Background: It is unclear which reconstructive route (retrocolic or antecolic) is more effective in preventing postoperative gastroesophageal reflux disease (GERD) in Roux-en-Y reconstruction following distal gastrectomy. Methods: Eighty-one eligible patients (retrocolic, n = 39; antecolic, n = 42) underwent endoscopies before surgery and 1 year after surgery to evaluate reflux esophagitis according to the Los Angeles classifications. The relative anatomical position of gastrojejunostomy to the cardia was measured by CT imaging. Results: The proportion of patients with reflux esophagitis was also significantly higher in the antecolic group than in the retrocolic group (38.1 vs. 10.3%, p = 0.005). Multivariate analysis revealed that antecolic reconstruction and body mass index (BMI) were independent risk factors for reflux esophagitis. The relative position of gastrojejunostomy to the cardia in the antecolic group was shifted to the left laterally (59.0 vs. 28.8 degree, p < 0.001) and ventrally (65.4 vs. 39.8 degree, p < 0.001) than in the retrocolic group. There was a positive correlation between BMI and left lateral and ventral shifts of gastrojejunostomy in the antecolic group. Conclusion: Retrocolic reconstruction may be superior to antecolic reconstruction in preventing postoperative GERD, especially in obese patients. The left lateral and ventral shifts of gastrojejunostomy after antecolic reconstruction may aggravate the occurrence of GERD.
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