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BACKGROUND: The controversy surrounding Roux-en-Y and Billroth II with Braun anastomosis as an anti-bile reflux procedure after distal gastrectomy has persisted. Recent studies have demonstrated their efficacy, but the long-term outcomes and postoperative quality of life (QoL) among patients have yet to be evaluated. Therefore, we compared the short-term and long-term outcomes of the two procedures as well as QoL.METHODS The clinical data of 151 patients who underwent total laparoscopic distal gastrectomy at the Second Hospital of Fujian Medical University from January 2016 to December 2019 were retrospectively analyzed. Of these, 57 cases with Roux-en-Y anastomosis (R-Y group) and 94 cases with Billroth II with Braun anastomosis were included (BII + B group). Operative and postoperative conditions, early and late complications, endoscopic outcomes at year 1 and year 3 after surgery, nutritional indicators, and quality of life scores at year 3 postoperatively were compared between the two groups.RESULTS The R-Y group recorded a significantly longer operative time (194.65 ± 21.52 min vs. 183.88 ± 18.02 min) and anastomotic time (36.96 ± 2.43 min vs. 27.97 ± 3.74 min) compared to the BII + B group (P < 0.05). However, no other significant differences were observed in terms of blood loss or postoperative conditions (P > 0.05). Both groups showed comparable rates of early and late complications. Endoscopic findings indicated similar food residuals at years 1 and 3 postsurgery for both groups. The R-Y group had a lower occurrence of residual gastritis and bile reflux at year 1 and year 3 after surgery, with a statistically significant difference (P < 0.001). Reflux esophagitis was not significantly different between the R-Y and BII + B groups in year 1 after surgery, but the R-Y group had a lower incidence than the BII + B group in year 3 after surgery (P = 0.023). Nutritional outcomes at 3 years after surgery did not differ significantly between the two groups (P > 0.05). Quality of life scores measured by the QLQ-C30 scale were not significantly different between the two groups. However, on the QLQ-STO22 scale, the reflux score was significantly lower in the R-Y group than in the BII + B group (0 [0, 0] vs. 5.56 [0, 11.11]) (P = 0.003). The rest of the scores were not significantly different (P > 0.05).CONCLUSION Both R-Y and B II + B are equally safe and efficient for TLDG. Nevertheless, R-Y reduces the incidence of residual gastritis, bile reflux, and reflux esophagitis, as well as postoperative reflux symptoms, and provides a better quality of life for patients.