title: A systematic review and meta-analysis of the effect of Billroth reconstruction on type 2 diabetes: A new perspective on old surgical methods.
abstract: BACKGROUND
  Studies have reported that Billroth II (BII) reconstruction after subtotal gastrectomy for cancer or intractable ulcers can more effectively improve type 2 diabetes mellitus (T2D) than Billroth I (BI) reconstruction by allowing patients to achieve normoglycemia without or with lower doses of diabetes medications. Thus, we conducted a systematic review and meta-analysis of studies to assess the effect of Billroth techniques on postoperative T2D status and identify the clinical predictors of amelioration.
  
  
  METHODS
  The MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials were searched for studies using a list of keywords. Moreover, reference lists from relevant review articles were searched. We included studies comparing BI with BII reconstruction as well as those with available outcome data for postoperative T2D status. Of the 52 potentially relevant studies, 8 met the inclusion criteria. Data were combined using a fixed- or random-effects model.
  
  
  RESULTS
  Compared with the BI group, the relative risk for postoperative T2D remission and amelioration in the BII group was 1.49 (95% confidence interval [CI], 1.01 to 2.19) and 1.31 (95% CI, 1.11 to 1.54), respectively. Patients who achieved amelioration had a higher body mass index than those who did not (weighted mean difference, .88 kg/m(2); 95% CI, .38 to 1.37) and shorter duration of diabetes (weighted mean difference, -0.40; 95% CI, -0.23 to -.70) at baseline.
  
  
  CONCLUSIONS
  BII reconstruction after subtotal gastrectomy for cancer or intractable ulcers more effectively improved T2D than BI reconstruction. Thus, BII reconstruction may provide a treatment strategy for diabetic patients with gastric cancer or ulcers and enable metabolic surgery for nonobese patients.
authors.affiliation: Metabolic and Bariatric Center, Department of Family Medicine, Korea University College of Medicine, Seoul, Korea.
authors.forename: Yeongkeun
authors.initials: Y
authors.lastname: Kwon
authors.affiliation: Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea.
authors.forename: Hyun
authors.initials: H
authors.lastname: Jung Kim
authors.affiliation: Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, Florida.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Lo Menzo
authors.affiliation: Metabolic and Bariatric Centre, Division of Upper Gastrointestinal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Korea. Electronic address: kugspss@korea.ac.kr.
authors.forename: Sungsoo
authors.initials: S
authors.lastname: Park
authors.affiliation: Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, Florida.
authors.forename: Samuel
authors.initials: S
authors.lastname: Szomstein
authors.affiliation: Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, Florida.
authors.forename: Raul J
authors.initials: RJ
authors.lastname: Rosenthal
mesh_terms: D015992:Body Mass Index; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D005763:Gastroenterostomy / Q000379:methods*; D006801:Humans; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*; D016896:Treatment Outcome
keywords: Billroth; Gastric cancer; Metabolic surgery; Subtotal gastrectomy; Type 2 diabetes