Background
Radical surgery is currently recommended for patients with initially operable gastric cancer (GC) [
1‐
4]. With the innovation of laparoscopic instruments and the widespread application of minimally invasive technologies in GC [
5,
6], laparoscopy-assisted gastrectomy (LAG) has transitioned to totally laparoscopic gastrectomy (TLG) [
7‐
9].
For digestive tract surgery, different anastomotic methods may affect postoperative complications and short-term prognosis. As a traditional anastomotic method, Roux-en-Y (RY) is widely applied in laparoscopic distal gastrectomy (LDG) or laparoscopic total gastrectomy (LTG) [
10,
11]. However, RY is often accompanied by Roux stasis syndrome (RSS) and so on [
12,
13]. These complications seriously affected postoperative recovery and quality of life (QoL) [
14]. Currently, uncut Roux-en-Y (URY) is most often applied to LDG [
15], and relatively little has been reported in LTG [
16]. URY has fewer postoperative complications than RY [
17,
18]. However, whether or not URY will have afferent loop recanalization [
19] and a better long-term prognosis remains controversial.
Existing studies on URY mainly focus on laparoscopic-assisted operations. However, there are few studies on TLG combined with URY. Whether the complications after digestive tract surgery affect the long-term survival of GC patients is a hot topic at present. Following the striking results of previous studies, this study was also surprised by the impact of the surgical technique on prognosis [
20]. Therefore, we added data from another center to confirm whether URY is also applicable to totally LDG (TLDG). This study reviewed the dual-center data (including totally LTG (TLTG) and TLDG) to compare whether URY and RY differ in long-term survival under TLG.
Discussion
With the advancement of laparoscopic surgery in the field of GC, TLG has been progressively embraced [
27,
28]. Totally laparoscopic digestive tract reconstruction demands a high level of technical proficiency from physicians. RY anastomosis was one of the most common surgical procedures of GC in the past few decades [
29]. However, RY anastomosis disrupts the normal anatomical structure of the gastrointestinal tract and seriously affects the QoL of patients. In light of its simplicity, URY has gradually been utilized in GC [
30]. URY can effectively mitigate RSS arising from digestive tract reconstruction and enhance QoL [
20,
29,
31]. However, whether URY entails afferent loop recanalization [
32], as well as its potential to ameliorate the long-term prognosis of GC patients, is currently a research focus [
20]. Therefore, this study collected patient data from two medical centers to explore whether URY could replace RY.
Through survival analysis, we found that OS and RFS of the URY were better than those of the RY. We implemented PSM to minimize confounding variability between the two groups in order to improve the reliability of the study. PSM effectively simulates randomization of prospective studies [
26]. In addition to improving long-term prognosis, URY also has fewer short-term and long-term complications compared to RY. We also found that URY is more suitable for advanced, poor pathological differentiation, and elderly GC patients. This is the first dual-center retrospective study to compare whether TLG combined with URY has a better benefit for GC.
URY has shown advantages in the perioperative period. URY possesses evident benefits in terms of overall operating or anastomosis time. This is attributed to the fact that URY did not sever the jejunum and mesentery vessels [
20,
33]. Simplifying surgical procedures can avoid excessive bleeding [
16,
17], which is consistent with the findings of this study. In addition, this study found that the URY group had shorter hospital stays. This is because not cutting off the jejunum can not only prevent gastrointestinal dysfunction resulting from retroperistalsis, but also reduce the trauma of small intestine surgery, which greatly alleviates the financial burden on patients and enhances the recovery experience. Short-term postoperative complications determine the speed of postoperative recovery [
20]. In this study, the short-term postoperative complications of URY were half as many as those in the RY group. Similarly, research on TLTG combined with URY for GC has confirmed that the postoperative short-term complications of URY were significantly less than those of the RY group [
20]. The short-term prognostic advantages of LDG combined with URY for GC were also validated [
29]. From the perspective of postoperative recovery, URY is more suitable for GC patients than RY. In addition, it is crucial to consider whether URY has afferent loop recanalization and the impact of anastomosis on long-term prognosis [
34].
After gastrectomy, GC patients experience a decline in QoL and nutritional deficiencies [
35]. With the advancements in precision medicine, the requirements for GC operation have become increasingly demanding. At present, surgical treatment in the field of GC is more about reducing long-term complications rather than solely improving survival rates. The long-term complications associated with RY anastomosis, especially RSS, were greatly relieved by URY anastomosis [
20,
29,
36]. Data from this study showed that the long-term complication of RY was twice that of the URY group (
P < 0.001). Initially, URY anastomosis was controversial due to the afferent loop recanalization [
37]. Two single-center RCTs in 2023 found that afferent loop recanalization occurred in 35.3% and 73.7% of URY patients, respectively [
38,
39]. These are inconsistent with these results and other studies [
13,
23,
40,
41]. It can be seen that URY is still a controversial hot spot. Combined with the experiences of the two medical centers and relevant literature, this study concluded that the reasons for the recanalization of the afferent loop may be as follows: (1) difficulties in achieving optimal ligature strength with silk thread; (2) inadequate selection of anastomosis location. In this study, 6-row nail uncut linear cutting closure was used (positioned 2 ~ 3 cm away from the gastrointestinal anastomosis); (3) the lack of suture reinforcement at the closure may lead to the recanalization of the afferent loop. During the follow-up period of 6 to 90 months, no recanalization of the afferent loop was observed. URY is an economical and effective option for achieving long-term QoL.
This study yielded unexpected findings, as the URY group exhibited superior RFS and OS compared to the RY group. Previous studies have not discovered that LTG or LDG combined with URY can enhance OS or RFS [
17,
40]. This may be due to the low incidence of RSS in GC patients, or it may be related to the different baseline characteristics of the patients. We conclude that URY improves long-term survival by reducing long-term complications, especially RSS. In certain specific populations, the advantage of URY is more pronounced. Cox regression analysis and subgroup analysis supported our conclusion. A single-center RCT in 2023 did not explore the long-term prognosis of patients [
38]. Another RCT study found that the long-term prognosis of URY and RY groups was similar [
39]. We found that the patients enrolled in the RCT study were early GC. These patients have minimal surgical difficulty and do not require postoperative chemotherapy. As a result, the survival advantage of these patients derived from different anastomosis modalities may not be significant. Because the subgroup analysis of OS and RFS in this study found that advanced patients were more likely to benefit from URY (Fig.
4). Therefore, the results of this study need to be further verified by RCT with large samples (including early and advanced GC patients). The improved OS and RFS of the URY group can be inferred as follows: ① URY improves the possibility of timely utilization of postoperative adjuvant chemotherapy by promoting postoperative rehabilitation. TNM staging is an important prognostic factor for GC patients [
42]. The proportion of advanced GC patients was higher in this study, all of whom require postoperative adjuvant chemotherapy to improve prognosis [
43]. A prospective randomized controlled clinical trial published in 2019 showed better tolerance of adjuvant chemotherapy in GC patients treated with laparoscopy [
44]. This illustrates the importance of quick recovery. This study also fully demonstrates the benefits of fewer postoperative complications and benefits, which are advantageous for timely use of postoperative adjuvant chemotherapy. This is similar to our results. After PSM, the long-term postoperative complication rate in the RY group was nearly three times that in the URY group, and the postoperative chemotherapy rate in the URY group was nearly double that in the RY group. Long-term complications hinder the application of postoperative chemotherapy, a predicament frequently faced by physicians and patients. This is also supported by the subgroup analysis showing that URY has a prognostic advantage in elder or advanced patients. ② URY can reduce postoperative complications. Complications are variables that affect the OS or RFS [
45]. ③ Compared to cutting the jejunum, not cutting the jejunum may be more conducive to maintain the intestinal microbial balance. The effects of digestive tract reconstruction on microenvironmental homeostasis and enteral nutrition are intricate. Alterations to the natural anatomy of the gut can exert significant influences on gut barrier function and immunity [
46,
47]. ④ A substantial amount of data have shown that increased intraoperative blood loss correlates with a worsened prognosis [
48,
49]. URY can reduce intraoperative bleeding. ⑤ URY may reduce intestinal inflammation. The anastomosis may have effects on intestinal inflammation [
50]. Therefore, it is necessary to further explore the role of URY in alleviating intestinal inflammation.
There remain certain constraints within this study. Primarily, there were slight differences in initial baseline characteristics. Cox regression analysis or PSM sought to rectify this issue, but the sample size was subsequently reduced. Secondly, data on postoperative nutritional status of patients was not collected. Said parameter directly affects the QoL of the patients. However, the loss of data is related to the inherent shortcomings of retrospective studies. Finally, retrospective studies have problems pertaining to data loss, such as gene mutations. These shortcomings will prompt further prospective randomized controlled trials.
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