Annals of Surgical Oncology

, Volume 20, Issue 5, pp 1591–1597 | Cite as

Comparison of Billroth I and Roux-en-Y Reconstruction after Distal Gastrectomy for Gastric Cancer: One-year Postoperative Effects Assessed by a Multi-institutional RCT

  • Motohiro Hirao
  • Shuji TakiguchiEmail author
  • Hiroshi Imamura
  • Kazuyoshi Yamamoto
  • Yukinori Kurokawa
  • Junya Fujita
  • Kenji Kobayashi
  • Yutaka Kimura
  • Masaki Mori
  • Yuichiro Doki
  • Osaka University Clinical Research Group for Gastroenterological Study
Gastrointestinal Oncology



This randomized, controlled trial evaluated the clinical efficacy of Billroth I (BI) and Roux-en-Y (RY) reconstruction at 1 year after distal gastrectomy for gastric cancer.


The primary end point was the amount of body weight lost at 1 postoperative year, and secondary end points included other items related to nutritional status such as serum albumin and lymphocyte count, as well as endoscopic examination findings of the remnant stomach and esophagus. Of the 332 patients enrolled, 163 were assigned to the BI group and 169 were randomized to the RY group.


The loss in body weight 1 year after surgery did not differ significantly between the BI and RY groups (9.1 % and 9.7 %, respectively, p = 0.39). There were no significant differences in other aspects of nutritional status between the 2 groups. Endoscopic examination 1 year after gastrectomy showed reflux esophagitis in 26 patients (17 %) in the BI group versus 10 patients (6 %) in the RY group (p = 0.0037), while remnant gastritis was observed in 71 patients (46 %) in the BI group versus 44 patients (28 %) in the RY group (p = 0.0013); differences were significant for both conditions. Multivariable analysis showed that the only reconstruction was the independently associated factor with the incidence of reflux esophagitis.


RY reconstruction was not superior to BI in terms of body weight change or other aspects of nutritional status at 1 year after surgery, although RY more effectively prevented reflux esophagitis and remnant gastritis after distal gastrectomy.


Reflux Esophagitis Distal Gastrectomy Delay Gastric Emptying Remnant Stomach Prognostic Nutritional Index 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank Dr. Tomoyuki Sugimoto at Osaka University for help with the statistical analysis. Participating institutions and chief participants: Sakai Municipal Hospital (H. Furukawa, H. Imamura), Osaka University (Y. Doki, S. Takiguchi), Osaka National Hospital (T. Tsujinaka, K. Fujitani), Toyonaka Municipal Hospital (J. Fujita, K. Kawanishi), Osaka Medical Center for Cancer and Cardiovascular Diseases (M. Yano, I. Miyashiro), Kinki Central Hospital of the Mutual Aid Association of Public School Teachers (K. Kobayashi), NTT West Osaka Hospital (Y. Kimura), Yao Municipal Hospital (Y. Fukushima, J. Matsuyama), Hyogo Prefectural Nishinomiya Hospital (H. Yano, H. Taniguchi), Kansai Rosai Hospital (S. Tamura, H. Miki), Ikeda Municipal Hospital (K. Shibata, T. Hirao), Belland General Hospital (K. Demura), SEMPOS Seamen’s Insurance hospital (Y. Tsukahara), Saiseikai Senri Hospital (H. Fukunaga), Nishinomiya Municipal Hospital (H. Oka), Suita Municipal Hospital (C. Ebisui, K. Okada), Itami Municipal Hospital (M. Hiratsuka), and Mino Municipal Hospital (S. Iijima, Y. Makari).


  1. 1.
    Yoshino K. History of gastric cancer surgery. J Jpn Surg Soc. 2000;101:855–60.Google Scholar
  2. 2.
    Taylor PR, Mason RC, Filipe MI, et al. Gastric carcinogenesis in the rat induced by duodenogastric reflux without carcinogens: morphology, mucin histochemistry, polyamine metabolism, and labeling index. Gut. 1991;32:1447–54.PubMedCrossRefGoogle Scholar
  3. 3.
    Fein M, Peters JH, Chandrasoma P, et al. Duodenoesophageal refluxinduces esophageal adenocarcinoma without exogenous carcinogen. J Gastrointest Surg. 1998;2:260–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Goldstein SR, Yang GY, Curtis SK, et al. Development of esophageal metaplasia and adenocarcinoma in a rat surgical model without the use of a carcinogen. Carcinogenesis. 1997;18:2265–70.PubMedCrossRefGoogle Scholar
  5. 5.
    Fukuhara K, Osugi H, Takeda N, et al. Reconstructive procedure after distal gastrectomy for gastric cancer that best prevents duodenenoesophageal reflux. World J Surg. 2002;26:1452–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Mathias JR, Fernandez A, Sninsky CA, et al. Nausea, vomiting, and abdominal pain after Roux-en-Y anastomosis: motility of the jejunal limb. Gastroenterology. 1985;88:101–7.PubMedGoogle Scholar
  7. 7.
    Kojima K, Yamada H, Inokuchi M, et al. A comparison of Roux-en-Y and Billroth-I reconstruction after laparoscopy-assisted distal gastrectomy. Ann Surg. 2008;247:962–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Ishikawa M, Kitayama J, Kaizaki S, et al. Prospective randomized trial comparing Billroth-I and Roux-en-Y procedures after distal gastrectomy for gastric cancer. World J Surg. 2005;29:1415–20.PubMedCrossRefGoogle Scholar
  9. 9.
    Montesani C, D’Amato A, Santella S, et al. Billroth-I versus Billroth-II versus Roux-en-Y after subtotal gastrectomy. Prospective randomized study. Hepatogastroenterology. 2002;49:1469–73.PubMedGoogle Scholar
  10. 10.
    Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma. 13th edition. Tokyo: Kanehara; 1999.Google Scholar
  11. 11.
    Lundell LR, Dent J, Bennett JR, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999;45:172–80.PubMedCrossRefGoogle Scholar
  12. 12.
    Demas GE, Drazen DL, Nelson RJ, et al. Reductions in total body fat decrease humoral immunity. Proc R Soc B Biol Sci. 2003;270:905–11.CrossRefGoogle Scholar
  13. 13.
    Marinho LA, Rettori O, Vieira-Matos AN, et al. Body weight loss as an indicator of breast cancer recurrence. Acta Oncol. 2001;40:832–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Tsugane S, Sasaki S, Tsubono Y. Under- and overweight impact on mortality among middle-aged Japanese men and women: a 10-y follow-up of JPHC study cohort I. Int J Obes Relat Metab Disord. 2002;6:529–37.CrossRefGoogle Scholar
  15. 15.
    Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients. Nippon Geka Gakkai Zashi. 1984;85:1001–5.Google Scholar
  16. 16.
    Imamura H, Takiguchi S, Yamamoto K, et al. Morbidity and mortality results from a prospective randomized controlled trial comparing billroth I and Roux-en-Y reconstructive procedures after distal gastrectomy for gastric cancer. World J Surg. 2012;36:632–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Takiguchi S, Yamamoto K, Hirao M, et al. A comparison of postoperative quality of life and dysfunction after Billroth I and Roux-en-Y reconstruction following distalgastrectomy for gastric cancer: results from a multi-institutional RCT. Gastric Cancer. 2012;15:198–205.PubMedCrossRefGoogle Scholar
  18. 18.
    Fujita J, Imamura H, Takiguchi K, et al. Randomized controlled trial comparing Billroth-I and Roux-en-Y reconstruction in distal gastrectomy for gastric cancer. ASCO GI. In press.Google Scholar
  19. 19.
    Shinoto K, Ochiai T, Suzuki T, et al. Effectiveness of Roux-en-Y reconstruction after distal gastrectomy based on an assessment of biliary kinetics. Surg Today. 2003;33:169–77.PubMedCrossRefGoogle Scholar
  20. 20.
    Fukuhara K, Osugi H, Takeda N, et al. Quantitative determinations of duodenogastric reflux, prevalence of Helicobacter pyroli infection, and concentrations of interleukin-8. World J Surg. 2003;27:567–70.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Motohiro Hirao
    • 1
  • Shuji Takiguchi
    • 2
    Email author
  • Hiroshi Imamura
    • 3
  • Kazuyoshi Yamamoto
    • 2
  • Yukinori Kurokawa
    • 2
  • Junya Fujita
    • 4
  • Kenji Kobayashi
    • 5
  • Yutaka Kimura
    • 6
  • Masaki Mori
    • 2
  • Yuichiro Doki
    • 2
  • Osaka University Clinical Research Group for Gastroenterological Study
  1. 1.Department of SurgeryNational Hospital Organization Osaka National HospitalOsakaJapan
  2. 2.Department of Gastroenterological SurgeryGraduate School of Medicine, Osaka UniversityOsakaJapan
  3. 3.Department of SurgerySakai Municipal HospitalSakaiJapan
  4. 4.Department of SurgeryToyonaka Municipal HospitalToyonakaJapan
  5. 5.Department of SurgeryKinki Central Hospital of the Mutual Aid Association of Public School TeachersItamiJapan
  6. 6.Department of SurgeryNTT West Osaka HospitalOsakaJapan

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