Totally laparoscopic distal gastrectomy with Billroth II: outcomes and quality of life in gastric adenocarcinoma

¹Department of Gastrointestinal Surgery, Nghe An Friendship General Hospital, Nghe An, Vietnam, ²Department of Surgery - Surgical Practice, Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam, ³Department of Surgery, Nghe An Friendship General Hospital, Nghe An, Vietnam

^&Corresponding author
Toan Huy Nguyen, Department of Surgery, Nghe An Friendship General Hospital, Nghe An, Vietnam

Introduction    

Gastric cancer is one of the most common malignancies worldwide, ranking fifth in incidence and third in cancer-related mortality [1]. According to GLOBOCAN 2020, approximately 1,089,103 new cases and 768,793 deaths occur annually [1]. In Vietnam, gastric cancer is the third most prevalent cancer, with an age-standardized incidence rate of 15.6 per 100,000 and a mortality rate of 11.5 per 100,000 [1]. Radical surgery remains the mainstay and only potentially curative option when the disease is detected early. For distal gastric cancer, distal gastrectomy with D2 lymphadenectomy is widely adopted. In recent years, laparoscopic distal gastrectomy has gained popularity due to its minimally invasive nature, reduced postoperative pain, faster recovery, and comparable oncological safety [2,3]. International studies, particularly from Japan and South Korea, have shown that totally laparoscopic distal gastrectomy with D2 lymphadenectomy achieves survival and complication rates equivalent to or better than open surgery. In Vietnam, leading institutions such as Viet Duc Hospital and the National Cancer Hospital have also implemented this technique with encouraging results.

Despite these advances, there is still no consensus on the optimal method of gastrointestinal reconstruction following laparoscopic distal gastrectomy. Options include Billroth I, Billroth II, and Roux-en-Y, with or without anti-reflux modifications, each associated with specific postoperative risks such as bile reflux or blind loop syndrome [4,5]. Among these, Billroth II reconstruction is widely utilised in clinical practice, particularly in settings with limited resources, due to its relative technical simplicity, shorter operative time, and feasibility in totally laparoscopic procedures without the need for advanced intracorporeal anastomosis techniques. In addition, Billroth II is especially suitable for distal tumours where tension-free anastomosis can be achieved more easily compared to Billroth I, while avoiding the technical complexity of Roux-en-Y reconstruction. In Vietnam, few studies have comprehensively analysed reconstruction techniques, especially in provincial hospitals where technical resources are limited. Existing reports mainly describe Billroth II procedures but rarely provide a detailed evaluation of outcomes, recovery, or complications [6]. Therefore, this study was conducted to assess the surgical results and quality of life among patients undergoing totally laparoscopic distal gastrectomy with D2 lymphadenectomy and Billroth II reconstruction in the treatment of gastric adenocarcinoma.

Methods     

Study design: this study was designed as a prospective descriptive cohort with longitudinal follow-up to evaluate surgical and oncologic outcomes of totally laparoscopic distal gastrectomy (TLDG) with D2 lymphadenectomy and Billroth II reconstruction in patients with distal gastric adenocarcinoma.

Setting: the study was conducted at Nghe An Friendship General Hospital, Vietnam, a regional tertiary surgical centre, between January 2021 and April 2024. Eligible patients undergoing curative laparoscopic distal gastrectomy were treated according to standardised perioperative and oncologic management protocols and followed through scheduled postoperative visits.

Participants: the study population comprised adults aged ≥18 years diagnosed with histologically confirmed adenocarcinoma of the gastric antrum or pylorus staged T1-T4a, M0 according to the AJCC 8th edition and considered suitable for curative TLDG. Patients were excluded if they had non-adenocarcinoma histology, T4b or metastatic disease, indications for open or laparoscopy-assisted surgery, reconstruction other than Billroth II, severe comorbidities precluding anaesthesia, incomplete records, refusal to participate, or inadequate follow-up. A total of 90 consecutive eligible patients were enrolled through convenience sampling.

Variables: baseline variables included demographic and clinical characteristics (age, sex, occupation, residence, admission mode, body mass index, comorbidities, and TNM stage). Surgical variables included operative parameters and perioperative outcomes. Primary outcomes were overall survival (OS), disease-free survival (DFS), and postoperative quality of life (QoL). OS was defined as time from surgery to death from any cause, and DFS as time from surgery to recurrence, metastasis, or gastric cancer-related death. QoL was measured longitudinally using the Spitzer Quality of Life Index across five domains (activity, daily living, health, support, self-evaluation). Associations between QoL and patient characteristics were also examined.

Data sources/measurement: data were collected prospectively from standardised clinical forms, operative reports, pathology records, and scheduled follow-up visits at 1, 6, 12, 24, and ≥36 months postoperatively. Surgical procedures followed a uniform TLDG technique with D2 lymphadenectomy according to Japanese Gastric Cancer Association guidelines and Billroth II reconstruction using linear staplers. Recurrence and survival status were determined through clinical visits, imaging or endoscopy, and telephone follow-up. QoL assessments were conducted at each follow-up time point using the validated Spitzer index. The QoL assessments were conducted using structured questionnaires administered through direct patient interviews by trained investigators to ensure consistency and completeness of responses.

Bias: selection bias was minimised by enrolling consecutive eligible patients undergoing the standardised surgical procedure during the study period. Measurement bias was reduced through prospective data collection, uniform surgical technique, and use of validated staging and QoL instruments. Loss-to-follow-up bias was mitigated through scheduled visits and telephone tracking; however, the single-centre design and convenience sampling may limit generalizability.

Study size: the study size consisted of all consecutive eligible patients meeting inclusion criteria during the study period, yielding a cohort of 90 patients undergoing TLDG with D2 lymphadenectomy and Billroth II reconstruction.

Quantitative variables: continuous variables, including age, body mass index, survival time, and QoL scores, were treated as quantitative measures and summarised using means and standard deviations. Categorical variables, including stage, comorbidities, recurrence status, and QoL categories, were expressed as frequencies and percentages. Survival time variables were calculated in months from the date of surgery.

Statistical methods: data analysis was performed using IBM SPSS Statistics version XX (IBM Corp., Armonk, NY, USA). Survival outcomes (OS and DFS) were estimated using the Kaplan-Meier method, with survival rates calculated at 12, 24, and 36 months and mean survival times reported. QoL scores were summarised across follow-up time points. Group comparisons for continuous variables were conducted using t-tests or analysis of variance, and categorical variables were compared using chi-square or Fisher's exact tests. Before applying parametric tests, assumptions of normality and homogeneity of variance were assessed using the Shapiro-Wilk test and Levene's test, respectively; non-parametric alternatives were used when these assumptions were not met. Statistical significance was defined as p < 0.05. Missing follow-up data were handled using a censoring approach for survival analysis, and cases with incomplete QoL data at specific time points were excluded from corresponding longitudinal analyses without imputation.

Ethical consideration statement: the study protocol was approved by the Ethics Committees of Hai Phong University of Medicine and Pharmacy and Nghe An Friendship General Hospital. All participants provided written informed consent after receiving information on study objectives, procedures, risks, and benefits. Participation was voluntary, withdrawal was permitted at any time without affecting clinical care, and all data were anonymised and used solely for research purposes in accordance with the Declaration of Helsinki.

Results     

Demographic characteristics

The study included 90 patients with a mean age of 65.5 years (36-86), mostly in the 60-79 age group (66.6%). Men were predominant with a male-to-female ratio of 1.8:1. Farmers accounted for the largest occupation group (38.9%), and most patients lived in rural areas (73.3%). The majority were admitted through routine examinations (64.4%). Mean BMI was 20.6 kg/m², with 81.1% in the normal range, 16.7% underweight, and 2.2% overweight.

The average time to death from gastric cancer was 23.1 ± 7.4 months (range 11-34 months). During follow-up, 16 patients (17.8%) died, including 14 cases (15.6%) due to recurrence or metastasis and 2 cases (2.2%) unrelated to recurrence/metastasis. The first non-cancer-related case was patient H.Ð.T (75 years old) with hypertension and prior stroke, who had a 4cm poorly differentiated adenocarcinoma at the pylorus with 18/34 positive lymph nodes; he received XELOX chemotherapy but developed respiratory and multiorgan failure, dying in the 5^th month after surgery. The second was patient N.B.Ð (85 years old) with hypertension, lower limb arterial thrombosis, and an unresectable abdominal aortic aneurysm; he had a 2cm antral tumor with 2/28 positive nodes, did not receive chemotherapy, and later died of cardiovascular disease at the 10^th postoperative month without evidence of recurrence. Overall, 15 patients experienced recurrence or metastasis, with 14 deaths attributed to gastric cancer. The highest number of recurrence/metastasis cases occurred around the 24^th month, while the peak cancer-related mortality was observed at 36 months with 7 cases, and no further recurrence or gastric cancer deaths were recorded beyond this point (Table 1).

Main outcomes

Table 2 presents overall survival and disease-free survival rates after surgery in 90 patients, showing survival at 12 months of 98.9% and 95.5%, at 24 months of 89.9% and 86.8%, and at 36 months of 78.8% and 78.8%, respectively, with mean overall survival of 44.6 ± 1.3 months and mean disease-free survival of 43.8 ± 1.5 months.

The mean total quality of life (QoL) score after surgery was 7.5 ± 1.0 at 1 month, 7.8 ± 0.9 at 6 months, 8.1 ± 1.7 at 12 months, 8.1 ± 1.8 at 24 months, and 8.3 ± 0.8 at more than 24 months. Across all five time points, the highest scores were recorded in the domains of daily living and support, with most patients reaching a level of 2 points. Domain-specific mean scores showed stability or slight improvement over time (Table 3).

Quality of life scores did not show significant associations with age group, place of residence, or disease stage across time points. At 24 months, male patients had significantly higher QoL scores compared to females (p < 0.05). At 6 months, 12 months, and beyond 24 months, patients without comorbidities had significantly higher scores than those with comorbidities (p < 0.05) (Table 4).

Discussion     

This study demonstrated that totally laparoscopic distal gastrectomy (TLDG) with D2 lymphadenectomy and Billroth II reconstruction achieved favourable oncologic outcomes, with mean OS and DFS exceeding 43 months and 3-year survival probabilities above 78%. The procedure also provided encouraging quality of life results, with mean scores consistently above 7 across all domains, particularly in daily living and social support. More than 85% of patients maintained good QoL scores throughout follow-up, with the highest proportions of excellent scores (9-10) observed at 12 and 24 months. Together, these findings highlight both the oncologic safety and functional benefits of TLDG in gastric cancer management.

The mean overall survival (OS) was 44.6 ± 1.3 months, with estimated OS rates of 98.9% at 12 months, 89.9% at 24 months, and 78.8% at 36 months. Similarly, the mean disease-free survival (DFS) was 43.8 ± 1.5 months, with DFS rates of 95.5%, 86.8%, and 78.8% at 12, 24, and 36 months, respectively. These findings are consistent with the favourable outcomes reported in previous studies, suggesting that laparoscopic distal gastrectomy provides oncologic safety comparable to that of conventional open surgery. When compared with international literature, our 3-year OS and DFS rates are consistent with those reported by Chen et al. (2013), who reported a 3-year OS of 82.9% and DFS of 82.3% following TLDG with Billroth II reconstruction. Stratified survival analysis in their study showed excellent outcomes for stage I (98.0%) and stage II (92.3%) patients, but lower survival for stage III (51.6%) [7]. Similarly, Huang et al. (2021) confirmed that laparoscopic surgery does not compromise long-term prognosis, reporting 5-year OS rates of 72.6% for laparoscopic versus 76.3% for open surgery [8]. Taken together, these results reinforce the oncologic adequacy of TLDG, particularly for patients with early-stage disease.

The assessment of quality of life (QoL) has become an essential endpoint in gastric cancer surgery, complementing survival outcomes. In this study, QoL was evaluated at 1, 6, 12, 24, and >24 months postoperatively using the Spitzer scale. Mean QoL scores across domains showed a trend of stability or slight improvement over time, with daily living and support domains consistently scoring highest. The mean total scores remained above 7 at all-time points, and more than 85% of patients achieved ≥7 points at each assessment. Notably, at 1 month after surgery, 98.8% of patients already had QoL scores ≥7, indicating early postoperative recovery.

The distribution of high QoL scores (9-10 points) increased at 12 and 24 months, exceeding 50% of patients, compared to less than 15% at 1 and 6 months. However, some decline in QoL was observed among patients approaching end-of-life, with six cases at both 12 and 24 months scoring below 5. These findings align with Zhang et al. who reported that TLDG improved social functioning and overall health at 3 and 6 months compared with laparoscopy-assisted surgery, though differences diminished by 12 months [9]. Similarly, another study comparing subtotal and total gastrectomy found better QoL in the distal gastrectomy group across global health, most functional domains, and multiple symptom domains at follow-up [10].

International evidence supports the positive impact of laparoscopic approaches on postoperative QoL. Wu et al. (1997) noted that while patients undergoing Billroth II reconstruction may experience more pronounced weight loss compared to Billroth I, many maintain a good appetite and dietary tolerance [11]. Additionally, laparoscopic techniques such as TLDG are associated with shorter hospital stays, reduced complications, and less invasiveness, contributing to faster recovery and better QoL compared with open surgery [12,13].

Finally, psychological and social well-being are critical dimensions of QoL after gastric cancer surgery. Although most patients return to normal activities and work, some report episodes of anxiety or depression, highlighting the importance of psychosocial support. Younger patients often demonstrate better QoL outcomes, likely reflecting greater physical resilience and recovery potential [11]. Overall, radical gastrectomy, including laparoscopic approaches, provides acceptable long-term QoL for potentially curable gastric cancer, reinforcing its role as a safe and effective treatment option [14].

Importantly, these findings have practical implications for surgical practice in provincial hospitals. The favourable outcomes observed in this study suggest that TLDG with Billroth II reconstruction can be safely implemented in regional centres when standardised protocols, appropriate training, and adequate equipment are available. The relative technical simplicity of Billroth II reconstruction compared to more complex techniques such as Roux-en-Y makes it particularly suitable for settings with limited resources, potentially facilitating wider adoption of minimally invasive gastric surgery beyond high-volume tertiary centres. This may contribute to improving equity in access to advanced surgical care for gastric cancer patients across different healthcare levels.

The results support the adoption of TLDG with D2 lymphadenectomy as a safe and effective surgical option, particularly for patients with early-stage gastric cancer. The procedure not only preserves survival outcomes comparable to open surgery but also enhances recovery and maintains favourable QoL in the long term. These findings underscore the importance of incorporating QoL assessments into routine postoperative evaluations and emphasise the role of minimally invasive techniques in improving patient-centred outcomes. Additionally, the evidence suggests that broader application of TLDG, even in provincial hospitals with proper training and resources, may help standardise high-quality care for gastric cancer patients.

This study has several limitations. The sample size was relatively small, with attrition across follow-up periods, which may reduce the statistical power for subgroup analyses. QoL was assessed using the Spitzer scale, which, although simple and practical, may not capture the full spectrum of symptom burden compared to more comprehensive tools such as EORTC QLQ-C30 or STO-22. Furthermore, the study was conducted in a single setting without randomisation, which may introduce selection bias and limit generalizability. In addition, the use of convenience sampling may have introduced selection bias, as only patients deemed suitable for totally laparoscopic surgery and able to complete follow-up were included, potentially leading to overestimation of favourable outcomes. Patients with more advanced disease, poorer performance status, or requiring alternative surgical approaches may have been underrepresented. Future multicenter studies with larger cohorts, longer follow-up, and the use of standardised QoL instruments are needed to validate and expand upon these findings.

Conclusion     

Totally laparoscopic distal gastrectomy with D2 lymphadenectomy and Billroth II reconstruction demonstrated favourable oncologic outcomes with 3-year OS and DFS rates exceeding 78% and provided sustained improvements in quality of life, with most patients maintaining good functional and social well-being throughout follow-up. These findings confirm the safety, feasibility, and patient-centred benefits of this minimally invasive approach, supporting its wider application in the surgical management of gastric cancer.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Khoa Dinh Dang: study conception, surgical procedures, data collection, data analysis, manuscript drafting. Huong Van Nguyen: patient management, data acquisition. Duyet Van Pham: study design, statistical analysis, manuscript review. Toan Huy Nguyen: supervision, critical revision of the manuscript. All authors read and approved the final manuscript.

Acknowledgments     

The authors sincerely thank the leadership, surgeons, anesthesiologists, nurses, and medical staff of Nghe An Friendship General Hospital for their support in patient care, follow-up, and data collection.

Tables     

Table 1: postoperative mortality cases

Table 2: overall survival and disease-free survival after surgery (N = 90)

Table 3: quality of life scores of patients after surgery by domains

Table 4: factors associated with quality of life (N = 90)

References