Irrational Fears of Cancer in the MGB by Bariatric Surgeons

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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

Published in: Education
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Irrational Fears of Cancer in the MGB by Bariatric Surgeons

  1. 1. 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
  2. 2. 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
  3. 3. Lack of Knoledge 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 knolwedgeable about GCa and Billroth II and General Surgery than other Bariatric Surgeons
  4. 4. Fear of Gastric Caner after Mini-Bypass Purpose: Education 1 Gastric Cancer (GCa) 2 Declining Risk 3 Causes Prevention GCa 4 HPylori 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 HPylori! 11 Gastroenterologists DO NOT recommend endo F/U for BII patients; Why? BECAUSE THE RISK IS TOO LOW 12 Irrational Fears: Hot Dogs, CATScans and Cognitive Biases in Humans and Bariatric Surgeons
  5. 5. Human Decision Making • Numeorus 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
  6. 6. Survey 102 Bariatric Surgeons • Experience with over 39,000 cases • Surgeons who expressed Fear of GCa after MGB • Significatly LESS Knowledgeable about GCa, General Surgery, outcomes of BII and MGB
  7. 7. Begin with Education
  8. 8. Gastric Cancer (GCa) • Studies Show just the Word "Cancer" engenders an inordainate 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...
  9. 9. 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,
  10. 10. 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
  11. 11. 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.
  12. 12. 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
  13. 13. Causes/Prevention GCa • H Pylori: 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
  14. 14. 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
  15. 15. HPylori GCa • H. pylori infection is a 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 no seem to be clear on this fact
  16. 16. 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
  17. 17. Billroth II and GCa Many Surgeons who fear the GCa Association with MGB were not clear on the research on this topic
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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!
  23. 23. 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!
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. Some Studies DO Show Association Billroth II and GCa • Ulcers associated with increased risk of GCa • Why? • Because H.Pylori Infection • H. Pylori causes GCa (RR = 1.53)
  28. 28. 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...
  29. 29. Reminder Ulcers and GCa CAUSED by HPylori!
  30. 30. 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
  31. 31. Some Studies DO Show Association Billroth II and GCa • Some Studies show increased Risk of GCa after BII; Flawed • Billroth II performed to Rx Ulcers • Ulcers = H. Pylori Infection • H. Pylori Infection => GCa • Effect of Increased GCa more from HPylori than BII
  32. 32. BII and GCa • Many Studies Show No Association between BII and GCa • Some studies DO show an association • But • In the studis 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
  33. 33. 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
  34. 34. 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
  35. 35. 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 Routely report the use of Billorth II reconstructions in GCa patients
  36. 36. Incidence/Frequency of GCa
  37. 37. Incidence/Frequency of GCa • From Cancer.org • USA Lifetime Risk of stomach Cancer * 0.5% * • MD India * 0.51% * • Declining Rates of Stomach Cancer
  38. 38. 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%
  39. 39. 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%
  40. 40. 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%
  41. 41. Declining Rates of Stomach Cancer • Stomach cancer incidence rates have decreased overall since the mid1970s • 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 20082010.
  42. 42. Comparison of Risk of Worst Predicted Ouctomes 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's80's) • CT Scan 0.78% vs BII 0.75% • Lifetime risk cancer
  43. 43. 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?
  44. 44. Fear the Hot Dog?
  45. 45. Fear the Hot Dog? • 100 g increment the association between processed meat increased risk of gastric cancer (** RR 5.0 **) • One Hot Dog = 100g
  46. 46. CANCER QUIZ: MORE DEADLY CANCER CAUSING AGENT? A OR B A B
  47. 47. CANCER QUIZ: MORE DEADLY Hot Dog or Mini-Gastric Bypass A • Answer Hot Dog • Do you Fear Hot Dog or a CAT Scan? • Remember Many Studies of Billroth II Show No increased Risk of GCa
  48. 48. 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)
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. • Rational Review of the Data vs. Fear Gastric Cancer / Bile Reflux • Rational Thinking vs. Reptilian Brain
  53. 53. 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
  54. 54. FEAR OF GASTRIC CANCER • FEAR gastric cancer? • Avoid: Alcohol, Tobacco, Processed & Preserved Meats Rx: H. Pylori, Eat Fruits & Veggies, Yogurt • Billroth II Probably Makes NO Difference
  55. 55. FEAR OF GASTRIC CANCER A Billroth II Probably Makes No Difference

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