Dr. Robert Rutledge conducted a literature review on the risk of gastric cancer after Billroth II surgery. He found: 1) Gastric cancer rates are declining worldwide by over 50% due to preventable environmental factors like diet, smoking, and H. pylori infection. 2) Large studies show no increased risk of gastric cancer after Billroth II surgery. 3) Any slight increased risk seen in some studies is likely due to pre-existing ulcers or H. pylori infection, not the surgery itself.

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. Results There were 6 main findings:
• -GCa rates are declining rapidly around the world, > 50%
• -GCa primarily environmental factors that are easily
modified; Diet, Lifestyle factors and H. Pylori;
Prevention: Avoid Etoh, smoking, processed & salted
meats and foods; Encourage high intake of fruits &
vegetables and Rx H. Pylori.
• -Many Large scale Studies document No Increased Risk
in GCa after B2.

6. Results There were 6 main findings:
• -Some studies *Do* show slight Increased risk of GCa
20-30 years after B2 (RR 1.5), But: B2 performed to Rx
Ulcer; Ulcer Increases Risk GCa (H. Pylori) Ulcer and H.
Pylori increase risk of GCa.
• -Endoscopic screening of B2 patients is generally *Not*
recommended because of Low Risk.
• -General, Trauma and Oncologic surgeons Routinely
use the B2. In 2007 16, 000 B2 procedures performed in
USA. The B2 is still the most widely used reconstruction
after distal gastric resection (Billroth II in use for over 100
years & over 1, 400 reported papers on Medline.)

7. Confusing Statistical With Clinical
Significance
• Statistical significance should not be
confused with clinical relevance!
• It is possible and common to have
clinically trivial results that are
nonetheless statistically significant.
• Sample Size Effect: Sufficiently Large
Samples almost always significantly
different vs small sample Hard to show
difference

8. Danger of the Hot Dog!!!

9. Danger of the Hot Dog!!!
• PubMed
• 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.

10. Danger of the Hot Dog!!!
• 521,457 men and women aged 35-70
years in 10 European countries
participated in the EPIC
• 6 years Follow up
• For every 50-g/day increase intake
processed Meat the Risk of Gastric
cancer risk statistically significantly
increased RR = 2.5

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

12. Danger of the Hot Dog!!!
• 50 g processed meat
= Inc RR 2.5
• Follow-up of 6.5 yr
• Billroth II 20-30 yr FU
• One Hot Dog 50 g
• Inc RR 0 - 2

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

14. Conclusions:
• Gastric Cancer declining rapidly,
primarily related to environmental factors;
easily modified.
• Risk of GCA after B2 related to Ulcer & H. Pylori,
if present at all.
• Endoscopic screening is not recommended.
• While some bariatric surgeons have expressed
fears of the B2 causing cancer; General and
Oncologic Surgeons continue to routinely use
the B2.