The document reviews studies on the risk of gastric cancer after Billroth II surgery and finds that while some older studies showed a slight increased risk, the majority of large studies find no increased risk, and that endoscopic screening is not generally recommended given the low overall risk. It also finds that factors like diet, H. Pylori infection, and lifestyle pose a greater cancer risk than the Billroth II procedure.

1. a-00020
Dr. Robert RUTLEDGE
Title of Paper: RISK OF GASTRIC CANCER AFTER BILLROTH II
IN THE MINI-GASTRIC BYPASS
Nationality: United States of America
Position: Director
Department: Surgery
Organization: Center For Laparoscopic Obesity Surgery
Tel: +1-702 714 0011
E-mail: drr@clos.net

2. RISK OF GASTRIC CANCER
AFTER BILLROTH II IN THE
MINI-GASTRIC BYPASS
Robert RUTLEDGE1
1Director, Surgery, Center For Laparoscopic
Obesity Surgery, United States of America

3. Gastric Cancer and Billroth II
• Many surgeons not well informed about
risks of gastric cancer (GCa).
• The purpose of this study was
to review the medical literature
on the use of the Billroth II (B2)
and the risk of GCa.

4. Methods:
• Review of the medical literature on B2 and
the risk of GCa.

5. Cell Phones & Fear

6. Oxidative and genotoxic effects of 900
MHz Cell Phone electromagnetic fields
• Exposure treatments induced significant
genotoxic effect
• DNA damaging capacity of 900 MHz
electromagnetic radiation.
• Induction of antioxidant stress response:
Enhanced catalase and glutathione
reductase activity
• Lipid & Protein damage.
Ecotoxicol Environ Saf. 2013 Apr;90:7-12. doi: 10.1016/j.ecoenv.2012.12.005.
Epub 2013 Jan 24. Oxidative and genotoxic effects of 900 MHz electromagnetic
fields in the earthworm Eisenia fetida. Tkalec M,

7. Effects of the exposure to mobile
phones on male reproduction
• Human spermatozoa exposed to RF-EMR have
• Decreased motility, morphometric abnormalities,
and increased oxidative stress
• Men using mobile phones
• Decreased sperm concentration, decreased
motility (particularly rapid progressive motility)
and decreased viability.
• These abnormalities seem to be directly related
to the duration of mobile phone use.
J Androl. 2012 May-Jun; Effects of the exposure to mobile phones on male
reproduction: a review of the literature. La Vignera S, Section of Endocrinology,
Andrology, and Internal Medicine

8. Meta-analyses Cell Phones Increase
Risk of Brain Tumor
• Three Meta-analyses Case-controlled
Studies
• Using cell phones Associated with
• Increased Risk of Brain Cancer
Electromagn Biol Med. 2013 Jan 15. Cancer risks related to low-level RF/MW
exposures, including cell phones. Szmigielski S.

9. Cellular neoplastic transformation
induced by 916 MHz microwave radiation
• Investigation cellular neoplastic transformation
effects of Cell Phone electromagnetic fields
• Animal carcinogenesis Masses developed mice
after being inoculated into Cell Phone cells for
more than 4 weeks.
• “Microwave radiation promotes neoplastic
transformation of NIH/3T3cells”
Cell Mol Neurobiol. 2012 Aug; Cellular neoplastic transformation induced by 916
MHz microwave radiation. Yang L, Beijing, People's Republic of China.

10. PRIMITIVE RESPONSE SYSTEMS
MODIFY RISK ASSESSMENT:
Fear of Gastric Cancer

11. Results Six Main Findings: #1
• 1-GCa rates are DECLINING RAPIDLY
around the world, > 50%

12. Six Main Findings: #2
Cause & Prevention
• 2-GCa Cause & Prevention:
• Cause: Modifiable Environmental Factors
Diet, Lifestyle & H. Pylori
• Prevention:
Avoid: Etoh, Tobacco,
Processed & salted meats & foods
Encourage: Fruits & vegetables &
Rx H. Pylori.

13. Six Main Findings: #3
Many Large Studies: No Increase Risk GCa after B2
• 3-Many Large Studies
• No Increased Risk in GCa after B2.
• E.G. Mayo Clinic Study

14. Six Main Findings: #4
Some Studies: DO Show Increase Risk GCa after B2
• 4-Some studies
*Do* show slight Increased risk of GCa
20-30 years after B2 (RR 1.5),
• But:
B2 performed to Rx Ulcer;
Ulcer (H. Pylori)
Increases Risk GCa

15. Six Main Findings: #5
Endoscopic Screening of B2 Not Recommended
• 5-Endoscopic screening of B2 patients is
generally *Not* recommended because of
Low Risk.
• Studies from Australia,
USA and Europe
• Routine Endoscopic
follow up
• “Not Rewarding”

16. RISK OF GASTRIC CANCER
AFTER BILLROTH II IS LOW
• Follow-up study of 1000 B2 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

17. Six Main Findings: #6
Surgeons Routinely use the B2
• 6-General, Trauma and Oncologic
surgeons Routinely use the B2.
• In 2007 16,000 B2 procedures performed
in USA.
• The B2 is widely used reconstruction
after distal gastric resection
• (Billroth II in use for over 100 years & over
1,400 reporteds)

18. Confusing Statistical With
Clinical Significance
• Statistical Significance CONFUSED with Clinical
Relevance!
• Possible and Common to have
Clinically INSIGNIFICANT results that are
Statistically Significant.
• LARGE Sample Size Effect:
“Given a sufficiently large sample size, a
statistical comparison will always show a
significant difference unless the population effect
size is exactly zero”

19. Danger of the Hot Dog!!!

20. Danger of the Hot Dog!!!
• “Meat intake and risk of stomach and
esophageal adenocarcinoma within the
European Prospective Investigation Into
Cancer and Nutrition (EPIC)”
• AU: González CA, et.al.
• SOJ Natl Cancer Inst. 2006;98(5):345.

21. Danger of the Hot Dog!!!
• 521,457 pts; 10 European countries
(EPIC)
• 6 years Follow up
• 50-g/day increase
Processed Meat
Risk of Gastric Cancer Risk
Significantly increased RR = 2.5

22. Danger of the Hot Dog!!!
• 50 g processed meat
=
Increased
RR
Gastric Cancer
2.5
• One Hot Dog = 50 g

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

24. Danger of the Hot Dog!!!
• One Hot Dog 50 g • Billroth II
• Follow-up **6.5 yr** • Follow up **30 yr**
• 50 g processed meat
• Inc RR 1.5
= Inc RR 2.5

25. Survey 112 Bariatric Surgeons
• 89% Said:
• Hot Dog was More Dangerous Billroth II

26. Conclusions:
• 1. Gastric Cancer declining rapidly
• 2. Primarily related to environmental factors;
Avoid Etoh, Tobacco, processed & salted meats
and foods; Encourage high intake of fruits &
vegetables and Rx H. Pylori
• 3. Many Studies Show No Increased Risk
(Mayo Clinic 1983)

27. Conclusions:
• 4. Some Studies Show
Increased Risk of GCA after B2
related to Ulcer & H. Pylori
• 5. Endoscopic screening is not
recommended.
• 6. While some bariatric surgeons have
expressed fears of the B2 causing cancer;
General and Oncologic Surgeons continue
to routinely use the B2.

28. Fear Gastric Cancer?
• The Hot Dog more Dangerous than BII

29. Fear of Cell Phones?
Fear of Gastric Cancer after B2?