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The Cochrane Database of Systematic Reviews logoLink to The Cochrane Database of Systematic Reviews
. 2022 Jun 30;2022(6):CD015014. doi: 10.1002/14651858.CD015014

Uncut Roux‐en‐Y reconstruction after distal gastrectomy for gastric cancer

Zhaolun Cai 1, Chunyu Liu 2,3, Gang Ji 4, Jingjing Chen 2, Mingchun Mu 1, Zhiyuan Jiang 1, Baike Liu 1, Bo Zhang 1,✉
Editor: Cochrane Colorectal Group
PMCID: PMC9245895

Objectives

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the benefits and harms of uncut Roux‐en‐Y reconstruction after distal gastrectomy for patients with gastric carcinoma.

Background

Description of the condition

Gastric cancer represents the fourth leading cause of death among all cancer types and caused 768,793 deaths worldwide, and is responsible for 1,089,103 new cases in 2020 (Sung 2021). Complete surgical resection is the basic treatment for localised stomach cancer. For most tumours affecting the distal stomach, radical distal gastrectomy is the recommended operation (JGCA 2021). Reconstruction after distal gastrectomy is an important part of surgery for gastric cancer as well as a curative resection (Huang 2016a). 

Over the past decades, there has been much progress in gastric cancer screening. In addition, the treatment strategy for gastric cancer has shifted from an exclusive surgical approach to a multidisciplinary strategy including perioperative chemotherapy, pre‐ or postoperative chemoradiotherapy and postoperative chemotherapy (Cai 2018a; Cai 2018c). The prognosis of patients with gastric cancer has been greatly improved due to early detection and advances in treatment (Nakamura 2016)​​​​​​. Thus, quality of life and long‐term functional outcomes of the pouch reconstruction are now the focus for patients undergoing distal gastrectomy as well as curability (JGCA 2021; McCall 2016).

Description of the intervention

Surgeons are seeking the optimal reconstruction method after distal gastrectomy that reduces the occurrence of complications and maintains a better quality of postoperative life and long‐term functional outcomes. Billroth I gastroduodenostomy, Billroth II gastrojejunostomy, Roux‐en‐Y gastrojejunostomy, and jejunal interposition are the most frequently employed reconstruction methods in distal gastrectomy (JGCA 2021). The Billroth I procedure (Figure 1) consists of a gastroduodenostomy in which an anastomosis is created between the remaining stomach and the duodenum (McNally 2010). The Billroth II reconstruction (Figure 1) consists of a gastrojejunostomy in which an anastomosis is created between the gastric remnant and a loop of jejunum, with closure of the proximal duodenal remnant (McNally 2010). The Roux‐en‐Y procedure (Figure 1) includes the creation of a jejunojejunostomy (forming a Y‐shaped figure of small bowel) downstream from the anastomosis of the free jejunal end to the remaining stomach (gastrojejunostomy) (McNally 2010). Each reconstruction method has advantages and disadvantages. Billroth I reconstruction has advantages of procedure simplicity and preservation of physiological food passage, but the procedure can only be performed on specific patients as it is likely to cause excessive tension at the anastomotic site and reflux diseases (Chen 2019). Billroth II reconstruction solves the problem of anastomotic tension, however, it causes dumping symptoms in addition to reflux diseases (So 2018; Wang 2021). In contrast, Roux‐en‐Y reconstruction might partly resolve the reflux diseases that always occur after Billroth I and Billroth II reconstruction (Cai 2018b​​). A recent Cochrane Review demonstrated that Billroth II reconstruction probably increases bile reflux into the remnant stomach; and may reduce overall complications after surgery compared to Roux‐en‐Y reconstruction (Nishizaki 2021). Nevertheless, patients with Roux‐en‐Y reconstruction usually suffer from Roux stasis syndrome (Nakamura 2016). Furthermore, this procedure is more complex than the other two reconstruction methods, and the difficulty of postoperative duodenal endoscopic examination makes surgeons reluctant to perform Roux‐en‐Y reconstruction (Nakamura 2016; Yang 2017). 

1.

1

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Reconstruction methods after distal gastrectomy for gastric cancer.

To reduce the incidence of these postoperative complications, the uncut Roux‐en‐Y reconstruction was developed. Van Stiegmann G et al first reported this procedure in 1988 (Van Stiegmann 1988). Uyama I et al first described the laparoscopic‐assisted uncut Roux‐en‐Y reconstruction in 2005 (Uyama 2005). Uncut Roux‐en‐Y reconstruction (Figure 1) is a modification of the Billroth II reconstruction with Braun anastomosis, where the afferent jejunal lumen is closed with uncut closure devices. Currently, the most popular method of jejunal occlusion is stapling with an uncut linear stapler (Chung 2022; Huang 2016a; Park 2014; Zhu 2020). Besides, the placement of tightly tied seromuscular stitches circularly around the jejunal wall (Jangjoo 2010; Noh 2000; Yan 2022) and jejunal ligature with thick silk (Huang 2016b; Sah 2020; Ye 2022) or V‐Loc (Xue 2015) suture have been reported. Uncut Roux‐en‐Y reconstruction might reduce operative time and postoperative complications over the conventional Roux‐en‐Y reconstruction (Park 2014; Sun 2018). However, recanalisation of uncut Roux‐en‐Y reconstruction remains a concern (Wu 2021; Zhu 2020). Recanalisation means that the occluded afferent loop reopens spontaneously and returns to the same anatomy and function as Billroth II reconstruction with Braun anastomosis (Chung 2022). Previous studies have reported that the incidence of recanalisation ranges from 0% to 35.7% (Chung 2022; Wu 2021). The uncut techniques such as 2‐row (Yan 2022) and 3‐row linear staplers (Park 2018) might be associated with a higher rate of recanalisation compared with 6‐row linear stapler.

Thus, it remains controversial whether uncut Roux‐en‐Y reconstruction is superior to the other reconstruction methods in terms of benefits and safety.

How the intervention might work

In uncut Roux‐en‐Y reconstruction, the afferent jejunal limb is blocked with an uncut method, preventing the bile and pancreatic juice from entering the residual stomach (Ahn 2014). Moreover, the normal peristaltic of the duodenum can still pass through the jejunal limbs because the uncut Roux‐en‐Y reconstruction preserves the neuromuscular continuity, maintains nerve impulses generated from the normal pacemaker of the duodenum to distal jejunum, and prevents ectopic pacemaker (Huang 2016a; Miedema 1992; Morrison 1990; Tu 1995).

Why it is important to do this review

Uncut Roux‐en‐Y reconstruction is a controversial yet promising method of gastrointestinal reconstruction after distal gastrectomy. This field is relatively new, and gathering experience from current clinical trials could provide more information for clinical practice and further research. No Cochrane Review addressing the effects of uncut Roux‐en‐Y reconstruction after distal gastrectomy for patients with gastric cancer has been published so far. Therefore, a Cochrane Review is necessary. The results of this review might help surgeons make a more up‐to‐date and informed judgement.

Objectives

To assess the benefits and harms of uncut Roux‐en‐Y reconstruction after distal gastrectomy for patients with gastric carcinoma.

Methods

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs) (including cluster‐RCTs) with no restrictions regarding blinding status, language, publication date, publication status, and publication type will be included in the review. We will include RCTs reported as full text, as abstract only, and as unpublished data. We will also include quasi‐RCTs (trials with allocation according to variables such as medical record number or date or birth). We will exclude cross‐over trials because the nature of our research question does not allow for cross‐over designs. 

Types of participants

We will include participants with histologically confirmed gastric carcinoma who had been treated with robotic, laparoscopic, laparoscopy‐assisted, or open distal gastrectomy. 

There will be no restrictions regarding age, gender, histologic type of carcinoma (gastric adenocarcinoma is the most common histologic type of gastric carcinoma (Amin 2017)), race, or social status.

In trials with mixed populations, that is, trials in which some participants meet the inclusion criteria and others do not, we will attempt to include only the eligible participants, if this information is reported separately, or we are able to obtain it from trial authors. Otherwise, we will include studies with a mixed population if the majority (> 80%) of the participants meet the eligibility criteria.

Types of interventions

Intervention

Uncut Roux‐en‐Y reconstruction consists of a side‐to‐side or end‐to‐side gastrojejunostomy with closure of the proximal duodenal remnant and Braun anastomosis. Besides, the afferent jejunal lumen is occluded using uncut closure devices. There will be no restriction concerning jejunal occlusion methods.

Comparator

We are interested in the following three comparisons.

  • Billroth II reconstruction consists of a gastrojejunostomy in which an anastomosis is created between the gastric remnant and a loop of jejunum, with closure of the proximal duodenal remnant. We will include both Billroth II reconstruction with or without Braun anastomosis where a side‐to‐side jejunojejunostomy is established between the afferent and efferent jejunal limbs.

  • Billroth I reconstruction consists of a gastroduodenostomy in which an anastomosis is created between the remaining stomach and the duodenum.

  • Roux‐en‐Y reconstruction consists of a creation of a jejunojejunostomy downstream from the anastomosis of the free jejunal end to the remaining stomach.

Types of outcome measures

The following outcome measures will be considered in this review. Reporting of the outcomes listed here will not be an inclusion criterion for our review according to recommendations in Chapter 3.2.4 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019). 

Primary outcomes

  1. Health‐related quality of life after surgery, assessed by any generic and disease‐specific questionnaires on domains, such as global health status, physical and mental well‐being. Where the outcome is measured at multiple time points within a period, we will select the outcome measured at the longest follow‐up (at least 6 months). 

  2. Major postoperative complications within 30 days after surgery (grade III to V according to Clavien‐Dindo Classification (Clavien 2009)).

Secondary outcomes

  1. Incidence of anastomotic leakage within 30 days after surgery (assessed by laboratory test in combination with clinical features, radiological diagnostic methods, endoscopy, diagnostic laparoscopy, or as reported by the original studies).

  2. Minor postoperative complications within 30 days after surgery ​​​​​(grade I to II according to Clavien‐Dindo Classification (Clavien 2009)).​​​​​

  3. ​​​​Length of hospital stay (in days).

  4. aLoss of body weight (kg) from baseline.

  5. aIncidence and severity of bile reflux according to endoscopic examination, including reflux gastritis or reflux oesophagitis (assessed by RGB (Residue, Gastritis, Bile) Classification (Kubo 2002), Los Angeles Classification (Lundell 1999), or according to the criteria of the original studies).

  6. aDumping symptoms (assessed by symptom‐based questionnaires, oral glucose challenge testing, and other diagnostic investigations (Scarpellini 2020), or as reported by the original studies).

  7. a,bProportion of recanalisation in the uncut Roux‐en‐Y group as reported by the original studies.

aWhere the outcome is measured at multiple time points within a period, we will select the outcome measured at the longest follow‐up (at least 6 months).
bWhere possible, we will perform a meta‐analysis of proportion for this outcome regardless of any comparisons.

Search methods for identification of studies

Electronic searches

Two review authors will conduct a comprehensive literature search to identify all published and unpublished RCTs with no language restrictions. We will search the following electronic databases from inception to present:​​​​​​

  • PubMed (Appendix 1);

  • Embase Ovid (Appendix 2);

  • Cochrane Central Register of Controlled Trials (CENTRAL; latest issue), in the Cochrane Library (Appendix 3)​​​​​​;

  • Wanfang Data Knowledge Service Platform;

  • ​​​​​China National Knowledge Infrastructure (CNKI)​​​​​​.

We will search Wanfang Data Knowledge Service Platform with journal articles restriction.

We will combine the subject‐specific strategy with the sensitivity‐ and precision‐maximising version of the Cochrane highly sensitive search strategy for identifying randomised trials (2008 revision) (Higgins 2019). We will combine the Ovid Embase search with the RCT filter terms developed by the UK Cochrane Centre (Glanville 2019).

Searching other resources

Clinical trials registers and trial result registers:

  • ​​​​​​ClinicalTrials.gov;

  • World Health Organization International Clinical Trials Registry Platform (WHO ICTRP);

  • Chinese Clinical Trial Registry.

We will handsearch the references of included studies and relevant systematic reviews retrieved by the search to identify further reports of trials. We will combine the PubMed Systematic Reviews Filter defined by the US National Library of Medicine (NLM) to retrieve relevant systematic reviews in PubMed. We will also handsearch the proceedings of major conferences (ASCO Meeting Library, ESMO meeting resources) that are 2 years prior to the date of the electronic search for relevant trials. 

Data collection and analysis

Selection of studies

We will use the reference management software EndNote X9 (EndNote 2013) to merge search results and remove duplicate records. Two review authors will independently screen titles and abstracts for inclusion of all the potentially‐relevant studies we identify as a result of the search. Then, two review authors will independently screen the full text, identify studies for inclusion, and record reasons for exclusion of the ineligible studies. We will resolve any disagreement through discussion among all review authors. Study authors will be contacted in cases of ambiguity or missing data. We will identify and exclude duplicates and collate multiple reports of the same study so that each study, rather than each report, is the unit of interest in the review. We will record the selection process in sufficient detail to complete a PRISMA flow diagram (Page 2021), and 'Characteristics of excluded studies' table. Abstracts and full texts in all languages will be considered for inclusion. For screening of non‐English language papers we will, in the first instance, use Google Translate or Baidu Translate to assist eligibility assessment. If needed, we will seek translators in our university networks or through Cochrane TaskExchange to assist with assessing eligibility of studies and, if eligible, assist with data extraction by native speakers.

Data extraction and management

Two review authors will independently extract data using pre‐designed forms. We will extract the following study characteristics.

  • Methods: study design, number of study centres and location, study setting, withdrawals, and date of study.

  • Participants: number (N), mean age, age range, gender, pathological stage, diagnostic criteria (e.g. for anastomotic leakage, bile reflux, dumping symptoms, health‐related quality of life, and recanalisation), inclusion criteria, and exclusion criteria.

  • Interventions: intervention, comparison.

  • Outcomes: primary and secondary outcomes specified and collected, time points reported.

  • Notes: funding for the trial, notable conflicts of interest of trial authors.

The review authors will test and optimise the data extraction form before extraction after a preliminary test. If data for a trial are incomplete, the review authors will contact the primary trial author for further information and clarification. The review authors will aim to detect and resolve any discrepancies by discussion and cross‐checking.

We will use Engauge Digitizer to extract data from graphs or figures (Mark 2019). These data will also be extracted in duplicate. 

Assessment of risk of bias in included studies

Two review authors will independently assess the risk of bias for each study in accordance with Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019). We will use version two of the Cochrane tool for assessing risk of bias in randomised trials (RoB 2) (Sterne 2019​​​​​​). We will assess the risk of bias of outcomes described in the summary of findings tables. We will assess the risk of bias according to the following domains in accordance with Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019).​​​​​​

  • Bias arising from the randomisation process.

  • Bias due to deviations from intended interventions.

  • Bias due to missing outcome data.

  • Bias in measurement of the outcome.

  • Bias in selection of the reported result.

We will judge each domain to be at ‘low risk of bias’, ‘some concerns’, or ‘high risk of bias’. Where the risk of bias is unclear due to lack of information or uncertainty of potential for bias, we will contact trial investigators to seek clarification. We will use the data available in the published report if we do not receive a response within 4 weeks. 

We will also present an overall risk of bias judgement for each study by evaluating the risk of bias across all five domains. We will consider the risk of bias for each trial as follows.

  • Low risk of bias – if all domains for this outcome are deemed to be at low risk of bias.

  • Some concerns – there are some concerns for at least one domain for this result, but none of the domains are judged to be at high risk of bias.

  • High risk of bias – at least one domain is judged to be at high risk of bias, or there are some concerns for multiple domains in a way that substantially lowers confidence in the result.

We plan to use the RoB 2 Excel tool to implement RoB 2 (Sterne 2019). We will store RoB 2 data to be made available as supplemental files. We will use the latest version of Review Manager Web (RevMan Web) (online) (RevMan Web 2022) to input the risk of bias results and visualise RoB 2 data.

  • Risk of bias traffic lights alongside the forest plots in the analyses.

  • Risk of bias tables showcasing RoB 2 domain judgements and support for judgements.

For cluster‐randomised trials, we will consider an additional domain that specifically applies to the design of the cluster‐randomised trial, RoB 2 domain 1b, 'Bias arising from the timing of identification and recruitment of individual participants within clusters in relation to timing of randomisation'. We will follow the suggested algorithm for reaching risk of bias judgements for bias arising from the timing of identification and recruitment of participants in a cluster‐randomised trial (Eldridge 2021). At the time of review preparation, we will use the most recent recommendations for assessing risk of bias in cluster‐randomised trials.

Measures of treatment effect

For dichotomous outcomes (for example, the rate of alkaline reflux after distal gastrectomy), we will calculate risk ratios (RR) and risk difference (RD) with the associated 95% confidence intervals (CI). If the number of observed events is small (less than 1% of sample per group), and if studies have balanced treatment groups, we plan to report the Peto odds ratio (OR) with 95% CI (Deeks 2021). For continuous outcomes, we will calculate the mean difference (MD) and the 95% CI. If continuous outcomes are measured heterogeneously (for example, health‐related quality of life scores measured with different scales and the scales are reported using similar means (e.g. higher score equals more positive result)), we will calculate the standardised mean difference (SMD).

​​​​​​If possible, we will compare the pooled estimates with the minimally important difference (MID) values for continuous outcomes to aid interpretation. We will transform all MIDs to the most reported instrument. When multiple MID estimates are available for an outcome, we will use the smallest validated MID. For continuous outcomes for which we are unable to find a credible MID in the literature, we will assume that the MID is equal to ½ of the median SD across studies (Norman 2004). ​​​​​

Unit of analysis issues

We will include cluster‐RCTs along with individual‐RCTs. If we include cluster‐RCTs, we will use the intracluster correlation coefficient (ICC) to estimate the relative variability within and between clusters, as per the recommendation as described in Chapter 23.1.4 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019). 

Studies with more than two groups

If we include multiple‐arm studies, we will include a pairwise comparison between uncut Roux‐en‐Y and Billroth II reconstruction in the meta‐analysis, and we will exclude the other arms. If a study have more than two eligible intervention arms or control arms, we will describe all relevant study conditions in the qualitative data synthesis and combine groups to create a single pairwise comparison according to the recommendation described in Chapter 23.3.4 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019).

Dealing with missing data

We will contact investigators or study sponsors to verify key study characteristics and obtain missing numerical outcome data where possible (e.g. when a study is identified as abstract only or when data are not available for all participants). Where this is not possible, and the missing data are thought to introduce serious bias, we will explore the impact of including such studies on the overall assessment of results by a sensitivity analysis. Any assumptions and imputations to handle missing data will be clearly described and the effect of imputation will be explored by sensitivity analyses.

For continuous outcomes, we will calculate the MD or SMD based on the number of people analysed at that time point. If the number of people analysed is not presented for each time point, we will use the number of randomised people in each group at baseline.

Where possible, missing SDs will be computed from other statistics such as standard errors, CIs or P values, according to the methods recommended in Chapter 6 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019). When data are reported only in graphs, we will extract the data of interest (such as mean, SD or SE) using software such as Engauge Digitizer.

Assessment of heterogeneity

Clinical and methodological diversity will be assessed in terms of participants, interventions, outcomes, and study characteristics for the included studies to determine whether a meta‐analysis is appropriate. This will be conducted by observing these data from the data extraction tables. Statistical heterogeneity between the studies will be assessed by visual inspection of the forest plot and using the I2 and Chi2 statistical tests.

As recommended in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019), the interpretation of an I2 value of 0% to 40% may not be important; 30% to 60% may represent 'moderate' heterogeneity; 50% to 90% may represent 'substantial' heterogeneity; and 75% to 100% may represent 'considerable' heterogeneity. As noted in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019), we will keep in mind that the importance of I2 depends on: (i) magnitude and direction of effects and (ii) strength of evidence for heterogeneity.

The Chi2 test will be interpreted where a P value ≤ 0.10 will indicate evidence of statistical heterogeneity.

If we identify substantial heterogeneity, we will report it and investigate possible causes by following the recommendations in Chapter 10 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019).

Assessment of reporting biases

We will create funnel plots to assess reporting bias if more than 10 studies contribute to an outcome in our meta‐analysis and examine this for asymmetry according to Chapter 13.3.5 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019). We will use Egger's test to determine the statistical significance of reporting bias (Egger 1997).

Data synthesis

We will perform meta‐analysis if participants, interventions, comparisons, and outcomes are judged to be sufficiently similar to ensure an answer that is clinically meaningful. We will use RevMan Web (RevMan Web 2022) to perform meta‐analyses, based on recommendations from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019). If we are confident that trials are estimating the same underlying treatment effect (i.e. that the population, interventions, comparators, and outcome characteristics of the included studies are homogenous) we will use a fixed‐effect meta‐analysis model. If clinical heterogeneity is sufficient to expect that underlying treatment effects differ between trials, or if at least substantial heterogeneity is identified, we will use a random‐effects meta‐analysis model. We may meta‐analyse even when statistical heterogeneity is high, but will attempt to interpret the causes for this heterogeneity using subgroup analyses and meta‐regression for that purpose, if possible. 

If we are unable to pool data statistically using meta‐analysis, we will conduct a narrative synthesis of the results adhering to the Synthesis Without Meta‐analysis (SWiM) guideline (Campbell 2020).

Subgroup analysis and investigation of heterogeneity

If there are adequate studies (> 2) to justify subgroup analyses, we will perform subgroup analysis according to Chapter 10.11.5 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019). If appropriate, subgroup analyses will be used to assess the influence of pre‐defined characteristics on outcomes described in the summary of findings tables.

We plan to carry out the following subgroup analyses.

  • Open resection versus minimally invasive surgery including robotic, laparoscopic, and laparoscopy‐assisted distal gastrectomy.

  • Early clinical‐stage gastric cancer (stage I) versus others.

  • Enhanced recovery after surgery strategies versus traditional perioperative care.

  • 6‐row uncut stapler versus other uncut techniques (for primary outcomes, and for secondary outcomes 4, 5, and 6).

  • Follow‐up period < 12 months versus follow‐up period ≥ 12 months (for primary outcome 1, and secondary outcomes 4, 5, and 6).

If the study includes laparoscopic and laparoscopy‐assisted participants between 0% and 30%, 31% and 70%, 71% and 100%, and an unknown proportion, we will classify them as 'open‐surgery study', 'mixed‐surgery study', 'laparoscopic‐surgery study', and 'unknown approach study', respectively. If the study includes stage I participants between 0% and 30%, 31% and 70%, 71% and 100%, and an unknown proportion, we will classify them as 'advanced stage study', 'mixed study', 'early‐stage study', and 'unknown‐stage study', respectively.

We will consider the P value from the test for subgroup differences to determine whether these factors significantly modify the treatment effect. 

Sensitivity analysis

If we can include a sufficient number (> 2) of studies for outcomes described in the summary of findings tables, we will perform a sensitivity analysis to determine whether the conclusions are robust to decisions made during the review process.

  • Repeat the analysis excluding studies at an overall high risk of bias for the outcome of interest.

Summary of findings and assessment of the certainty of the evidence

We will create a summary of findings (SoF) table, according to the guidelines in Chapter 14 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019) and informative statements to communicate the findings of systematic reviews of interventions (Santesso 2020). For each comparison, we will prepare a separate SoF table. In the SoF table, we will include an overall assessment of the certainty of the evidence for the following outcomes.

  • Health‐related quality of life.

  • Major postoperative complications within 30 days after surgery.

  • Incidence of anastomotic leakage within 30 days after surgery.

  • Loss of body weight (kg) from baseline.

  • Incidence and severity of bile reflux.

  • Dumping symptoms.

Two review authors will independently assess the certainty of the evidence. Disagreements between review authors will be resolved by discussion. We will use the five GRADE considerations (risk of bias, consistency of effect, imprecision, indirectness, and publication bias) to assess the certainty of a body of evidence as it relates to the studies which contribute data to the meta‐analyses for the pre‐specified outcomes, and report the certainty of evidence as high, moderate, low, or very low. We will use the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2019). We will use the latest version of GRADEpro Guideline Development Tool (GDT) software to prepare the SoF tables (GRADEpro GDT 2021). We will justify all decisions to downgrade the quality of studies using footnotes, and we will make comments to aid the readers' understanding of the review where necessary. 

Acknowledgements

Cochrane Colorectal group supported the authors in the development of this protocol. We would also like to thank Guanjian Liu, statistician, Cochrane China Centre, for statistical support in the protocol development and Qin Ma, surgeon, Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, for medical illustration support.

The following people conducted the editorial process for this article.

  • Sign‐off Editor (final editorial decision): Nicole Skoetz, University of Cologne and University Hospital Cologne, Germany, Co‐ordinating Editor of the Cochrane Haematology Group.

  • Managing Editor (selected peer reviewers, provided comments, collated peer‐reviewer comments, provided editorial guidance to authors, edited the article): Lara Kahale, Cochrane Central Editorial Service.

  • Editorial Assistant (conducted editorial policy checks and supported editorial team): Leticia Rodrigues, Cochrane Central Editorial Service.

  • Copy Editor (copy‐editing and production): Luisa M Fernandez Mauleffinch, Cochrane Copy Edit Support.

  • Peer‐reviewers (provided comments and recommended an editorial decision): Yong Jin Kim, Department of Surgery, H+ Yangji Hospital (clinical review); Rachel Richardson, Cochrane Evidence Production and Methods Directorate (methods review); Robin Featherstone, Cochrane Central Editorial Service (search review). Two additional peer reviewers provided content and consumer peer review but chose not to be publicly acknowledged.

Appendices

Appendix 1. Appendix 1. PubMed search strategy

#1 "stomach neoplasms"[MeSH Terms] OR (("gastric*"[tiab] OR "gastro*"[tiab] OR "gut"[tiab] OR "stomach*"[tiab]) AND ("adenocarcinoma*"[tiab] OR "cancer*"[tiab] OR "carcinoma*"[tiab] OR "neoplasm*"[tiab] OR tumor*[tiab] OR tumour*[tiab]))

#2 "gastroenterostomy"[MeSH Terms] OR "gastroenterostom*"[tiab] OR "gastro enterostom*"[tiab] 

#3 "gastroduodenostom*"[tiab] OR "gastro duodenostom*"[tiab] OR "gastrojejunostom*"[tiab] OR "gastro jejunostom*"[tiab] OR "billroth*"[tiab]

#4  "anastomosis, roux en y"[MeSH Terms] OR "roux en y"[tiab] OR "Roux‐Y"[tiab] OR "gastric bypass*"[tiab] 

#5 (gastrojejunal[Tiab] OR gastro‐jejunal[Tiab] OR jejunogastric[Tiab] OR jejunum‐gastric[Tiab] OR jejuno‐gastric[Tiab] OR gastroduoden*[Tiab] OR gastro‐duoden*[Tiab]) AND (anastom*[Tiab] OR fixation*[Tiab] OR reconstruct*[Tiab])

#6  "gastroenterostomy/methods"[MeSH Major Topic]

#7 #2 OR #3 OR #4 OR #5 

#8 #1 AND #7

#9 #8 OR #6

#10 (randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR placebo[tiab] OR clinical trials as topic[mesh:noexp] OR randomly[tiab] OR trial[ti] NOT (animals[mh] NOT humans [mh]))

#11 (((systematic review[ti] OR systematic literature review[ti] OR systematic scoping review[ti] OR systematic narrative review[ti] OR systematic qualitative review[ti] OR systematic evidence review[ti] OR systematic quantitative review[ti] OR systematic meta‐review[ti] OR systematic critical review[ti] OR systematic mixed studies review[ti] OR systematic mapping review[ti] OR systematic cochrane review[ti] OR systematic search and review[ti] OR systematic integrative review[ti]) NOT comment[pt] NOT (protocol[ti] OR protocols[ti])) NOT MEDLINE [subset]) OR (Cochrane Database Syst Rev[ta] AND review[pt]) OR systematic review[pt] 

#12 #10 OR #11

#13 #9 AND #12

Appendix 2. Appendix 2. Embase Ovid search strategy

  1. exp stomach tumor/

  2. ((gastric or gastro* or stomach) adj3 (cancer* or carcinoma* or malignan* or tumor* or tumour* or neoplas* or adenocarcinoma*)).tw,kw.

  3. or/1‐2

  4. exp gastrectomy Billroth II/ or exp gastrectomy Billroth I/

  5. Billroth*.tw,kw.

  6. (Roux‐en‐Y or Roux‐Y).tw,kw.

  7. exp gastroenterostomy/ or exp gastrojejunostomy/ or  exp gastroduodenostomy/

  8. exp gastric bypass surgery/

  9. (gastrojejunostom* or gastro‐jejunostom* or ((gastrojejunal or gastro‐jejunal or jejunogastric or jejunum‐gastric or jejuno‐gastric) adj2 (anastom* or fixation* or reconstruct*))).tw,kw.

  10. (gastroenterostom* or gastro‐enterostom* or gastroduodenostom* or gastro‐duodenostom* or ((gastroduoden* or gastro‐duoden*) adj2 (anastom* or fixation* or reconstruct*))).tw,kw.

  11. or/4‐10

  12. 3 and 11

  13. randomized controlled trial/

  14. controlled clinical trial/

  15. 13 or 14

  16. random$.ti,ab.

  17. randomization/

  18. intermethod comparison/

  19. placebo.ti,ab.

  20. (compare or compared or comparison).ti.

  21. ((evaluated or evaluate or evaluating or assessed or assess) and (compare or compared or comparing or comparison)).ab.

  22. (open adj label).ti,ab.

  23. ((double or single or doubly or singly) adj (blind or blinded or blindly)).ti,ab.

  24. double blind procedure/

  25. parallel group$1.ti,ab.

  26. (crossover or cross over).ti,ab.

  27. ((assign$ or match or matched or allocation) adj5 (alternate or group$1 or intervention$1 or patient$1 or subject$1 or participant$1)).ti,ab.

  28. (assigned or allocated).ti,ab.

  29. (controlled adj7 (study or design or trial)).ti,ab.

  30. (volunteer or volunteers).ti,ab.

  31. human experiment/

  32. trial.ti.

  33. or/16–32

  34. 33 not 15

  35. (random$ adj sampl$ adj7 (“cross section$” or questionnaire$1 or survey$ or database$1)).ti,ab. not (comparative study/or controlled study/or randomi?ed controlled.ti,ab. or randomly assigned.ti,ab.)

  36. Cross‐sectional study/not (randomized controlled trial/or controlled clinical study/or controlled study/or randomi?ed controlled.ti,ab. or control group$1.ti,ab.)

  37. (((case adj control$) and random$) not randomi?ed controlled).ti,ab.

  38. (Systematic review not (trial or study)).ti.

  39. (nonrandom$ not random$).ti,ab.

  40. “Random field$”.ti,ab.

  41. (random cluster adj3 sampl$).ti,ab.

  42. (review.ab. and review.pt.) not trial.ti.

  43. “we searched”.ab. and (review.ti. or review.pt.)

  44. “update review”.ab.

  45. (databases adj4 searched).ab.

  46. (rat or rats or mouse or mice or swine or porcine or murine or sheep or lambs or pigs or piglets or rabbit or rabbits or cat or cats or dog or dogs or cattle or bovine or monkey or monkeys or trout or marmoset$1).ti. and animal experiment/

  47. Animal experiment/not (human experiment/or human/)

  48. or/35–47

  49. 34 not 48

  50. 12 and 49

Appendix 3. Appendix 3. CENTRAL Ovid search strategy

  1. exp Stomach Neoplasms/

  2. ((gastric or gastro* or stomach) adj3 (cancer* or carcinoma* or malignan* or tumor* or tumour* or neoplas* or adenocarcinoma*)).tw,kw.

  3. 1 or 2

  4. exp Gastric Bypass/ 

  5. exp gastroenterostomy/

  6. exp anastomosis, roux‐en‐y/

  7. (Roux‐en‐Y or Roux‐Y).tw,kw.

  8. Billroth*.tw,kw.

  9. (gastrojejunostom* or gastro‐jejunostom* or ((gastrojejunal or gastro‐jejunal or jejunogastric or jejunum‐gastric or jejuno‐gastric) adj2 (anastom* or fixation* or reconstruct*))).tw,kw.

  10. (gastroenterostom* or gastro‐enterostom* or gastroduodenostom* or gastro‐duodenostom* or ((gastroduoden* or gastro‐duoden*) adj2 (anastom* or fixation* or reconstruct*))).tw,kw.

  11. or/4‐10

  12. 3 and 11

Contributions of authors

  • Co‐ordinating the protocol: Bo Zhang, Zhaolun Cai.

  • Conceiving the protocol: Zhaolun Cai, Bo Zhang.

  • Designing the protocol: Zhaolun Cai, Chunyu Liu, Bo Zhang, Gang Ji, Mingchun Mu, Zhiyuan Jiang, Baike Liu.

  • Develop and run the search strategy: Zhaolun Cai, Jingjing Chen.

  • Draft the protocol: Zhaolun Cai, Chunyu Liu, Jingjing Chen, Mingchun Mu, Zhiyuan Jiang, Baike Liu.

  • Revise the protocol: Zhaolun Cai, Bo Zhang, Jingjing Chen, Gang Ji.

  • Providing general advice on the protocol: Gang Ji, Bo Zhang, Mingchun Mu, Zhiyuan Jiang, Baike Liu.

Sources of support

Internal sources

  • 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University (ZYJC18034), China

    None

External sources

  • None, China

    None

Declarations of interest

  • Zhaolun Cai has no interest to declare.

  • Chunyu Liu has no interest to declare.

  • Gang Ji is the original researcher of the RCT entitled 'Total laparoscopic uncut Roux‐en‐Y for radical distal gastrectomy'. This trial has been registered at the Chinese Clinical Trial Registry: ChiCTR‐INR‐17010594.

  • Jingjing Chen has no interest to declare.

  • Mingchun Mu has no interest to declare.

  • Zhiyuan Jiang has no interest to declare.

  • Baike Liu has no interest to declare.

  • Bo Zhang has no interest to declare.

Since Gang Ji is the original researcher of a study that might be included in the review, he did not participate in the determination of the overall study inclusion and exclusion criteria; and will not make study eligibility decisions about, extract data from, carry out the risk of bias assessment for, or perform GRADE assessments of that study.

New

References

Additional references

Ahn 2014

  1. Ahn SH, Son SY, Lee CM, Jung DH, Park do J, Kim HH. Intracorporeal uncut Roux-en-Y gastrojejunostomy reconstruction in pure single-incision laparoscopic distal gastrectomy for early gastric cancer: unaided stapling closure. Journal of the American College of Surgeons 2014;218(1):e17-e21. [DOI: 10.1016/j.jamcollsurg.2013.09.009] [DOI] [PubMed] [Google Scholar]

Amin 2017

  1. Amin MB, Edge SB, Greene FL, Byrd DR, Brookland RK, Washington MK, et al. AJCC Cancer Staging Manual. 8th edition. New York: Springer International Publishing, 2017. [Google Scholar]

Cai 2018a

  1. Cai Z, Yin Y, Yin Y, Shen C, Wang J, Yin X, et al. Comparative effectiveness of adjuvant treatments for resected gastric cancer: a network meta-analysis. Gastric Cancer 2018;21(6):1031-40. [DOI: 10.1007/s10120-018-0831-0] [DOI] [PubMed] [Google Scholar]

Cai 2018b

  1. Cai Z, Zhou Y, Wang C, Yin Y, Yin Y, Shen C, et al. Optimal reconstruction methods after distal gastrectomy for gastric cancer: a systematic review and network meta-analysis. Medicine 2018;97(20):e10823. [DOI: 10.1097/MD.0000000000010823] [DOI] [PMC free article] [PubMed] [Google Scholar]

Cai 2018c

  1. Cai Z, Yin Y, Shen C, Wang J, Yin X, Chen Z, et al. Comparative effectiveness of preoperative, postoperative and perioperative treatments for resectable gastric cancer: a network meta-analysis of the literature from the past 20 years. Surgical Oncology 2018;27(3):563-74. [DOI: 10.1016/j.suronc.2018.07.011] [DOI] [PubMed] [Google Scholar]

Campbell 2020

  1. Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ  2020;368:16890. [DOI: 10.1136/bmj.l6890] [DOI] [PMC free article] [PubMed] [Google Scholar]

Chen 2019

  1. Chen S, Chen DW, Chen XJ, Lin YJ, Xiang J, Peng JS. Postoperative complications and nutritional status between uncut Roux-en-Y anastomosis and Billroth II anastomosis after D2 distal gastrectomy: a study protocol for a multicenter randomized controlled trial. Trials 2019;20(1):428. [DOI: 10.1186/s13063-019-3531-0] [DOI] [PMC free article] [PubMed] [Google Scholar]

Chung 2022

  1. Chung JH, Im DW, Choi CW, Kim SJ, Hwang SH, Lee SH.  A 3-year follow-up study of uncut Roux-en-Y reconstruction: clinical results and outcomes. Surgical Endoscopy 2022 Apr 5 [Epub ahead of print]. [DOI: 10.1007/s00464-022-09198-7] [DOI] [PubMed]

Clavien 2009

  1. Clavien PA, Barkun J, Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Annals of Surgery 2009;250(2):187-96. [DOI: 10.1097/SLA.0b013e3181b13ca2] [DOI] [PubMed] [Google Scholar]

Deeks 2021

  1. Deeks JJ, Higgins JP, Altman DG, editor(s). Chapter 10: Analysing data and undertaking meta-analyses. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6.2 (updated February 2021). Cochrane, 2021. Available from training.cochrane.org/handbook.

Egger 1997

  1. Egger M, Davey SG, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315:629-34. [DOI: 10.1136/bmj.315.7109.629] [DOI] [PMC free article] [PubMed] [Google Scholar]

Eldridge 2021

  1. Eldridge S, Campbell M, Campbell M, Drahota-Towns A, Giraudeau B, Reeves B, et al. Revised Cochrane risk of bias tool for randomized trials (RoB 2). Additional considerations for cluster-randomized trials (RoB 2 CRT); March 2021. Available at sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool/rob-2-for-cluster-randomized-trials.

EndNote 2013 [Computer program]

  1. EndNote. Version X9. PA, USA: Clarivate Analytics, 2013. Available at download.endnote.com/downloads/X9/ENX9Inst.exe.

Glanville 2019

  1. Glanville J, Foxlee R, Wisniewski S, Noel-Storr A, Edwards M, Dooley G. Translating the Cochrane EMBASE RCT filter from the Ovid interface to Embase.com: a case study. Health Information and Libraries Journal 2019;36(3):264-77. [DOI: 10.1111/hir.12269] [DOI] [PubMed] [Google Scholar]

GRADEpro GDT 2021 [Computer program]

  1. McMaster University (developed by Evidence Prime) GRADEpro GDT. Version accessed prior to 20 June 2022. Hamilton (ON): McMaster University (developed by Evidence Prime), 2021. Available at gradepro.org.

Higgins 2019

  1. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al, editor(s). Cochrane Handbook for Systematic Reviews of Interventions. 2nd edition. Chichester (UK): John Wiley & Sons, 2019. [DOI: 10.1002/9781119536604] [DOI] [Google Scholar]

Huang 2016a

  1. Huang Y, Wang S, Shi Y, Tang D, Wang W, Chong Y, et al. Uncut Roux-en-Y reconstruction after distal gastrectomy for gastric cancer. Expert Review of Gastroenterology & Hepatology 2016;10(12):1341-7. [DOI: 10.1080/17474124.2016.1248404] [DOI] [PubMed] [Google Scholar]

Huang 2016b

  1. Huang Y, Wang S, Tang D, Jiang X, Wang J, Wang D. Application of uncut Roux-en-Y anastomosis in laparoscopic distal radical gastrectomy of gastric cancer [非离断式Roux-en-Y吻合在腹腔镜远端胃癌根治性切除术中的应用]. Chinese Journal of Digestive Surgery 2016;15(3):247-52. [DOI: 10.3760/cma.j.issn.1673-9752.2016.03.008] [DOI] [Google Scholar]

Jangjoo 2010

  1. Jangjoo A, Mehrabi Bahar M, Aliakbarian M. Uncut Roux-en-y esophagojejunostomy: a new reconstruction technique after total gastrectomy. Indian Journal of Surgery 2010;72(3):236-9. [DOI: 10.1007/s12262-010-0059-7] [DOI] [PMC free article] [PubMed] [Google Scholar]

JGCA 2021

  1. Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer 2021;24(1):1-21. [DOI: 10.1007/s10120-020-01042-y] [DOI] [PMC free article] [PubMed] [Google Scholar]

Kubo 2002

  1. Kubo M, Sasako M, Gotoda T, Ono H, Fujishiro M, Saito D, et al. Endoscopic evaluation of the remnant stomach after gastrectomy: proposal for a new classification. Gastric Cancer 2002;5(2):83-9. [DOI: 10.1007/s101200200014] [DOI] [PubMed] [Google Scholar]

Lundell 1999

  1. Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 1999;45(2):172. [DOI: 10.1136/gut.45.2.172] [DOI] [PMC free article] [PubMed] [Google Scholar]

Mark 2019 [Computer program]

  1. Engauge Digitizer Software. Mark M, Baurzhan M, Tobias W, Bas S, Alexander W, kylesower, et al, Version 12.1. Mark Mitchell, 2019. Available at markummitchell.github.io/engauge-digitizer.

McCall 2016

  1. McCall MD, Graham PJ, Bathe OF. Quality of life: a critical outcome for all surgical treatments of gastric cancer. World Journal of Gastroenterology 2016;22(3):1101. [DOI: 10.3748/wjg.v22.i3.1101] [DOI] [PMC free article] [PubMed] [Google Scholar]

McNally 2010

  1. McNally PR. GI/Liver Secrets Plus. 4th edition. Elsevier Health Sciences, 2010. [DOI: 10.1016/B978-0-323-06397-5.X0001-9] [DOI] [Google Scholar]

Miedema 1992

  1. Miedema BW, Kelly KA. The Roux stasis syndrome: treatment by pacing and prevention by use of an 'uncut' Roux limb. Archives of Surgery 1992;127(3):295-300. [DOI: 10.1001/archsurg.1992.01420030057011] [DOI] [PubMed] [Google Scholar]

Morrison 1990

  1. Morrison P, Miedema BW, Kohler L, Kelly KA. Electrical dysrhythmias in the Roux jejunal limb: cause and treatment. American Journal of Surgery 1990;160(3):252-6. [DOI: 10.1016/S0002-9610(06)80017-6] [DOI] [PubMed] [Google Scholar]

Nakamura 2016

  1. Nakamura M, Nakamori M, Ojima T, Iwahashi M, Horiuchi T, Kobayashi Y, et al. Randomized clinical trial comparing long-term quality of life for Billroth I versus Roux-en-Y reconstruction after distal gastrectomy for gastric cancer. British Journal of Surgery 2016;103(4):337-47. [DOI: 10.1002/bjs.10060] [DOI] [PubMed] [Google Scholar]

Nishizaki 2021

  1. Nishizaki D, Ganeko R, Hoshino N, Hida K, Obama K, Furukawa TA, et al. Roux-en-Y versus Billroth-I reconstruction after distal gastrectomy for gastric cancer. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No: CD012998. [DOI: 10.1002/14651858.CD012998.pub2] [DOI] [PMC free article] [PubMed] [Google Scholar]

Noh 2000

  1. Noh SM. Improvement of the Roux limb function using a new type of "uncut Roux" limb. American Journal of Surgery 2000;180(1):37-40. [DOI: 10.1016/s0002-9610(00)00421-9] [DOI] [PubMed] [Google Scholar]

Norman 2004

  1. Norman GR, Sloan JA, Wyrwich KW. The truly remarkable universality of half a standard deviation: confirmation through another look. Expert Review of Pharmacoeconomics & Outcomes Research 2004;4(5):581-5. [DOI: 10.1586/14737167.4.5.581] [DOI] [PubMed] [Google Scholar]

Page 2021

  1. Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ 2021;372:n160. [DOI: 10.1136/bmj.n160] [DOI] [PMC free article] [PubMed] [Google Scholar]

Park 2014

  1. Park JY, Kim YJ. Uncut Roux-en-Y reconstruction after laparoscopic distal gastrectomy can be a favorable method in terms of gastritis, bile reflux, and gastric residue. Journal of Gastric Cancer 2014;14(4):229-37. [DOI: 10.5230/jgc.2014.14.4.229] [DOI] [PMC free article] [PubMed] [Google Scholar]

Park 2018

  1. Park YS, Shin DJ, Son SY, Kim KH, Park DJ, Ahn SH, et al. Roux stasis syndrome and gastric food stasis after laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction in gastric cancer patients: a propensity score matching analysis. World Journal of Surgery 2018;42(12):4022-32. [DOI: 10.1007/s00268-018-4715-6] [DOI] [PubMed] [Google Scholar]

RevMan Web 2022 [Computer program]

  1. The Cochrane Collaboration Review Manager Web (RevMan Web). Version 4.10.0. The Cochrane Collaboration, 2022. Available at revman.cochrane.org.

Sah 2020

  1. Sah BK, Li J, Yan C, Li C, Yan M, Zhu ZG. Anastomosis for distal gastrectomy in Chinese patients: uncut Roux-Y or Roux-Y? . BMC Surgery 2020;20(1):7. [DOI: 10.1186/s12893-019-0672-8] [DOI] [PMC free article] [PubMed] [Google Scholar]

Santesso 2020

  1. Santesso N, Glenton C, Dahm P, Garner P, Akl EA, Alper B, et al. GRADE guidelines 26: informative statements to communicate the findings of systematic reviews of interventions. Journal of Clinical Epidemiology 2020;119:126-35. [DOI: 10.1016/j.jclinepi.2019.10.014] [DOI] [PubMed] [Google Scholar]

Scarpellini 2020

  1. Scarpellini E, Arts J, Karamanolis G, Laurenius A, Siquini W, Suzuki H, et al. International consensus on the diagnosis and management of dumping syndrome. Nature Reviews. Endocrinology 2020;16(8):448-66. [DOI: 10.1038/s41574-020-0357-5] [DOI] [PMC free article] [PubMed] [Google Scholar]

So 2018

  1. So JB, Rao J, Wong AS, Chan YH, Pang NQ, Tay AYL, et al. Roux-en-Y or Billroth II reconstruction after radical distal gastrectomy for gastric cancer. Annals of Surgery 2018;267(2):236-42. [DOI: 10.1097/SLA.0000000000002229] [DOI] [PubMed] [Google Scholar]

Sterne 2019

  1. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019;366:l4898. [DOI: 10.1136/bmj.l4898] [DOI] [PubMed] [Google Scholar]

Sun 2018

  1. Sun MM, Fan YY, Dang SC. Comparison between uncut Roux-en-Y and Roux-en-Y reconstruction after distal gastrectomy for gastric cancer: a meta-analysis. World Journal of Gastroenterology 2018;24(24):2628-39. [DOI: 10.3748/wjg.v24.i24.2628] [DOI] [PMC free article] [PubMed] [Google Scholar]

Sung 2021

  1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a Cancer Journal for Clinicians 2021;71(3):209-49. [DOI: 10.3322/caac.21660] [DOI] [PubMed] [Google Scholar]

Tu 1995

  1. Tu BN, Kelly KA. Elimination of the Roux stasis syndrome using a new type of “uncut Roux” limb. American Journal of Surgery 1995;170(4):381-6. [DOI: 10.1016/S0002-9610(99)80308-0] [DOI] [PubMed] [Google Scholar]

Uyama 2005

  1. Uyama I, Sakurai Y, Komori Y, Nakamura Y, Syoji M, Tonomura S, et al. Laparoscopy-assisted uncut Roux-en-Y operation after distal gastrectomy for gastric cancer. Gastric Cancer 2005;8(4):253-7. [DOI: 10.1007/s10120-005-0344-5] [DOI] [PubMed] [Google Scholar]

Van Stiegmann 1988

  1. Van Stiegmann G, Goff JS. An alternative to Roux-en-Y for treatment of bile reflux gastritis. Surgery, Gynecology & Obstetrics 1988;166(1):69-70. [PMID: ] [PubMed] [Google Scholar]

Wang 2021

  1. Wang J, Wang Q, Dong J, Yang K, Ji S, Fan Y, et al. Total laparoscopic uncut Roux-en-Y for radical distal gastrectomy: an interim analysis of a randomized, controlled, clinical trial. Annals of Surgical Oncology 2021;28(1):90-6. [DOI: 10.1245/s10434-020-08710-4] [DOI] [PubMed] [Google Scholar]

Wu 2021

  1. Wu F, Ni Z, Diao H, Huang C, Wang S, Ge B, et al. Recanalization in uncut Roux-en-Y reconstruction: an animal experiment and a clinical study. Frontiers in Surgery 2021;8:644864. [DOI: 10.3389/fsurg.2021.644864] [DOI] [PMC free article] [PubMed] [Google Scholar]

Xue 2015

  1. Xue K, Li ZY, Shan F, Wang YK, Ji JF. V-Loc based uncut Roux-en-Y reconstruction in totally laparoscopic distal gastrectomy: a report of 7 patients [全腹腔镜远端胃癌根治术中基于V-Loc缝线改良非离断式Roux-en-Y重建7例报告]. Chinese Journal of Practical Surgery 2015;35(10):1095-8. [DOI: 10.7504/CJPS.ISSN1005-2208.2015.10.18] [DOI] [Google Scholar]

Yan 2022

  1. Yan Y, Wang D, Liu Y, Lu L, Wang X, Zhao Z, et al. Optimal reconstruction after laparoscopic distal gastrectomy: a single-center retrospective study. Cancer Control 2022;29:10732748221087059. [DOI: 10.1177/10732748221087059] [DOI] [PMC free article] [PubMed] [Google Scholar]

Yang 2017

  1. Yang K, Zhang WH, Liu K, Chen XZ, Zhou ZG, Hu JK. Comparison of quality of life between Billroth-І and Roux-en-Y anastomosis after distal gastrectomy for gastric cancer: a randomized controlled trial. Scientific Reports 2017;7(1):1-10. [DOI: 10.1038/s41598-017-09676-2] [DOI] [PMC free article] [PubMed] [Google Scholar]

Ye 2022

  1. Ye XS, Lin X, Liu JJ, Shi Y, Qian F, Yu PW, et al. Comparison of clinical efficacy and quality of life between uncut Roux-en-Y and Billroth II with Braun anastomosis in laparoscopic distal gastrectomy for gastric cancer [腹腔镜远端胃癌根治术非离断Roux-en-Y吻合与毕Ⅱ+Braun吻合的临床疗效及生活质量的比较]. Zhonghua Wei Chang Wai Ke za Zhi [Chinese Journal of Gastrointestinal Surgery] 2022;25(2):166-72. [DOI: 10.3760/cma.j.cn441530-20210702-00257] [DOI] [PubMed] [Google Scholar]

Zhu 2020

  1. Zhu GX, Qu JJ, Zhou SJ. Prevention of closure point recanalization after uncut Roux-en-Y anastomosis for radical resection of distal gastric cancer [远端胃癌根治性切除非离断Roux-en-Y吻合术后闭合点再通的预防]. Zhonghua Wei Chang Wai Ke za Zhi [Chinese Journal of Gastrointestinal Surgery] 2020;23(7):717-9. [DOI: 10.3760/cma.j.cn.441530-20190716-00277] [DOI] [PubMed] [Google Scholar]

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