Mgb cancer & MGB Guidelines

1. MGB - Billroth II,
Billroth II & Gastric Cancer
MGB Guidelines

2. Billroth II and Gastric Cancer

3. MINI-GASTRIC BYPASS
BASED 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.

4. BARIATRIC SURGEONS FEAR BILLROTH II;
CANCER SURGEONS CHOOSE BILLROTH II
• 1,490 articles on performance of the Billroth II
• General/Trauma/Oncologic surgeons Routinely 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

5. GASTRIC CANCER
RAPIDLY DECLINING
• The incidence of gastric cancer
in the United States has
• Decreased four-fold since
1930
• Approximately 7 cases per
100,000 people.

6. BARIATRIC SURGEONS FEAR BILLROTH II;
CANCER SURGEONS CHOOSE BILLROTH II
• 1,490 articles on performance of the Billroth II
• General/Trauma/Oncologic surgeons Routinely 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

7. BARIATRIC SURGEONS FEAR BILLROTH II
WHAT IS MAGNITUDE OF THE PROBLEM
• 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

8. 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

10. ULCERS INCREASE RISK CANCER
• Meta-analysis:
7 studies Small increased risk
5 studies No Increased Risk
• Studies with increased Risk; Flawed
• Billroth II = Surgery Rx Ulcers
• ULCERS increase risk of Gastric Cancer!
• Ulcers and Gastric Cancer Common Etiology
=H. Pylori=

11. ULCERS INCREASE RISK CANCER
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
Ulcers & Gastric Cancer:
Common Etiology = H. Pylori=

12. BARIATRIC SURGEONS FEAR BILLROTH II
GASTROENTEROLOGISTS IGNORE BILLROTH II
• Hundreds of thousands of people with Billroth II’s
• If cancer IS SUCH A BIG RISK…
• Shouldn’t gastroenterologists be looking for these people,
screening them with endoscopy?
• No, there is no recommendation for BII follow up screening;
Why? THE RISK IS LOW
• 63,000 yrs Follow up 23 cancers = Gen Pop.

13. RISK OF GASTRIC CANCER AFTER
BILLROTH II IS LOW
• Follow-up study of 1000 patients
• 22-30 year follow-up
• 196 endoscopy and biopsy No Cancer of the gastric
remnant seen
• Endoscopic screening will be “unrewarding”
• Br J Surg. 1983 Sep;70(9):552-4. Risk of gastric cancer after Billroth II resection for
duodenal ulcer. Fischer AB

14. WHAT CAUSES GASTRIC CANCER?
ITS NOT BILLROTH II
• Diets rich in fried, salted, smoked or preserved foods
increased cancer risk in many studies.
• Foods contain nitrites and these chemicals can be converted
to more harmful compounds (carcinogens) by bacteria in the
stomach.
• Diets high in fruit and vegetables protects against Cancer
• Stomach cancer is much more common in smokers and in
those with heavy alcohol intake.
• H. Pylori, No H. Pylori No Cancer

15. DIET AND CANCER PREVENTION
• Avoid ETOH, Tobacco,
Processed & Preserved
Meats, Salt
• RX H. Pylori,
• Eat Fruits and Veggies,
Yogurt and
• Drink Green Tea
•
Gonzalez CA, Cancer Research, Institut Català d'Oncologia, Av. Gran Via s/n, km
2.7, 08907 L'Hospitalet, Barcelona, Spain.

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

17. CANCER QUIZ: MORE DEADLY
Hot Dog or Mini-Gastric Bypass
• American Institute
for Cancer
Research
• Hot Dog / day
• Increase the risk
cancer 21%

18. 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)

19. 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

20. 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

21. 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

22. MGB Guidelines
Much of this information available online
https://mgbguidelines.wordpress.com/
mgbguidelines.
.wordpress.com