical outcomes. (A) Pooled data on operation time, (B) pooled data on anastomosis time, (C) pooled data
on intraoperative blood loss, (D) pooled data on number of harvested lymph nodes, (E) pooled data on length of hospital stay. BB, Billroth II
with Braun; CI, confidence interval; RY, Roux‐en‐Y; SD, standard deviation.
 27696448, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/mog2.48 by Cochrane Saudi Arabia, Wiley Online Library on [08/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CHEN ET AL. | 7 of 13

F I G U R E 3 Meta‐analysis of postoperative complications. (A) Pooled data on total postoperative complications, (B) pooled data on
delayed gastric emptying, (C) pooled data on anastomotic leakage, (D) pooled data on postoperative ileus, (E) pooled data on postoperative
pancreatitis. BB, Billroth II with Braun; CI, confidence interval; RY, Roux‐en‐Y; SD, standard deviation.
 27696448, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/mog2.48 by Cochrane Saudi Arabia, Wiley Online Library on [08/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8 of 13 | CHEN ET AL.

F I G U R E 4 Meta‐analysis of postoperative functional findings and nutritional status. (A) Pooled data on residual food, (B) pooled data
on gastritis, (C) pooled data on bile reflux, (D) pooled data on postoperative body weight, (E) pooled data on postoperative hemoglobin,
(F) pooled data on postoperative albumin. BB, Billroth II with Braun; CI, confidence interval; RY, Roux‐en‐Y; SD, standard deviation.

CHEN ET AL.
F I G U R E 5 Funnel plot of total complications rate in all
included studies. OR, odds ratio; SE, standard error.
2.6 | Subgroups analyses of studies
using totally laparoscopic technique
We noticed that a totally laparoscopic technique was
used for all patients in three studies.17,18,20 To identified
the influence of totally laparoscopic technique to the
results, subgroup analyses were undertaken for relevant
outcome measures by including studies with totally
laparoscopic technique only (Supporting Information:
Table S2). Interestingly, the subgroup analyses showed
that more harvested lymph nodes in the BB group
(WMD, 2.75; 95% CI, 1.98 to 3.52; p < 0.00001; Support-
ing Information: Figure S1B), which differed from the
results when all studies were included. Further, signifi-
cant differences were observed in outcomes, including
operation time (WMD, −20.98; 95% CI, −27.06 to −14.90;
p < 0.00001), total complications (OR, 0.50; 95% CI, 0.26
to 0.96; p = 0.04) and Clavien–Dindo classification grades
I–II (OR, 0.41; 95% CI, 0.17 to 0.95; p = 0.04), which were
similar to the results when all studies were included.
2.7 | Evaluation of publication bias
To identify potential publishing bias, a funnel plot of the
overall postoperative complications was created in which
no asymmetry was observed, indicating no evidence of
publication bias in the study (Figure 5).
3 | DISCUS SION
The optimal choice for reconstruction after DG remains
controversial. BI reconstruction, as it maintains the
physiological passage of food into the duodenum, is usually
performed after DG when technically feasible.23 Likewise,
the utilization of BII reconstruction is frequently employed
in cases where BI is deemed technically unviable due to the
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| 9 of 13
presence of anastomotic tension. One of the primary
limitations associated with BI and BII anastomoses is the
persistent occurrence of chronic bile reflux into the
remnant, leading to subsequent alterations in the physiolog-
ical gastric acid environment,24 which may lead to
esophagitis, Barrett's esophagus, and remnant gastritis.25
The BB anastomosis has been proposed as a potential
method to decrease the occurrence of bile reflux into
the remnant. The RY and URY techniques, which are
predominantly implemented in Western countries, have
been introduced with the intention of mitigating the
potential for bile reflux. However, they are more compli-
cated to perform and some patients may develop functional
RSS with a potential risk for internal hernia (Petersen's
hernia).26 BB seems to be a promising method for
gastrointestinal reconstruction after distal gastrectomy but
controversy remains regarding which is the optimal method
for reconstruction after distal gastrectomy between BB and
RY. Therefore, this meta‐analysis was performed to evaluate
and compare the safety and efficacy of BB reconstruction
and RY reconstruction after distal gastrectomy.
The meta‐analysis revealed that the operative time and
anastomotic time were reduced in patients who under-
went BB reconstruction compared to RY reconstruction.
Despite a lack of significance, BB displayed a trend toward
reducing intraoperative blood loss. Furthermore, by
excluding the study by Chi et al.,18 a significant difference
(p = 0.04) was found between the two groups with
moderate heterogeneity (I2 = 62%). Therefore, the results
may be influenced by the related heterogeneity and
smaller sample size of the included studies. Thus, it is
possible that BB was related to reduced intraoperative
blood loss. Hence, BB has an advantage in shortening the
operative time, anastomotic time, and intraoperative blood
loss. This is explained by the additional procedures
required in RY, including cutting off the bowel, separating
the part of the mesentery, and handling the mesenteric
vessels, which require more time and cause more trauma
than BB.
The number of harvested lymph nodes was similar
between the two groups when all studies were included.
However, in the subgroup of studies using the totally
laparoscopic technique, BB was associated with more
harvested lymph nodes (Supporting Information:
Figure S2B), and interestingly, when a fixed model was
used and all studies were included, the groups differed
significantly (p < 0.00001) with 66% heterogeneity. Con-
sidering the heterogeneity of the included studies and that
number of harvested lymph nodes was influenced by the
different dissection type, increased use of stapling and
energy devices, operating surgeon experience, and hospital
volume, it is difficult to determine which technique is
associated with more harvested lymph nodes.

10 of 13 | CHEN
The incidence of postoperative complications is
often used to assess the safety of a surgical procedure.
In this meta‐analysis, despite the lack of statistical
significance (p = 0.05), BB reconstruction was associ-
ated with reduced overall postoperative complications.
Furthermore, the groups differed significantly (p = 0.04,
Supporting Information: Figure S1A) when only the
studies categorizing complications according to the
Clavien–Dindo classification were included. Thus, BB
is associated with lower risk of overall postoperative
complications, possibly because of the need to cut off
the bowel and separate part of the mesentery in RY,
which disrupts intestinal continuity and physiology
leading to more trauma than BB.
The incidence of delayed gastric emptying (DGE) was
2.3% and 5.7% in the BB and RY groups, respectively and
risk was significantly lower in the BB group (p = 0.02,
Figure 3B), consistent with a previously published
analysis27 that reported a higher incidence of DGE after
RY reconstruction (known as RSS). RSS is characterized
by abdominal pain, vomiting, and nausea after oral
intake of food. RSS appears to be associated with
functional rather than mechanical obstruction of the
“Y” limb. The possible mechanisms of this syndrome
include the altered electrical stimulation and retrograde
peristalsis of the “Y” limb caused by the altered intestinal
continuity and intestinal innervation. Although these
factors may lead to delayed gastric emptying, the
incidence and cause of RSS are not yet clearly elucidated.
The incidence of anastomotic leakage was similar
between the two groups, consistent with previous findings.28
No significant difference was found in postoperative
complications including anastomotic leakage, ileus, pancrea-
titis, duodenal stump leakage, intra‐abdominal abscess, or
wound issues between the two groups. This may be because
of the small difference between the two groups, and another
reason to explain this is that postoperative complications
such as surgical site infection have been reduced with the
development of surgical technique and the using of
antimicrobial prophylaxis these years,29 which make it
difficult to observed the difference between the two groups
with the small sample size of the included studies.
Three studies15,16,20 reported postoperative functional
findings using RGB classification. A significant difference
was observed only for bile reflux (p = 0.02) with high
heterogeneity (I2 = 82%) when including all three studies
(Figure 4C), however, when excluding the study by
Yalikun et al,20 a significantly lower risk of bile reflux
(p < 0.00001) and gastritis (p < 0.00001) was observed in
the RY group with low heterogeneity (Supporting
Information: Table S1), similar to previous reports.15,16
Interestingly, we noticed that Yalikun et al.20 used a
modified BB reconstruction technique, in which the
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ET AL.
distance between the gastrojejunostomy and Braun
anastomosis was increased by 10 cm compared to
conventional BB reconstruction, and for this reason,
bile reflux and gastritis were reduced in their BB group.
Therefore, BB is inferior to RY in terms of preventing
bile reflux and gastritis, but hopefully, by modifying
BB reconstruction, this drawback can be remedied.
Only two studies reported changes in nutritional
status at 1 year of follow‐up after surgery. This meta‐
analysis revealed no significant difference in body
weight, hemoglobin, or albumin levels between the two
groups, however, body weight was higher in the BB
group than in the RY group. Therefore, postoperative
nutritional status could not be fully assessed due to lack
of sufficient data. Consequently, further studies with
larger samples, including more nutritional indicators and
longer follow‐up are needed to address this question.
This meta‐analysis has several advantages. First, it is the
first study comparing BB with RY anastomosis. Second,
unlike the comparison of the procedures in previous reports,
our study focused on a comparison of BB and RY and
provides relevant evidence‐based findings. Third, all the
extracted data were cross‐checked and sensitivity and
subgroup analyses were performed to improve the credibility
of our results. However, there are several limitations to this
study. First, all the included studies were conducted in Asian
countries, probably because the incidence of gastric cancer is
higher in East Asia than in most Western countries,1,30
making the results more generalizable to East Asia than
other populations. Second, there was potential selection bias,
given that the included studies are mostly observational.
Third, although we included all relevant studies, the sample
size may not be sufficient. Hence, additional RCTs and large‐
scale studies are needed. Nonetheless, our study provides
clinical evidence of the optimal reconstruction for surgeons,
which we hope is useful for surgeons worldwide.
4 | CONCLUSIONS
BB has the advantage in shortening the operative time,
anastomotic time, and intraoperative blood loss, and
reducing overall postoperative complication and delayed
gastric emptying. RY has the advantage of preventing bile
reflux and gastritis after surgery.
5 | MATERIALS AND METHODS
The study protocol was registered on PROSPERO
(Registration Number: CRD42022331178). The study
was performed according to assessing the methodological
quality of systematic reviews (AMSTAR) guidelines and

CHEN ET AL.
the Preferred Reporting Items for Systematic Reviews
and Meta‐Analyses (PRISMA).31,32
5.1 | Literature search strategy
The PubMed, Embase, Web of Science, and Cochrane
Library databases were searched for primary studies
published between 2000 and October 2022. Search terms
included the following MeSH terms (Medical Subject
Headings) and their combinations: “Billroth” (tiab) AND
“Braun” (tiab) AND “Roux en Y” (tiab) with no language
restriction. To search for additional potentially eligible
studies, all references of the retrieved studies were
reviewed. Both RCT and OCS were included in the study
and all titles and abstracts were extracted and evaluated.
The eligible studies were assessed and research data were
extracted by two reviewers independently. In there was
any disagreement, consensus was reached after discuss-
ing with a third researcher.
5.2 | Inclusion and exclusion criteria
All studies that met all of the following criteria were
included: (1) patients with gastric cancer who underwent
DG; (2) study compared BB and RY reconstruction; (3) study
included at least one of the surgical outcomes mentioned; (4)
original research with ≥ 10 patients; and (5) study was
published in English. If two or more articles were published
by the same study group, institution, or used the same data
set, the article with the largest sample size or the longest
follow‐up was selected. Any study that met one of the
following criteria was excluded: (1) article type was abstract,
case reports, review articles, expert opinions, basic research,
animal experiments, or letters. (2) study without available
data or full text; (3) study including patients with benign
disease; (4) sample size <10; or (5) study published
before 2000.
5.3 | Definitions
Perioperative outcomes included operation time, anasto-
mosis time, intraoperative blood loss, harvested lymph
nodes, hospital stay, and time to first flatus or defecation
as defined as reported in the studies using the same or
similar terms. Total complications were defined as all the
postoperative complications reported or categorized ac-
cording to the Clavien–Dindo classification.22 Anasto-
motic leakage, ileus, postoperative pancreatitis, duodenal
stump leakage, DGE, wound problems, and intra‐
abdominal abscess were defined as reported in the studies
27696448, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/mog2.48 by Cochrane Saudi Arabia, Wiley Online Library on [08/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 11 of 13
using the same or similar terms. Residual food, gastritis,
and bile reflux as evaluated by the postoperative endo-
scopic findings 1 year after surgery and based on food
residue, gastritis, and bile reflux classification (RGB score),
score ≥ grade 1 were regarded as positive findings.33 Body
weight, hemoglobin, and albumin were defined as the
data measured 1 year after surgery reported in the study.
5.4 | Quality assessment
The quality of the selected studies was assessed by two
authors independently. The nonrandomized OCS was
evaluated using the Newcastle‐Ottawa Quality Assess-
ment Scale and the RCT was assessed using the Jadad
scoring system.34,35
5.5 | Outcomes of interest
Perioperative outcomes, postoperative complications,
postoperative functional findings, and nutritional status
were evaluated. The main perioperative outcomes were
operation time, anastomosis time, intraoperative blood
loss, harvested lymph nodes, hospital stay, and time to
first flatus or defecation. Postoperative complications
included anastomotic leakage, ileus, postoperative pan-
creatitis, duodenal stump leakage, DGE, wound problem,
and intra‐abdominal abscess. Postoperative functional
findings included residual food, gastritis, and bile reflux
which were endoscopically proven 1 year after surgery
using RGB score. Postoperative nutritional status
included serum hemoglobin, total protein, albumin
levels, and body weight.
5.6 | Data extraction
Two authors collected the data from each of the selected
research papers independently, and disagreements were
discussed before a final decision was made. Outcomes of
interest as well as population characteristics of each
study were collected carefully. The population character-
istics included author name, study period, geographical
region, operation type, sample size, mean age, sex, tumor
stage, body mass index, and American Society of
Anesthesiologists (ASA) score.
5.7 | Statistical analysis
Review Manager Version 5.4 software (Nordic Cochrane
Centre; Denmark) was used to conduct meta‐analyses. The

12 of 13 | CHEN
OR with a 95% CI was used to examine the dichotomous
variables. The WMD with 95% CI was used to evaluate the
continuous variables. Statistical significance was defined as
a p‐value < 0.05. Before performing a meta‐analysis, the I2
value was calculated using a chi‐square test to evaluate the
homogeneity of effect sizes. If there was a significant
heterogeneity (I2 > 50%), a random‐effects model was
applied. If the heterogeneity was not statistically significant
(I2 < 50%), a fixed effects statistical model was applied.
Subgroup and sensitivity analyses were carried out to
identify the cause of the heterogeneity if it was high. To
identify potential publishing bias, a funnel plot was created.
The mean and standard deviation figures were not
accessible in some publications, the procedures utilized to
calculate these values using the available median and range
data have been reported previously.36
AUTHOR CONTRIBUTIONS
Defei Chen: Conceptualization (equal); methodology
(equal); writing—original draft (equal). Chenglin Tang:
Data curation (equal); formal analysis (equal). Fan He:
Data curation (equal); formal analysis (equal). Fuyu
Yang: Writing—review and editing (equal). Saed Wor-
aikat: Writing—review and editing (equal). Kun Qian:
Conceptualization (equal); funding acquisition (equal);
investigation (equal). All authors have read and approved
the final manuscript.
ACKNOWLEDGMENTS
The authors are grateful to all their colleagues who helped
prepare this article and Editage (www.editage.com) for
English language editing. This study was funded by the
Chongqing Medical Scientific Research Project (Joint project
of Chongqing Health Commission and Science and
Technology Bureau) General Program under Grant (number
2021MSXM096). The funder was not involved in the study
design, collection, analysis, interpretation of data, writing of
this article, or decision to submit it for publication.
CONFLI CT OF I NTER EST STATEMENT
The authors declare no conflict of interest.
DATA A VAILABILITY S TATEMENT
All data generated or analyzed during this study are
included in this published article. No additional
unpublished data are available.
ETHI CS STATEMENT
Our study is a systematic review and meta‐analysis;
hence, ethical approval was not required.
ORCID
Defei Chen http://orcid.org/0000-0002-2579-3866
27696448, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/mog2.48 by Cochrane Saudi Arabia, Wiley Online Library on [08/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ET AL.
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SU PPOR T ING INF OR MATI ON
Additional supporting information can be found online
in the Supporting Information section at the end of this
article.
How to cite this article: Chen D, Tang C, He F,
Yang F, Woraikat S, Qian K. Comparison of
Billroth II with Braun and Roux‐en‐Y
reconstructions after distal gastrectomy for gastric
cancer: a meta‐analysis. MedComm – Oncology.
2023;2:e48. doi:10.1002/mog2.48