The document discusses the irrational fears that some bariatric surgeons have regarding the risk of gastric cancer after a Billroth II procedure or mini-gastric bypass. It notes that numerous studies show no increased risk of gastric cancer from these procedures. Some older studies showed a potential increased risk but these were for patients who received Billroth II due to ulcers caused by H. pylori infection, which is a risk factor for gastric cancer. The overall risk of gastric cancer is declining worldwide due to reduced H. pylori and lifestyle changes. General surgeons commonly perform Billroth II but bariatric surgeons irrationally fear it despite evidence it poses minimal increased cancer risk, less than activities like getting 2 CT scans

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. 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. 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

4. 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, CATScans and Cognitive Biases in
Humans and Bariatric Surgeons

5. 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

6. Survey 102 Bariatric Surgeons
• Experience with over 39,000
cases
• Surgeons who expressed
Fear of GCa after MGB
• Significantly LESS
Knowledgeable about GCa,
General Surgery, outcomes of BII
and MGB

7. Begin with Education

8. 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...

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

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Reminder Ulcers and GCa
CAUSED by H Pylori!

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. 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 H Pylori than BII

32. 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

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. 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. 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

36. Incidence/Frequency of GCa

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. 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. 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. 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. 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. 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's80's)
• CT Scan 0.78% vs BII 0.75%
• Lifetime risk cancer

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. Fear the Hot Dog?

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

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

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