Fear of Cancer, General Surgeons Use the Billroth II, Bariatric Surgeons FEAR the Billroth II

Irrational Fear of Gastric Cancer:CHOOSING THE BEST WEIGHT LOSS

SURGERY

R Rutledge MD, www.CLOS.net

Email: [email protected]

Irrational Fears of CancerGeneral Surgeons Use the Billroth II

Bariatric Surgeons FEAR the Billroth II (Mini-Bypass)

At WORST Lifetime Risk Billroth II isLess Risky than 2 CATScans or

Eating a Hot Dog!Surgeons with Greatest Fear =>

Least Well Informed

Dr Rutledge: Training & Background

• Undergrad/Medical School; Teacher Dr. Lester Dragstedt Pioneer / Inventor of the Highly Controversial Vagotomy and Pyloroplasty

• 2 Years Cardiac Surgery National Institutes of Health National Heart Lung Blood Institute

• 20 years University of NC; Professor of Surgery, Associate Chief of Staff, Director of Section Medical Informatics, Director North Carolina Trauma Registry

• Author of 100 papers and articles

Dr Rutledge: Training & Background

• Specialty: Trauma, Critical Care, Medical Informatics and Bariatric Surgery (1978-1998 20 years University NC)

• Experience: Trauma Surgery, Director NC Trauma Registry

• Peptic Ulcer Surgery; Vagotomy & Pyloroplasty; Antrectomy & Billroth II

• Bariatric Surgery 33 years: Open RNY & Vertical Banded Gastroplasty

• 1997 one first surgeons laparoscopic RNY

• Mini-Gastric Bypass; 14 years, over 6,000 cases

Dr. Rutledge

USA 001-702-714-0011 [email protected]

CONSIDERING THE MGB?MGB IS A SUPERB SURGERY

BUT…WARNING:

“THERE ARE “TRICKS AND TRAPS”

OFFER A SAFE & SUCCESSFUL MGB PROGRAM

• Call / Email: Anytime question or advice on any clinical, technical or patient MGB question

• USA 001-702-714-0011 [email protected]

• Personal Visit: Dr. Rutledge Visiting Professor: France, Turkey, Austria & India, Upcoming visits Greece, Istanbul, United Kingdom, Czech Republic, Italy, Germany

• Please Use the Knowledge of Others Before You Start; Experience; over 14 years, over 6,000 patients

• USA 001-702-714-0011 [email protected]

MGB Results

• In Short• By every measure• In every study• By Every Author• MGB Equal to or Better Than

any other form of Bariatric Surgery

Fear of Mini-Bypass

• Numerous studies now confirm that the Mini-Gastric Bypass (MGB) is

• Short, simple, highly effective, very safe, very durable and easily revised surgery

• In almost every way the MGB out performs the Sleeve, Band and RNY

Lack of Knowledge and Patient Outcomes

• Studies Show Correlation Between Surgeon's knowledge in there areas of expertise and patient outcomes

• Survey Data Showed :

• Surgeons who FEAR GCa after MGB were much less knowledgeable about GCa and Billroth II and General Surgery than other Bariatric Surgeons

Fear of Gastric Caner after Mini-BypassPurpose: Education

1 Gastric Cancer (GCa)

2 Declining Risk

3 Causes Prevention GCa

4 H Pylori GCa

5 Billroth II and GCa

6 General Surgeons Routine

Use of BII

7 Incidence/Frequency of GCa

8 Studies showing NO

Increased Risk of GCa Post

BII

9 Some Studies DO show Increased Risk of GCa after BII...BUT in these studies BII Done for ULCERS!

10 Reminder Ulcers and GCa CAUSED by H Pylori!

11 Gastroenterologists DO NOT recommend endo F/U for BII patients; Why? BECAUSE THE RISK IS TOO LOW

12 Irrational Fears: Hot Dogs, CAT-Scans and Cognitive Biases in Humans and Bariatric Surgeons

Human Decision Making

• Numerous Studies show that Human Decision Making is far from the ideal logical and rational skill that many of us imagine

• Cognitive Biases

• Foundation of Good Decision Making is a Clear understanding of the data

Survey 102 Bariatric Surgeons

• Experience with over 39,000 cases

• Surgeons who Fear of GCa after MGB

• Significantly LESS Knowledgeable about GCa, General Surgery, outcomes of BII and MGB

Begin with Education

Gastric Cancer (GCa)

• Studies Show just the Word "Cancer" engenders an inordinate amount of fear in study participants

• Example what's more deadly cancer or bowel obstruction

• To judge the right response to a risk we need to look at the actual data...

Gastric Cancer (GCa)Declining Risk

• There has been a long-term decline in incidence of stomach cancer in virtually all countries worldwide

• This is linked to falling rates of infection with H. pylori, and the use of refrigeration instead of salting to preserve foods,

Gastric cancer is declining in Japan and all over the world

• The incidence of gastric cancer is declining in Japan and all over the world.

• In a study conducted in Osaka prefecture,

• the age-adjusted mortality rate for gastric cancer decreased from 84 (1963–65) to 41 (1987–89) for males and from

• 41 to 18 for females during the same period


• Researchers at Harvard School of Public Health CGA declined 60% between 1978 and 2008

• H. pylori infection and smoking accounted for 47%

• Predicted 2008-2040, U.S. CGA rates will fall an additional 47%, and

• H. pylori and smoking will contribute to more than 80% of the decline.


• What to KNOW1. Worldwide Massive Decline of GCa2. Why?

= Decline in Smoking= Refrigeration => Decrease in Nitrate in Preserved Foods/More Fresh Fruit and Veges AND= Decline in H.Pylori

3. NOT Billroth II

Causes/Prevention GCa

• H. pylori can cause peptic ulcers. cause of stomach cancer

• Smoking: Heavy smokers are most at risk.

• Diet: Smoked, Salted, Or Pickled increased risk

• Diet high in fresh fruits & vegetables lower risk

• Sedentary and Obesity Increase Risk

Fear Gastric Cancer?Prevention is Simple!

• Rx H Pylori

• STOP Smoking

• Diet: DO NOT EAT Smoked, Salted, Or Pickled foods

• * DO Eat * fresh fruits & vegetables

• Be Active and Rx Obesity

H Pylori GCa

• H. pylori infection is the major cause of gastric (stomach) cancer

• "Helicobacter pylori causes gastric cancer in human and in experimental animals. "

• Many surgeons who fear GCa in MGB did not seem to be clear on this simple fact

Fear Gastric Cancer?

• Rx H Pylori• STOP Smoking




Billroth II and GCa

Many Surgeons who fear the GCa Association with MGB not

clear on the research on this topic

Billroth II and GCaStudies showing NO Increased Risk of GCa

Post BII

• Many Surgeons who fear the GCa Association with MGB do not know that

• Many Studies of BII and GCa Show

• NO ASSOCIATION

• Studies showing NO Increased Risk of GCa Post BII

BARIATRIC SURGEONS FEAR BILLROTH IIMany Studies Show NO Association

• Mayo Clinic Study (Example)

• 338 Billroth II patients

• Followed 25-years

• 5,635 person-years

• Only 2 Cancers in 5,000+ pt years of Follow Up

• Schafer et al, Risk of gastric carcinoma after treatment for benign ulcer disease. N Engl J Med. 1983 Nov 17;309

BARIATRIC SURGEONS FEAR BILLROTH IIMAGNITUDE OF THE PROBLEM

• Population based study, 338 Billroth II pts

• Followed 25-years

• 5,635 person-years

• Only 2 Cancers Found in 5,000 years• Predicted 2.6 cancers (relative risk

0.8)

Schafer et al, Risk of gastric carcinoma after treatment for benign ulcer disease. N Engl J Med. 1983 Nov 17;309

BARIATRIC SURGEONS FEAR BILLROTH IINo Association of Billroth II and Gastric Ca

• 338 Billroth II pts, Followed 25-yrs• 5,635 person-years• Only 2 Cancers in 5,000 pt yrs follow

up• Lifetime Risk GCa after BII 0.04%• RATE of Gastric Cancer is Declining• 24 - 50% Expected Decrease from

1983• Future risk <<1 patient / 5,000 pt years


• Only 2 Cancers in 5,000 pt yrs follow up• Lifetime Risk GCa after BII 0.04%• Remember!• RATE of Gastric Cancer is Declining• This was Published in 1983!• 24 - 50% Expected Decrease from 1983• Future risk GCa: ~1 pt / 5,000 pt yrs• Lifetime Risk of GCa after 5,000 pt yrs FU

0.02% Less than the risk for the rest of the population!


• Remember!

• RATE of Gastric Cancer is Declining

• This was Published in 1983!

• 24 - 50% Expected Decrease from 1983

• Future risk GCa: ~1 pt / 5,000 pt yrs

• Lifetime Risk of GCa after 5,000 pt yrs FU 0.02%

• Less than the risk for the rest of the population!

Billroth II and GCa

• Many Surgeons who fear the GCa Association with MGB do not know that

• Many Studies of BII and GCa Show

• NO ASSOCIATION

RememberIf You Fear Gastric Cancer?

• Rx H Pylori

• STOP Smoking




Some Studies DO show Increased Risk of GCa after BII...BUT in these studies

BII Done for ULCERS!

Meta-analysis: 7 studies show Small increased risk

5 studies No Increased Risk

Some Studies DO ShowAssociation Billroth II and GCa

• Ulcers associated with increased risk of GCa

• Why?

• Because H.Pylori Infection

• AND

• H. Pylori causes GCa (RR = 1.53)


• Meta-analysis: 7 studies show Small increased risk 5 studies No Increased Risk

• Some Studies DO ShowAssociation Billroth II and GCa

• (RR = 1.5) similar to ulcers

• BUT...

Reminder: Ulcers and GCa

BothCAUSED by H Pylori!


• 7 studies show Small increased riskBUT...

• Studies increased Risk; Flawed

• Why Billroth II? Rx Ulcers

• Ulcers = H. Pylori Infection

• H. Pylori Infection => GCa


• Increased Risk of BII vs Population; Flawed

• Billroth II performed to Rx Ulcers

• Ulcers = H. Pylori Infection

• H. Pylori Infection => GCa

• Increased GCa from H Pylori NOT BII

BII and GCa

• Many Studies Show No Association between BII and GCa

• Some studies DO show an association• But• In the studies that do show an

association the BII was done for Ulcers• Ulcers = H. Pylori• H. Pylori causes GCa• Billroth II probably has little or nothing

to do with RR of GCa

General Surgeons Routine Use of BII

Bariatric Surgeons Fear Billroth II;

General Surgeons Choose Billroth IITrauma Surgeons Choose Billroth II

Oncologic Surgeons Choose Billroth II

BARIATRIC SURGEONS FEAR BILLROTH II;CANCER SURGEONS CHOOSE BILLROTH II

• 1,490 articles on performance of the Billroth II

• General/Trauma/Oncologic surgeons commonly use the Billroth II

• Over 16,000 Billroth II operation performed in USA 2007

• While Bariatric Surgeons Fear the Billroth II General Surgeons use the Billroth II routinely

BARIATRIC SURGEONS FEAR BILLROTH II;CANCER SURGEONS CHOOSE BILLROTH II

• Studies from Oncologic Surgeons from Korea and China

• Location of some of the highest rates of GCa in the world

• Routinely report the use of Billroth II reconstructions in GCa patients

Incidence/Frequency of GCa

Do you fear being struck by Lighting?

Do you fear Gastric Cancer after Billroth II?

Incidence/Frequency of GCa

• From Cancer.org

• USA Lifetime Risk of stomach Cancer * 0.5% *

• MD India * 0.51% *

• Declining Rates of Stomach Cancer

Cancer from CAT ScansAdditional Cancer Risk(%)

Abd/Pelvis CT

Additional Cancer Risk(%) ++0.14%

2 Abd/Pel CtScan + Contrast 40mSv

Additional Cancer Risk(%) ++0.28%

Lifetime Risk of Gastric Cancer & Predicted Increased Risk from

WORST Billroth II Studies (RR1.5)

Baseline Lifetime Risk of GCa 0.50%

Using Worst Billroth II studies

Predicted Additional Cancer Risk(%) ++0.25%

Lifetime Risk of Gastric Cancer & Predicted Increased Risk from

WORST Billroth II Studies (RR1.5)

Baseline Lifetime Risk of GCa 0.50%

Using Worst Billroth II studies

Predicted Additional Cancer Risk(%) ++0.25%

Declining Rates of Stomach Cancer

• Stomach cancer incidence rates have decreased since the mid-1970s

• For males, European AS incidence rates decreased by *59%* between 1975-1977 and 2008-2010.

• The decline is slightly bigger for women, with rates decreasing by *64%* between 1975-1977 and 2008-2010.

Comparison of Risk of Worst Predicted Outcomes of BII

Compared to 1 or 2 CT Scans

• 1 or 2 CT Scans vs BII (as predicted by the worst BII risk studies, published in the 60's-80's)

• CT Scan 0.78% vs BII 0.75%

• Lifetime risk cancer

Fear CTScans?

• Many studies show no increased risk of GCa after BII

• Of the old studies that do show an increased risk the magnitude of the risk is about the risk see with one or two CT Scans

• Fear CT Scans?

Fear the Hot Dog?

Fear the Hot Dog?

• 100 g increment the association between processed meat increased risk of gastric cancer

(** RR 5.0 **)

• One Hot Dog = 100g

CANCER QUIZ: MORE DEADLY CANCER CAUSING AGENT? A OR B

AA BB

• Answer Hot Dog

• Do you Fear Hot Dog or a CAT Scan?

• Remember Many Studies of Billroth II Show No increased Risk of GCa

CANCER QUIZ: MORE DEADLY Hot Dog or Mini-Gastric Bypass

AA

UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II

• 1. Gastric Cancer Declining Rapidly, > 50%

• 2. Gastric Cancer Cause: Environmental Factors / Easily Prevented

Diet, Lifestyle changes and Rx of H. Pylori

(Avoid Etoh, smoking, processed & salted meats and foods, seek high intake of fruits and vegetables)


• 3. Some studies Slight Increased Risk of gastric cancer after 20 – 30 years (RR 1.5):But: BII to Rx Ulcer => Ulcer => Increased Risk

• (Worried? Rx H Pylori, Eat healthy etc.)

• 4. Many Large Studies: No Increased RiskThousands of patients followed for Decades


• 5. Endoscopic screening of Billroth II patients is Not Recommended. Why? Low Risk!

• 6. General, Trauma and Oncologic surgeons routinely use the Billroth II (Thousands of publications)

• 7. 2007 ~16,000 BII procedures were performed in the USA


• 8. Billroth II and the Mini-Gastric BypassExcellent, Safe and Effective

• 9. FEAR Gastric Cancer? Avoid ETOH, Tobacco, Processed & Preserved Meats, Rx H. Pylori, Eat Fruits and Veggies, Yogurt and Drink Green Tea

• A Billroth II probably makes NO difference

• Rational Review of the Data vs.Fear Gastric Cancer / Bile Reflux

• Rational Thinking vs. Reptilian Brain

Rational Data Analysis vs.Irrational FEAR Gastric Cancer

• 1. Gastric Cancer Declining Rapidly

• 2. GC Environmental Causes; Easily Prevented

• 3. Some studies show Small Increased Risk Probably from Ulcers / H. Pylori

• 4. Many large studies: NO increased risk

• 5. Endoscopic Screening: Not Recommended

• 6. General, Trauma & Oncologic Surgeons Use Billroth II

FEAR OF GASTRIC CANCER

• FEAR gastric cancer?

• Avoid: Alcohol, Tobacco, Processed & Preserved MeatsRx: H. Pylori, Eat Fruits & Veggies, Yogurt

• Billroth II Probably Makes NO Billroth II Probably Makes NO DifferenceDifference

FEAR OF GASTRIC CANCER

A Billroth II Probably Makes No

Difference