Fear & Confusion about the Risk of Cancer after Bariatric Surgery

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Esophageal Cancer from
Fear & Confusion about the Risk of Cancer after Bariatric Surgery
Sleeve & Band vs Risk of Gastric Cancer after Mini-Gastric Bypass
Dr Rutledge
The Centers for Laparoscopic Obesity Surgery, www.CLOS.net www.MiniBypass.net Email: DrR@clos.net

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Fear & Confusion about the Risk of Cancer after Bariatric Surgery

  1. 1. Esophageal Cancer from Sleeve & Band vs Risk of Gastric Cancer after Mini-Gastric Bypass Dr RutledgeThe Centers for Laparoscopic Obesity Surgery www.CLOS.net www.MiniBypass.net Email: DrR@clos.net
  2. 2. What Happens When General Surgeons Become Bariatric Surgeons And Forget Their General Surgery Training? Dr Rutledge The Centers for Laparoscopic Obesity Surgery www.CLOS.net www.MiniBypass.net Email: DrR@clos.net
  3. 3. PRIMITIVE RESPONSE SYSTEMS MODIFY RISK ASSESSMENT
  4. 4. MINI-GASTRIC BYPASSBASED ON SOUND SURGICAL PRACTICE •Billroth II Performedover 100 years •16,000 Billroth II’s •USA in 2007 •Operation of choice:Trauma, Ulcers, CancerStomach etc.
  5. 5. 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)
  6. 6. Fear of Gastric Cancer Bile RefluxRational vs. Reptilian Brain Decision Making Surgeons who Have Forgotten Their General Surgery
  7. 7. 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 IICollins 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.
  8. 8. 1. Gastric Cancer; Declining Rapidly •Gastric cancerDecreasing in the •USA & around the world • Decreased four-foldsince 1930 • Approximately 40deaths per 1,000,000people.
  9. 9. 1. Gastric Cancer; Declining Rapidly• There were approximately 40 deaths from stomachcancer per 1,000,000 population in USA 2009.• 73 Median age at death for cancer of the stomach 73years• = 2/3 stomach cancer patients are older than 65Howlader 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 2011SEER data submission, posted to the SEER web site, 2012.
  10. 10. 2. Environmental Causes of Gastric Cancer; Easily Prevented What 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
  11. 11. 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
  12. 12. 2. Environmental Causes of Gastric Cancer; Easily PreventedAvoidETOH, Tobacco,Processed & PreservedMeats,Salted FoodsRx H. Pylori,Eat Fruits & Veggies, YogurtDrink Green TeaGonzalez CA, Cancer Research, Institut Català dOncologia,Av. Gran Via s/n, km 2.7, 08907 LHospitalet, Barcelona,Spain.
  13. 13. 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. NEngl J Med. 1983 Nov 17;309
  14. 14. 3. Many Large Studies: NO Increased Risk Gastric Cancer with Billroth II •Population based study, 338 Billroth IIpts •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 JMed. 1983 Nov 17;309
  15. 15. 3. Many Large Studies: NO Increased Risk Gastric Cancer with Billroth II• 338 Billroth II pts, Followed 25-years• 5,635 person-years• Only 2 Cancers in 5,000 pt years followup• RATE of Gastric Cancer is Declining• 24 - 50% Expected Decrease from 1983• Future risk 1 patient / 5,000 pt years
  16. 16. 3. Many Large Studies: NO Increased Risk Gastric Cancer with Billroth IIMany large scale studies;•No increased risk of Gastric Cancer after Billroth•II30 yr follow up, over 500 pts,•"Risk of gastric cancer is * Not * increased after•Billroth II."Bassily R, J Gastro Hepatl. 2000•
  17. 17. 4. Some studies Small Increase Risk Gastric Cancer after Billroth II• (Confusion Association vs. Causation)• Some studies Small Increase Risk of Gastric Cancerafter Billroth II• In all of these studies Billroth II used to treat Ulcers• H. Pylori is the common Etiological Agent ofBoth Ulcers & Gastric Cancer• H. Pylori Causes Both Ulcers and Cancer
  18. 18. 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
  19. 19. 4. Some studies Small Increased Risk Gastric Cancer after Billroth IIULCERS 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
  20. 20. BARIATRIC SURGEONS FEAR BILLROTH IIWhat is the Risk of Gastric Cancer?• Statistical significance tells us that an observeddifference is reliable, but whether the difference is largeenough to be important cannot be resolved by applying astatistical formula.• A STATISTICALLY SIGNIFICANT difference is notnecessarily one that is of CLINICAL SIGNIFICANCE
  21. 21. 5. No Endoscopic Screening for Billroth II Gastric 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 forduodenal ulcer. Fischer AB
  22. 22. 5. BARIATRIC SURGEONS FEAR BILLROTH IIGASTROENTEROLOGISTS IGNORE BILLROTH IIHundreds of thousands of people with Billroth IIIf cancer after Billroth II was a clinically importantRISK…GastroenterologistsDO NOT Offer Screening Endoscopy for Billroth IINo 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
  23. 23. 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
  24. 24. 6. BARIATRIC SURGEONS FEAR BILLROTH II;CANCER SURGEONS CHOOSE BILLROTH II •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,
  25. 25. 6. BARIATRIC SURGEONS FEAR BILLROTH II;CANCER SURGEONS CHOOSE BILLROTH II 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*
  26. 26. 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 laparoscopicBillroth-II distal gastrectomy forgastric cancer. Lee J, Kim D, Kim W.130 Gastric Cancer Patients Rx Billroth II Performedusing technique identical to MGB
  27. 27. UNINFORMED SURGEONS FEAR BILLROTH II GENERAL 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.
  28. 28. UNINFORMED SURGEONS FEAR BILLROTH II GENERAL 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.
  29. 29. UNINFORMED SURGEONS FEAR BILLROTH II EDUCATED 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
  30. 30. UNINFORMED SURGEONS FEAR BILLROTH II EDUCATED SURGEONS USE BILLROTH II3. Many Large Studies: No Increased Risk Thousands of patients/followed for Decades4. 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)
  31. 31. UNINFORMED FEAR BILLROTH II EDUCATED USE BILLROTH II5. 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
  32. 32. UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH IIBillroth II and the Mini-Gastric Bypass Excellent, Safe and EffectiveIF FEAR Gastric Cancer? Avoid ETOH, Tobacco, Processed & Preserved Meats, Rx H. Pylori, Eat Fruits and Veggies, Yogurt and Drink Green TeaA Billroth II probably makes NO difference
  33. 33. Rational Data Analysis vs. Irrational FEAR Gastric Cancer1.Gastric Cancer; Declining Rapidly2. 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
  34. 34. ? FEAR OF GASTRIC CANCER ?“ IF ” FEAR Gastric Cancer; ” THEN: ”1. Avoid: Alcohol, Tobacco,Processed & Preserved Meats2. Eat: Fruits & Veggies, Yogurt3. Rx: H. PyloriBillroth II Makes NO Difference !!
  35. 35. •Rational Review of the Data vs.•Fear Gastric Cancer / Bile Reflux•Rational Thinking vs.•Reptilian Brain
  36. 36. FEAR OF GASTRIC CANCER A Billroth IIProbably Makes No Difference
  37. 37. FEAR OF GASTRIC CANCER A Billroth IIProbably Makes No Difference
  38. 38. Fear of Cancer after Bariatric Surgery IS APPROPRIATE!FEAR ESOPHAGEAL CANCERAFTER SLEEVE AND BAND
  39. 39. Fear of Cancer After Bariatric Surgery? Acid Reflux Primary Cause of Cancer of EsophagusGERD Increases Risk of Cancer of Esophagus. LongerGERD = More Risk.GERD can cause Barretts = even higher risk, from theAmerican Cancer Society.JAMA. 2002 Apr 17;287(15):1972-81. Gastroesophageal reflux, barrettesophagus, and esophageal cancer: scientific review. Shaheen N, RansohoffDF. Division of Digestive Diseases and Nutrition, Center for EsophagealDisease and Swallowing, CB#7080, University of North Carolina-Chapel Hill,Chapel Hill, NC 27599-7080, USA. nshaheen@med.unc.edu
  40. 40. Fear of Cancer After Bariatric Surgery?Acid Reflux Primary Cause of Cancer of EsophagusTreating or PreventingGastro Esophageal Reflux Disease(GERD) can protect & preventBarretts & Esophageal cancer.
  41. 41. Fear of Cancer After Bariatric Surgery? Acid Reflux Primary Cause of Cancer of EsophagusNumerous 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 forobesity 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, Divisionof 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.rweiner@khs-ffm.deSurg Obes Relat Dis. 2011 Nov-Dec;7(6):709-13. Epub 2011 Aug 16. Gastroesophageal reflux after sleeve gastrectomy inmorbidly 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, Barretts esophagus: a late complication of laparoscopic adjustablegastric banding, Varela JE., Minimally Invasive and Bariatric Surgery, Washington University, 660 South Euclid, Box 8109,St Louis, MO 63110, USA. varelae@wudosis.wustl.edu
  42. 42. Sleeve & Band: 20-30% New Onset GERD GERD => Increased Risk of Esophageal CancerDr. Rutledge•
  43. 43. Gastroesophageal reflux disease and sleeve gastrectomy USA•Postoperatively, 49% complained of immediate(within 30 d) GERD symptoms,•47.2% had persistent GERD symptoms thatlasted >1 month after LSG, and•33.8% of patients were taking medicationspecifically for GERD after LSG.•Surg Obes Relat Dis. 2011 Gastroesophageal reflux disease andsleeve gastrectomy. Carter PR LaGrange, IL USA.
  44. 44. Gastroesophageal reflux disease and sleeve gastrectomy USA•Many studies designed to evaluate theoutcome of reflux symptoms followingconventional and surgical treatment ofobesity.•Among bariatric procedures, gastric sleeve& band have been shown to worsen refluxsymptoms in the postoperative setting.•Curr Gastroenterol Rep. 2011 Jun, Obesity and GERD:pathophysiology and effect of bariatric surgery.Tutuian R.Bern, Switzerland.
  45. 45. Gastroesophageal reflux disease and sleeve gastrectomy USA•We Know Esophageal Cancer DangerousDeadly and Rising Rapidly•We Know That Acid Reflux (GERD) IsMost Important Causative Factor inEsophageal Cancer•Numerous Studies Including the SleeveConsensus Conference Show Band &Sleeve Cause 20-30% New Onset GEReflux•The Sleeve & Band Pre-cancerousLesions In Up To 1/4 -1/3 Patients
  46. 46. Imagine; Your Post Op Sleeve or Band PatientPost 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!•
  47. 47. Fear of Cancer after Bariatric Surgery IS APPROPRIATE!FEAR ESOPHAGEAL CANCERAFTER SLEEVE AND BAND

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