fear & confusion about the risk of cancer after bariatric surgery

Esophageal Cancer from Sleeve & Band

vs Risk of Gastric Cancer after

Mini-Gastric Bypass

Dr Rutledge The Centers for Laparoscopic Obesity Surgery

www.CLOS.net www.MiniBypass.netEmail: [email protected]

What Happens When General SurgeonsBecome Bariatric Surgeons

And Forget Their General Surgery Training?

Dr Rutledge The Centers for Laparoscopic Obesity Surgery

www.CLOS.net www.MiniBypass.netEmail: [email protected]

PRIMITIVE RESPONSE SYSTEMSMODIFY RISK ASSESSMENT

MINI-GASTRIC BYPASSBASED ON SOUND SURGICAL PRACTICE

•Billroth II Performed over 100 years

•16,000 Billroth II’s

•USA in 2007

•Operation of choice: Trauma, Ulcers, Cancer Stomach etc.

MINI-GASTRIC BYPASS

•The Mini-Gastric Bypass: •1997 – 2011 ; >6,000 pts, •15 yr Data; Multiple Centers,

R.C.Trials

•Two Components: •Vertical Gastric Tube; •(Collis Gastroplasty)•Gastric Bypass; •(Billroth II Gastro-jejunostomy)

Fear of Gastric Cancer \ Bile RefluxRational vs. Reptilian Brain Decision Making

Surgeons who Have Forgotten Their General Surgery

STATISTICAL ILLITERACY; "MANY DOCTORS MISUNDERSTAND MEDICAL LITERATURE"

• Example: “In the absence of a Roux limb,

the long-term effects of chronic alkaline reflux

are unknown.”

• REALLY? Rational?

• Billroth II >100 years & >1,450 papers on Billroth II

Collins BJ, Miyashita T, Schweitzer M, Magnuson T, Harmon JW., Gastric Bypass; Why Roux-en-Y? A

Review of Experimental Data, Arch Surg. 2007; 142(10):1000-1003.

1. Gastric Cancer; Declining Rapidly

•Gastric cancer Decreasing in the

•USA & around the world

• Decreased four-fold since 1930

• Approximately 40 deaths per 1,000,000 people.

1. Gastric Cancer; Declining Rapidly

•There were approximately 40 deaths from stomach

cancer per 1,000,000 population in USA 2009.•73 Median age at death for cancer of the stomach 73

years •= 2/3 stomach cancer patients are older than 65 •Howlader N,. SEER Cancer Statistics Review, 1975-2009 (Vintage 2009

Populations), National Cancer Institute. Bethesda, MD,

http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011

SEER data submission, posted to the SEER web site, 2012.

2. Environmental Causes of Gastric Cancer; Easily PreventedWhat Does Cause Gastric Cancer? Its Not Billroth II

• Diet: Fried, Salted, Smoked or Preserved foods

• Nitrites converted to (carcinogens) by bacteria in the stomach.

• Fruit and Vegetables protects against Cancer

• Stomach cancer: Much more common: Smoking & Heavy alcohol intake

• H. Pylori,

•No H. Pylori = No Cancer

2. Gastric Cancer; Environmental Causes; Easily Prevented

•H. Pylori Treatment Normalizes Risk of Gastric Cancer in

Ulcer Patients.•Early treatment of H. Pylori in Gastric Ulcer patients => •Risk of Gastric Cancer decreased to NORMAL!•Decrease risk from 1.60 to 1.05 ( = general population);•"Early Helicobacter pylori eradication decreases risk of gastric cancer in

patients with peptic ulcer disease." Wu CY,et al. Div of Gastro., Taichung,

Taiwan

2. Environmental Causes of Gastric Cancer; Easily Prevented

Avoid ETOH, Tobacco, Processed & Preserved Meats, Salted FoodsRx H. Pylori, Eat Fruits & Veggies, YogurtDrink Green Tea

Gonzalez CA, Cancer Research, Institut Català d'Oncologia, Av. Gran Via s/n, km 2.7, 08907 L'Hospitalet, Barcelona, Spain.

3. Many Large Studies: NO Increased Risk

Gastric Cancer with Billroth II

• 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

3. Many Large Studies: NO Increased Risk Gastric Cancer with Billroth II

•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


• 338 Billroth II pts, Followed 25-years

• 5,635 person-years

• Only 2 Cancers in 5,000 pt years follow up

• RATE of Gastric Cancer is Declining• 24 - 50% Expected Decrease from 1983

• Future risk 1 patient / 5,000 pt years


•Many large scale studies; •No increased risk of Gastric Cancer after Billroth II•30 yr follow up, over 500 pts,•"Risk of gastric cancer is * Not * increased after

Billroth II." •Bassily R, J Gastro Hepatl. 2000

4. Some studies Small Increase Risk Gastric Cancer after Billroth II

•(Confusion Association vs. Causation)•Some studies Small Increase Risk of Gastric Cancer

after Billroth II•In all of these studies Billroth II used to treat Ulcers•H. Pylori is the common Etiological Agent of

Both Ulcers & Gastric Cancer•H. Pylori Causes Both Ulcers and Cancer

4. Some studies Small Increased Risk Gastric Ca after Billroth II; Association vs. Causation

Meta-analysis 12 Studies:

Relation of Billroth II with Gastric Cancer: Small increased risk; 7 studies No Increased Risk; 5 studies

Studies that show increased Risk; [Flawed] Billroth II Surgery was used to treat “Ulcers”

ULCERS increase risk of Gastric Cancer!

Ulcers & Gastric Cancer Common Etiology H. Pylori

4. Some studies Small Increased Risk Gastric Cancer after Billroth II

ULCERS INCREASE RISK GASTRIC CANCER

• Study 3,078 gastric cancer vs. 89,082 controls

• Ulcer increases risk gastric cancer

= (relative risk 1.53) =

• Same as Increased Risk reported Billroth II

• Many other studies confirm these findings:

• Ulcer Increases Risk Gastric Cancer

• Both Ulcers & Gastric Cancer:

• Common Etiology = H. Pylori

BARIATRIC SURGEONS FEAR BILLROTH IIWhat is the Risk of Gastric Cancer?

• Statistical significance tells us that an observed

difference is reliable, but whether the difference is large

enough to be important cannot be resolved by applying a

statistical formula.

• A STATISTICALLY SIGNIFICANT difference is not

necessarily one that is of CLINICAL SIGNIFICANCE

5. No Endoscopic Screening for Billroth IIGastric Ca Risk after Billroth II = General Population

•Follow-up study of 1,000 Billroth II patients

•22-30 year follow-up

•196 Endoscopies & Biopsy: No Cancer•Conclusion in 1983!:

•Endoscopic screening “UNREWARDING”•Since 1983 Rate Gastric Ca Down 50%!!

•Br J Surg. 1983 Sep;70(9):552-4. Risk of gastric cancer after Billroth II resection for

duodenal ulcer. Fischer AB

5. BARIATRIC SURGEONS FEAR BILLROTH IIGASTROENTEROLOGISTS IGNORE BILLROTH II

Hundreds of thousands of people with Billroth II

If cancer after Billroth II was a clinically important RISK…

Gastroenterologists

DO NOT Offer Screening Endoscopy for Billroth II

No recommendation for BII follow up screening;

Why? THE RISK IS LOW (Equal General Population)

One Study: 63,000 Pt yrs:

23 cancers = Same General Population

6. 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


•According to the National Inpatient

Sample from USA, over 16,000 Billroth II

operations were performed in 2007 in the

USA.

•The Nationwide Inpatient Sample (NIS) is a unique and

powerful database of hospital inpatient stays. Researchers and

policymakers use the NIS to identify, track, and analyze

national trends in health care utilization, access, charges,

quality, and outcomes.


Korea has the Highest Risk of Gastric Cancer in the World.

In April 2012 two papers by Oncologic Surgeons from Korea (379 cases) and China (70 cases) reported

Two series of Laparosocpic Antrectomy & Billroth II for distal Gastric Cancer.

In the first 3 months of 2012 there 20 other similar papers. Antrectomy & Billroth II by these cancer surgeons

was a viewed as *reasonable and acceptable* surgical choice.

2012 Study Cancer Surgeon Reports Gastrectomy & Billroth-II for Gastric Cancer = MINI-GASTRIC BYPASSJ Korean Surg Soc. 2012 Mar;82(3):135-42. Epub 2012 Feb 27. Comparison of laparoscopy-assisted and totally laparoscopic Billroth-II distal gastrectomy forgastric cancer. Lee J, Kim D, Kim W.

130 Gastric Cancer Patients Rx Billroth II Performed using technique identical to MGB

UNINFORMED SURGEONS FEAR BILLROTH IIGENERAL SURGEONS USE BILLROTH II

•A Billroth II gastro-jejunostomy is a common and

accepted reconstruction after antretomy;

•A Billroth II * IS NOT * an acceptable

reconstruction following total or sub total

gastrectomy because of bile reflux into the

esophagus.

UNINFORMED SURGEONS FEAR BILLROTH IIGENERAL SURGEONS USE BILLROTH II

•Billroth II with anastomosis at the junction of the body

and the antrum of the stomach in the Mini-Gastric

Bypass is a *reasonable and acceptable* surgical

choice.

•The OLD Mason Loop Gastric Bypass placed the

Billroth II high on the stomach adjacent to the

esophagus, NOT *reasonable or acceptable* and

could be predicted to fail.

UNINFORMED SURGEONS FEAR BILLROTH IIEDUCATED SURGEONS USE BILLROTH II

1. Gastric Cancer Declining Rapidly, > 50%

2. Gastric Cancer Cause/Prevention:

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

UNINFORMED SURGEONS FEAR BILLROTH IIEDUCATED SURGEONS USE BILLROTH II

3. Many Large Studies: No Increased RiskThousands of patients/followed for Decades

4. Some Billroth II studies: Slight Increased Risk 20 – 30 years (RR 1.5)

But: Billroth II performed to Rx Ulcer Ulcer => Increases Risk Gastric Ca (H. Pylori)

UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II

5. Endoscopic screening of Billroth II

Not Recommended. Why? Low Risk!

6. General, Trauma and Oncologic surgeons

Routinely use the Billroth II

(Thousands of publications)

2007 16,000 BII procedures performed in USA

UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II

Billroth II and the Mini-Gastric Bypass Excellent, Safe and Effective

IF 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 Data Analysis vs.Irrational FEAR Gastric Cancer

1.Gastric Cancer; Declining Rapidly 2. Gastric Cancer Environmental Causes;

Easily Prevented3. Many large studies:

NO Increased Risk Gastric Cancer after Billroth II4. Some studies Small Increased Risk

Gastric Cancer Billroth II, Billroth II used to Rx Ulcers; H. Pylori = Ulcers & Gastric Cancer(Confusion Association vs. Causation)

5. Endoscopic Screening: Not Recommended (Clinical Relevance vs. Statistical Significance)

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

? FEAR OF GASTRIC CANCER ?

“ IF ” FEAR Gastric Cancer; ” THEN: ”

1. Avoid: Alcohol, Tobacco,

Processed & Preserved Meats

2. Eat: Fruits & Veggies, Yogurt

3. Rx: H. Pylori

Billroth II Makes NO Difference !!Billroth II Makes NO Difference !!

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

FEAR OF GASTRIC CANCER

A Billroth II Probably Makes

No Difference

FEAR OF GASTRIC CANCER

A Billroth II Probably Makes No Difference

Fear of Cancer after Bariatric Surgery

IS APPROPRIATE!FEAR ESOPHAGEAL CANCER AFTER SLEEVE AND BAND

Fear of Cancer After Bariatric Surgery?Acid Reflux Primary Cause of Cancer of

Esophagus

GERD Increases Risk of Cancer of Esophagus. Longer

GERD = More Risk.

GERD can cause Barrett's = even higher risk, from the American Cancer Society.

JAMA. 2002 Apr 17;287(15):1972-81. Gastroesophageal reflux, barrett

esophagus, and esophageal cancer: scientific review. Shaheen N, Ransohoff

DF. Division of Digestive Diseases and Nutrition, Center for Esophageal

Disease and Swallowing, CB#7080, University of North Carolina-Chapel Hill,

Chapel Hill, NC 27599-7080, USA. [email protected]


Esophagus

Treating or Preventing

Gastro Esophageal Reflux Disease

(GERD) can protect & prevent

Barrett's & Esophageal cancer.


Esophagus

Numerous Studies Now Show that the Band & Sleeve increase acid reflux & Barretts & Esophageal Caner.Dis Esophagus. 2011 Jan;24(1):E8-10. Esophageal adenocarcinoma after laparoscopic gastric band placement for obesity Stauffer JA, Mathew J, Odell JA, Department of General Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Ann Surg. 2010 Aug;252(2):319-24. Long-term results of laparoscopic sleeve gastrectomy for obesity. Himpens J, Division of Bariatric Surgery, AZ St-Blasius, Kroonveldlaan, Dendermonde, Belgium.

Obes Facts. 2011;4 Suppl 1:42-6. Epub 2011 Apr 4. Failure of laparoscopic sleeve gastrectomy--further procedure? Weiner RA, Theodoridou S, Weiner S. Department of Surgery, Krankenhaus Sachsenhausen, Frankfurt/M, Germany. [email protected]

Surg Obes Relat Dis. 2011 Nov-Dec;7(6):709-13. Epub 2011 Aug 16. Gastroesophageal reflux after sleeve gastrectomy in morbidly obese patients. Howard DD, Caban AM, Cendan JC, Ben-David K. Department of Surgery, Minimally Invasive, Gastroesophageal and Bariatric Surgery Service, University of Florida, Gainesville, Florida 32610, USA.

Obes Surg. 2010 Feb;20(2):244-6. Epub 2009 Dec 8, Barrett's esophagus: a late complication of laparoscopic adjustable gastric banding, Varela JE., Minimally Invasive and Bariatric Surgery, Washington University, 660 South Euclid, Box 8109, St Louis, MO 63110, USA. [email protected]

Sleeve & Band:20-30% New Onset GERD

GERD =>Increased Risk of

Esophageal Cancer

•Dr. Rutledge

Gastroesophageal reflux disease and sleeve gastrectomy USA

•Postoperatively, 49% complained of immediate (within 30 d) GERD symptoms,•47.2% had persistent GERD symptoms that lasted >1 month after LSG, and•33.8% of patients were taking medication specifically for GERD after LSG.•Surg Obes Relat Dis. 2011 Gastroesophageal reflux disease and sleeve gastrectomy. Carter PR LaGrange, IL USA.


•Many studies designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity.•Among bariatric procedures, gastric sleeve & band have been shown to worsen reflux symptoms in the postoperative setting.•Curr Gastroenterol Rep. 2011 Jun, Obesity and GERD: pathophysiology and effect of bariatric surgery.Tutuian R. Bern, Switzerland.


•We Know Esophageal Cancer Dangerous Deadly and Rising Rapidly •We Know That Acid Reflux (GERD) Is Most Important Causative Factor in Esophageal Cancer•Numerous Studies Including the Sleeve Consensus Conference Show Band & Sleeve Cause 20-30% New Onset GE Reflux •The Sleeve & Band Pre-cancerous Lesions In Up To 1/4 -1/3 Patients

Imagine; Your Post Op Sleeve or Band Patient

•Post Op Patient Visit"•"Dr. I found out the operation that you performed on me may cause cancer, esophageal cancer. •You did not tell me this."•Your answer?•We need to warn our patients!

Fear of Cancer after Bariatric Surgery

IS APPROPRIATE!FEAR ESOPHAGEAL CANCER AFTER SLEEVE AND BAND

fear & confusion about the risk of cancer after bariatric surgery

Education

benign ulcer

acid reflux

oncologic

laparoscopic

billroth iibillroth

gastroesophageal

laparoscopic

acceptable