Short- and Mid-Term Surgical Outcomes of Billroth I Versus Billroth II/Roux-en-Y Reconstruction: A Prospective Observational Cohort Study

<i>Background and Objectives</i>: The best method for reconstructing the stomach after distal gastrectomy surgery in gastric cancer patients continues to be a subject of ongoing discussion. The most beneficial surgical option for patients is Billroth I (BI), yet surgeons may perform Billroth II and Roux-en-Y (BII/RY) procedures because they are easier to execute, although their impact on recovery complications and postoperative function remains unclear. This prospective observational cohort study compares the short- and mid-term surgical outcomes between BI and BII/RY reconstructions. <i>Materials and Methods</i>: We included 150 patients who received curative intent distal gastrectomy at the General Surgical Clinic of Emergency County Hospital in Târgu Mureș, Romania, between October 2021 and December 2024 (72 BI and 78 BII/RY patients), with a mean age of 61.5 ± 10.8 years (60.7% male). The outcomes included recovery parameters, postoperative complications (Clavien-Dindo), and mid-term functional results (PPI use, Los Angeles classification esophagitis, bile reflux gastritis, Sigstad dumping score). Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline covariates. <i>Results</i>: The results indicated that IPTW adjustment did not change the baseline demographics, tumor characteristics, or perioperative factors. The baseline characteristics were comparable between groups (<i>p</i> > 0.05). There were no significant differences in time to flatus (<i>p</i> = 0.12), oral diet (<i>p</i> = 0.70), or hospital stay (<i>p</i> = 0.69). Major morbidity (Clavien-Dindo ≥ III) occurred in 12.7% overall (<i>p</i> = 0.17), and the 90-day mortality was 5.3% (<i>p</i> = 1.00). At 6 months, bile reflux gastritis was more frequent after BII/RY (<i>p</i> = 0.16), whereas dumping syndrome occurred more often after BI (<i>p</i> = 0.16). <i>Conclusions</i>: The short-term surgical results, together with the total postoperative complications, showed no difference between the BI and BII/RY reconstruction methods. The study revealed distinct functional results between the two groups during the mid-term assessment, which demonstrates that surgeons should maintain their practice of choosing reconstruction techniques according to patient-specific requirements.