Objective To systematically compare the perioperative outcomes of four Billroth-I anastomotic techniques in totally laparoscopic distal early gastric cancer resection：Overlap, Delta, modified Delta, and laparoscopy-assisted Billroth-I anastomosis and to provide evidence-based guidance for the selection of surgical methods. Methods Following PRISMA-NMA guidelines and in Chinese and English databases up to January 16, 2025, 8 randomized controlled trials （RCTs） and 35 non-randomized studies were included. Risk of bias was assessed using the Cochrane ROB 2.0 and ROBINS-I tools of the Robvis package. A Bayesian network meta-analysis （NMA） was conducted, with mean difference （MD） and relative risk ratio （RR） as effect measures. Heterogeneity was evaluated using the I² statistic. Model convergence was verified via trace plots and potential scale reduction factors （PSRF = 1.0-1.05）. Inconsistency was assessed using node-splitting and non-consistent mean effect models. Ranking probabilities were quantified by surface under the cumulative ranking curve （SUCRA）, and publication bias was adjusted via funnel plots. Results The Overlap anastomosis demonstrated the shortest operative time （MD = -6 min, 95% CrI： -11 to -1.5; SUCRA = 80%） and shortest hospital stay （MD = -1.7 days, 95% CrI： -2.8 to -0.54; SUCRA = 87%）. Although its anastomotic leakage risk was numerically lower than other techniques,the difference lacked statistical significance （RR = 0.41, 95% CrI： 0.12-1.2; SUCRA = 88%）, yet the clinical relevance might be meaningful. Delta anastomosis showed the least intraoperative blood loss （MD = -39 mL, 95% CrI： -52 to -26; SUCRA = 97%） but no significant difference in anastomotic leakage risk （RR = 0.75, 95% CrI： 0.47-1.20; SUCRA = 47%）. Modified Delta anastomosis had a trend toward increased lymph node harvest （MD = 2.7, 95% CrI：-0.57 to6.00; SUCRA = 84%）. Conclusions For distal early gastric cancer （cT1-2N0M0）,the Overlap anastomosis is characterized by simplified surgical steps, low complication rate, and rapid recovery, while the Delta anastomosis excels in minimizing blood loss but requires cautious complication assessment. The modified Delta anastomosis is recommended in centers with advanced laparoscopic expertise to optimize oncological outcomes.
Key words
totally laparoscopic distal early gastric cancer resection /
Billroth-I anastomosis /
perioperative outcomes /
Bayesian network meta-analysis
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