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Fear of Cancer , General Surgeons Use the Billroth II , Bariatric Surgeons FEAR the Billroth II

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Irrational Fears of Cancer General Surgeons Use the Billroth II Bariatric Surgeons FEAR the Billroth II (Mini-Bypass) …

Irrational Fears of Cancer General Surgeons Use the Billroth II Bariatric 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

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  • 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