Modified Billroth I versus Roux-en-Y reconstruction after laparoscopic distal gastrectomy: Propensity-matched analysis of perioperative, pathologic, and quality-of-life outcomes in a European cohort

Abstract

Background: Although laparoscopic distal gastrectomy is well established, optimal reconstruction-especially in European practice-remains undefined and evidence on patient-reported outcomes is limited. We therefore conducted the first European propensity score-matched comparison of stapled delta-Billroth I versus Roux-en-Y reconstruction, examining perioperative efficiency, oncologic adequacy, and early (6-month) quality of life outcomes.

Methods: From a prospective cohort of 246 stage I-II gastrectomies (September 2022-December 2024), we generated 27 well-balanced Billroth I-Roux-en-Y pairs (matched for age, sex, body mass index, American Society of Anesthesiologists physical status, Lee index, cT stage, neoadjuvant therapy). Primary end points were operative time, blood loss, morbidity, and length of stay; secondary end points were pathologic variables and quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30-Item and Stomach 22-Item22) in a random 34 + 34-patient subset.

Results: Billroth I outperformed Roux-en-Y in operative efficiency: operative time 216.6 ± 10.1 minutes vs 251.7 ± 9.0 minutes (Δ -35.1, 95% confidence interval -62.0 to -8.2; P = .016), blood loss 33 ± 5 mL vs 105 ± 11 mL (Δ -72; 95% confidence interval -106 to -38; P = .003), and hospital stay 6.7 ± 0.4 days vs 10.0 ± 1.0 days (Δ -3.3; 95% confidence interval -5.4 to -1.2; P = .044). Major (Clavien III-V) morbidity (7% vs 11%; P = .64) and 30-day mortality (0% both) were low and comparable. Quality of life global scores were similar; Roux-en-Y reduced reflux symptoms (22-Item Quality of Life Questionnaire-Stomach reflux -13.7; 95% confidence interval -22.3 to -5.1; P = .0039) but entailed greater 6-month weight loss (-7.0 kg; 95% confidence interval -11.6 to -2.4; P = .0046).

Conclusion: Stapled delta-Billroth I shortens operative time without compromising early postoperative outcomes, whereas Roux-en-Y affords superior reflux control and is associated with greater early weight loss. These results support an individualized, patient-centered choice of reconstruction after minimally invasive distal gastrectomy.