Irrational Fears of CancerGeneral Surgeons Use the Billroth IIBariatric Surgeons FEAR the Billroth II (Mini-Bypass) Irrational Fear of Gastric Cancer:CHOOSING THE BEST WEIGHT LOSS SURGERY, R Rutledge MD, www.CLOS.net, Email: DrR@clos.net. http://www.slideshare.net/DrRRMD/fear-g-ca-02-0214v2

1. Irrational Fear of Gastric Cancer:
CHOOSING THE BEST WEIGHT LOSS
SURGERY
R Rutledge MD,
www.CLOS.net
Email: DrR@clos.net

2. Irrational Fears of Cancer
General Surgeons Use the Billroth II
Bariatric Surgeons FEAR the Billroth II
(Mini-Bypass)
At WORST Lifetime Risk Billroth II is
Less Risky than 2 CATScans or
Eating a Hot Dog!
Surgeons with Greatest Fear =>
Least Well Informed

3. 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

4. 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

5. Dr. Rutledge
USA 001-702-714-0011 DrR@clos.net
CONSIDERING THE MGB?
MGB IS A SUPERB SURGERY
BUT…
WARNING:
“THERE ARE “TRICKS AND
TRAPS”

6. 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 DrR@clos.net
• 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 DrR@clos.net

7. 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

8. 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

9. 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

10. Fear of Gastric Caner after Mini-Bypass
Purpose: 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

11. 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

12. 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

13. Begin with Education

14. 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...

15. 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,

16. 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

17. Gastric Cancer (GCa)
Declining Risk
• 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.

18. Gastric Cancer (GCa)
Declining Risk
• What to KNOW
1. Worldwide Massive Decline of GCa
2. 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

19. 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

20. 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

21. 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

22. Fear Gastric Cancer?
•Rx H Pylori
• STOP Smoking
• Diet: DO NOT EAT Smoked, Salted,
Or Pickled foods
• * DO Eat * fresh fruits & vegetables
• Be Active and Rx Obesity

23. Billroth II and GCa
Many Surgeons who fear the
GCa Association with MGB not
clear on the research on this
topic

24. Billroth II and GCa
Studies 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

25. BARIATRIC SURGEONS FEAR BILLROTH II
Many 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

26. BARIATRIC SURGEONS FEAR BILLROTH II
MAGNITUDE 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

27. BARIATRIC SURGEONS FEAR BILLROTH II
No 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

28. BARIATRIC SURGEONS FEAR BILLROTH II
No Association of Billroth II and Gastric Ca
• 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!

29. BARIATRIC SURGEONS FEAR BILLROTH II
No Association of Billroth II and Gastric Ca
• 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!

30. 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

31. Remember
If You Fear Gastric Cancer?
• Rx H Pylori
• STOP Smoking
• Diet: DO NOT EAT Smoked, Salted,
Or Pickled foods
• * DO Eat * fresh fruits & vegetables
• Be Active and Rx Obesity

32. 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

33. Some Studies DO Show
Association Billroth II and GCa
• Ulcers associated with increased
risk of GCa
• Why?
• Because H.Pylori Infection
• AND
• H. Pylori causes GCa (RR = 1.53)

34. Some Studies DO Show
Association Billroth II and GCa
• Meta-analysis:
7 studies show Small increased risk
5 studies No Increased Risk
• Some Studies DO Show
Association Billroth II and GCa
• (RR = 1.5) similar to ulcers
• BUT...

35. Reminder:
Ulcers and GCa
Both
CAUSED by H Pylori!

36. Some Studies DO Show
Association Billroth II and GCa
• 7 studies show Small increased risk
BUT...
• Studies increased Risk; Flawed
• Why Billroth II? Rx Ulcers
• Ulcers = H. Pylori Infection
• H. Pylori Infection => GCa

37. Some Studies DO Show
Association Billroth II and 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

38. 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

39. General Surgeons Routine Use of BII
Bariatric Surgeons Fear Billroth II;
General Surgeons Choose Billroth II
Trauma Surgeons Choose Billroth II
Oncologic Surgeons Choose Billroth II

40. 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

41. 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

42. Incidence/Frequency of
GCa
Do you fear being struck by
Lighting?
Do you fear Gastric Cancer after
Billroth II?

43. Incidence/Frequency of
GCa
• From Cancer.org
• USA Lifetime Risk of stomach
Cancer * 0.5% *
• MD India * 0.51% *
• Declining Rates of Stomach
Cancer

44. Cancer from CAT Scans
Additional Cancer Risk(%)
Abd/Pelvis CT
Additional Cancer Risk(%) ++0.14%
2 Abd/Pel CtScan + Contrast 40mSv
Additional Cancer Risk(%) ++0.28%

45. 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%

46. 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%

47. 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.

48. 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

49. 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?

50. Fear the Hot Dog?

51. Fear the Hot Dog?
• 100 g increment the
association between
processed meat
increased risk of
gastric cancer
(** RR 5.0 **)
• One Hot Dog = 100g

52. CANCER QUIZ: MORE DEADLY
CANCER CAUSING AGENT? A
OR B
AA BB

53. • 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

54. UNINFORMED FEAR BILLROTH II
EDUCATED 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)

55. UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II
• 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 Risk
Thousands of patients followed for Decades

56. UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II
• 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

57. UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II
• 8. Billroth II and the Mini-Gastric Bypass
Excellent, 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

58. • Rational Review of the Data vs.
Fear Gastric Cancer / Bile Reflux
• Rational Thinking vs. Reptilian
Brain

59. 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

60. FEAR OF GASTRIC CANCER
• FEAR gastric cancer?
• Avoid: Alcohol, Tobacco, Processed
& Preserved Meats
Rx: H. Pylori,
Eat Fruits & Veggies, Yogurt
• Billroth II Probably Makes NOBillroth II Probably Makes NO
DifferenceDifference

61. FEAR OF GASTRIC CANCER
A Billroth II
Probably Makes No
Difference