Esophageal Cancer from Fear & Confusion about the Risk of Cancer after Bariatric Surgery Sleeve & Band vs Risk of Gastric Cancer after Mini-Gastric Bypass Dr Rutledge The Centers for Laparoscopic Obesity Surgery, www.CLOS.net www.MiniBypass.net Email: DrR@clos.net

1. Esophageal Cancer from
Sleeve & Band
vs
Risk of Gastric Cancer after
Mini-Gastric Bypass
Dr Rutledge
The Centers for Laparoscopic Obesity Surgery
www.CLOS.net www.MiniBypass.net
Email: DrR@clos.net

2. What Happens When General Surgeons
Become Bariatric Surgeons
And Forget Their General Surgery
Training?
Dr Rutledge
The Centers for Laparoscopic Obesity Surgery
www.CLOS.net www.MiniBypass.net
Email: DrR@clos.net

3. PRIMITIVE RESPONSE SYSTEMS
MODIFY RISK ASSESSMENT

4. MINI-GASTRIC BYPASS
BASED ON 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.

5. MINI-GASTRIC BYPASS
•The Mini-Gastric Bypass:
•1997 – 2011 ; >6,000 pts,
•15 yr Data; Multiple Centers,
R.C.Trials
•Two Components:
•Vertical Gastric Tube;
•(Collis Gastroplasty)
•Gastric Bypass;
•(Billroth II Gastro-jejunostomy)

6. Fear of Gastric Cancer Bile Reflux
Rational vs. Reptilian Brain Decision Making
Surgeons who Have
Forgotten Their General Surgery

7. STATISTICAL ILLITERACY;
"MANY DOCTORS MISUNDERSTAND MEDICAL
LITERATURE"
• Example: “In the absence of a Roux limb,
the long-term effects of chronic alkaline reflux
are unknown.”
• REALLY? Rational?
• Billroth II >100 years & >1,450 papers on Billroth II
Collins BJ, Miyashita T, Schweitzer M, Magnuson T, Harmon JW., Gastric Bypass; Why Roux-en-Y? A
Review of Experimental Data, Arch Surg. 2007; 142(10):1000-1003.

8. 1. Gastric Cancer; Declining Rapidly
•Gastric cancer
Decreasing in the
•USA & around the world
• Decreased four-fold
since 1930
• Approximately 40
deaths per 1,000,000
people.

9. 1. Gastric Cancer; Declining Rapidly
•
There were approximately 40 deaths from stomach
cancer per 1,000,000 population in USA 2009.
•
73 Median age at death for cancer of the stomach 73
years
•
= 2/3 stomach cancer patients are older than 65
Howlader N,. SEER Cancer Statistics Review, 1975-2009 (Vintage 2009
•
Populations), National Cancer Institute. Bethesda, MD,
http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011
SEER data submission, posted to the SEER web site, 2012.

10. 2. Environmental Causes of Gastric Cancer; Easily Prevented
What Does Cause Gastric Cancer? Its Not Billroth II
• Diet: Fried, Salted, Smoked or Preserved foods
• Nitrites converted to (carcinogens) by bacteria in
the stomach.
• Fruit and Vegetables protects against Cancer
• Stomach cancer: Much more common:
Smoking & Heavy alcohol intake
• H. Pylori,
•No H. Pylori = No Cancer

11. 2. Gastric Cancer; Environmental Causes;
Easily Prevented
•
H. Pylori Treatment Normalizes Risk of Gastric Cancer in
Ulcer Patients.
•
Early treatment of H. Pylori in Gastric Ulcer patients =>
•
Risk of Gastric Cancer decreased to NORMAL!
•
Decrease risk from 1.60 to 1.05 ( = general population);
"Early Helicobacter pylori eradication decreases risk of gastric cancer in
•
patients with peptic ulcer disease." Wu CY,et al. Div of Gastro., Taichung,
Taiwan

12. 2. Environmental Causes of Gastric
Cancer; Easily Prevented
Avoid
ETOH, Tobacco,
Processed & Preserved
Meats,
Salted Foods
Rx H. Pylori,
Eat Fruits & Veggies, Yogurt
Drink Green Tea
Gonzalez CA, Cancer Research, Institut Català d'Oncologia,
Av. Gran Via s/n, km 2.7, 08907 L'Hospitalet, Barcelona,
Spain.

13. 3. Many Large Studies: NO Increased Risk
Gastric Cancer with Billroth II
• 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

14. 3. Many Large Studies: NO Increased Risk
Gastric Cancer with Billroth II
•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

15. 3. Many Large Studies: NO Increased Risk
Gastric Cancer with Billroth II
• 338 Billroth II pts, Followed 25-years
• 5,635 person-years
• Only 2 Cancers in 5,000 pt years follow
up
• RATE of Gastric Cancer is Declining
• 24 - 50% Expected Decrease from 1983
• Future risk 1 patient / 5,000 pt years

16. 3. Many Large Studies: NO Increased Risk
Gastric Cancer with Billroth II
Many large scale studies;
•
No increased risk of Gastric Cancer after Billroth
•
II
30 yr follow up, over 500 pts,
•
"Risk of gastric cancer is * Not * increased after
•
Billroth II."
Bassily R, J Gastro Hepatl. 2000
•

17. 4. Some studies Small Increase Risk
Gastric Cancer after Billroth II
•
(Confusion Association vs. Causation)
•
Some studies Small Increase Risk of Gastric Cancer
after Billroth II
•
In all of these studies Billroth II used to treat Ulcers
•
H. Pylori is the common Etiological Agent of
Both Ulcers & Gastric Cancer
•
H. Pylori Causes Both Ulcers and Cancer

18. 4. Some studies Small Increased Risk Gastric Ca
after Billroth II; Association vs. Causation
Meta-analysis 12 Studies:
Relation of Billroth II with Gastric Cancer:
Small increased risk; 7 studies
No Increased Risk; 5 studies
Studies that show increased Risk; [Flawed]
Billroth II Surgery was used to treat “Ulcers”
ULCERS increase risk of Gastric Cancer!
Ulcers & Gastric Cancer Common Etiology H. Pylori

19. 4. Some studies Small Increased Risk
Gastric Cancer after Billroth II
ULCERS INCREASE RISK GASTRIC CANCER
• Study 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
• Both Ulcers & Gastric Cancer:
• Common Etiology = H. Pylori

20. BARIATRIC SURGEONS FEAR BILLROTH II
What is the Risk of Gastric Cancer?
• Statistical significance tells us that an observed
difference is reliable, but whether the difference is large
enough to be important cannot be resolved by applying a
statistical formula.
• A STATISTICALLY SIGNIFICANT difference is not
necessarily one that is of CLINICAL SIGNIFICANCE

21. 5. No Endoscopic Screening for Billroth II
Gastric Ca Risk after Billroth II = General Population
•Follow-up study of 1,000 Billroth II patients
•22-30 year follow-up
•196 Endoscopies & Biopsy: No Cancer
•Conclusion in 1983!:
•Endoscopic screening “UNREWARDING”
•Since 1983 Rate Gastric Ca Down 50%!!
•Br J Surg. 1983 Sep;70(9):552-4. Risk of gastric cancer after Billroth II resection for
duodenal ulcer. Fischer AB

22. 5. BARIATRIC SURGEONS FEAR BILLROTH II
GASTROENTEROLOGISTS IGNORE BILLROTH II
Hundreds of thousands of people with Billroth II
If cancer after Billroth II was a clinically important
RISK…
Gastroenterologists
DO NOT Offer Screening Endoscopy for Billroth II
No recommendation for BII follow up screening;
Why? THE RISK IS LOW (Equal General Population)
One Study: 63,000 Pt yrs:
23 cancers = Same General Population

23. 6. 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

24. 6. BARIATRIC SURGEONS FEAR BILLROTH II;
CANCER SURGEONS CHOOSE BILLROTH II
•According to the National Inpatient
Sample from USA, over 16,000 Billroth II
operations were performed in 2007 in the
USA.
•The Nationwide Inpatient Sample (NIS) is a unique and
powerful database of hospital inpatient stays. Researchers and
policymakers use the NIS to identify, track, and analyze
national trends in health care utilization, access, charges,

25. 6. BARIATRIC SURGEONS FEAR BILLROTH II;
CANCER SURGEONS CHOOSE BILLROTH II
Korea has the Highest Risk of Gastric Cancer in
the World.
In April 2012 two papers by Oncologic Surgeons
from Korea (379 cases) and China (70 cases)
reported
Two series of Laparosocpic
Antrectomy & Billroth II for distal Gastric Cancer.
In the first 3 months of 2012 there
20 other similar papers.
Antrectomy & Billroth II by these cancer surgeons
was a viewed as *reasonable and acceptable*

26. 2012 Study Cancer Surgeon Reports Gastrectomy &
Billroth-II for Gastric Cancer = MINI-GASTRIC BYPASS
J Korean Surg Soc. 2012 Mar;82(3):135-42. Epub 2012 Feb 27. Comparison of laparoscopy-assisted and totally laparoscopic
Billroth-II distal gastrectomy forgastric cancer. Lee J, Kim D, Kim W.
130 Gastric Cancer Patients Rx Billroth II Performed
using technique identical to MGB

27. UNINFORMED SURGEONS FEAR BILLROTH II
GENERAL SURGEONS USE BILLROTH II
•A Billroth II gastro-jejunostomy is a common and
accepted reconstruction after antretomy;
•A Billroth II * IS NOT * an acceptable
reconstruction following total or sub total
gastrectomy because of bile reflux into the
esophagus.

28. UNINFORMED SURGEONS FEAR BILLROTH II
GENERAL SURGEONS USE BILLROTH II
•Billroth II with anastomosis at the junction of the
body and the antrum of the stomach in the Mini-
Gastric Bypass is a *reasonable and acceptable*
surgical choice.
•The OLD Mason Loop Gastric Bypass placed the
Billroth II high on the stomach adjacent to the
esophagus, NOT *reasonable or acceptable* and
could be predicted to fail.

29. UNINFORMED SURGEONS FEAR BILLROTH II
EDUCATED SURGEONS USE BILLROTH II
1. Gastric Cancer Declining Rapidly, > 50%
2. Gastric Cancer Cause/Prevention:
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

30. UNINFORMED SURGEONS FEAR BILLROTH II
EDUCATED SURGEONS USE BILLROTH II
3. Many Large Studies:
No Increased Risk
Thousands of patients/followed for Decades
4. Some Billroth II studies:
Slight Increased Risk 20 – 30 years (RR 1.5)
But:
Billroth II performed to Rx Ulcer
Ulcer => Increases Risk Gastric Ca (H. Pylori)

31. UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II
5. Endoscopic screening of Billroth II
Not Recommended. Why? Low Risk!
6. General, Trauma and Oncologic surgeons
Routinely use the Billroth II
(Thousands of publications)
2007 16,000 BII procedures performed in USA

32. UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II
Billroth II and the Mini-Gastric Bypass
Excellent, Safe and Effective
IF 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

33. Rational Data Analysis vs.
Irrational FEAR Gastric Cancer
1.Gastric Cancer; Declining Rapidly
2. Gastric Cancer Environmental Causes;
Easily Prevented
3. Many large studies:
NO Increased Risk Gastric Cancer after Billroth II
4. Some studies Small Increased Risk
Gastric Cancer Billroth II, Billroth II used to Rx Ulcers;
H. Pylori = Ulcers & Gastric Cancer
(Confusion Association vs. Causation)
5. Endoscopic Screening: Not Recommended
(Clinical Relevance vs. Statistical Significance)
6. General, Trauma & Oncologic Surgeons
Routinely Use Billroth II

34. ? FEAR OF GASTRIC CANCER ?
“ IF ” FEAR Gastric Cancer; ” THEN: ”
1. Avoid: Alcohol, Tobacco,
Processed & Preserved Meats
2. Eat: Fruits & Veggies, Yogurt
3. Rx: H. Pylori
Billroth II Makes NO Difference !!

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

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

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

38. Fear of Cancer after Bariatric
Surgery
IS APPROPRIATE!
FEAR ESOPHAGEAL CANCER
AFTER SLEEVE AND BAND

39. Fear of Cancer After Bariatric Surgery?
Acid Reflux Primary Cause of Cancer of
Esophagus
GERD Increases Risk of Cancer of Esophagus. Longer
GERD = More Risk.
GERD can cause Barrett's = even higher risk, from the
American Cancer Society.
JAMA. 2002 Apr 17;287(15):1972-81. Gastroesophageal reflux, barrett
esophagus, and esophageal cancer: scientific review. Shaheen N, Ransohoff
DF. Division of Digestive Diseases and Nutrition, Center for Esophageal
Disease and Swallowing, CB#7080, University of North Carolina-Chapel Hill,
Chapel Hill, NC 27599-7080, USA. nshaheen@med.unc.edu

40. Fear of Cancer After Bariatric Surgery?
Acid Reflux Primary Cause of Cancer of
Esophagus
Treating or Preventing
Gastro Esophageal Reflux Disease
(GERD) can protect & prevent
Barrett's & Esophageal cancer.

41. Fear of Cancer After Bariatric Surgery?
Acid Reflux Primary Cause of Cancer of
Esophagus
Numerous Studies Now Show that the Band
& Sleeve increase acid reflux & Barretts &
Esophageal Caner.
Dis Esophagus. 2011 Jan;24(1):E8-10. Esophageal adenocarcinoma after laparoscopic gastric band placement for
obesity Stauffer JA, Mathew J, Odell JA, Department of General Surgery, Mayo Clinic, Jacksonville, Florida, USA.
Ann Surg. 2010 Aug;252(2):319-24. Long-term results of laparoscopic sleeve gastrectomy for obesity. Himpens J, Division
of Bariatric Surgery, AZ St-Blasius, Kroonveldlaan, Dendermonde, Belgium.
Obes Facts. 2011;4 Suppl 1:42-6. Epub 2011 Apr 4. Failure of laparoscopic sleeve gastrectomy--further procedure?
Weiner RA, Theodoridou S, Weiner S. Department of Surgery, Krankenhaus Sachsenhausen, Frankfurt/M, Germany.
rweiner@khs-ffm.de
Surg Obes Relat Dis. 2011 Nov-Dec;7(6):709-13. Epub 2011 Aug 16. Gastroesophageal reflux after sleeve gastrectomy in
morbidly obese patients. Howard DD, Caban AM, Cendan JC, Ben-David K. Department of Surgery, Minimally Invasive,
Gastroesophageal and Bariatric Surgery Service, University of Florida, Gainesville, Florida 32610, USA.
Obes Surg. 2010 Feb;20(2):244-6. Epub 2009 Dec 8, Barrett's esophagus: a late complication of laparoscopic adjustable
gastric banding, Varela JE., Minimally Invasive and Bariatric Surgery, Washington University, 660 South Euclid, Box 8109,
St Louis, MO 63110, USA. varelae@wudosis.wustl.edu

42. Sleeve & Band:
20-30% New Onset GERD
GERD =>
Increased Risk of
Esophageal Cancer
Dr. Rutledge
•

43. Gastroesophageal reflux disease and
sleeve gastrectomy USA
•Postoperatively, 49% complained of immediate
(within 30 d) GERD symptoms,
•47.2% had persistent GERD symptoms that
lasted >1 month after LSG, and
•33.8% of patients were taking medication
specifically for GERD after LSG.
•Surg Obes Relat Dis. 2011 Gastroesophageal reflux disease and
sleeve gastrectomy. Carter PR LaGrange, IL USA.

44. Gastroesophageal reflux disease and
sleeve gastrectomy USA
•Many studies designed to evaluate the
outcome of reflux symptoms following
conventional and surgical treatment of
obesity.
•Among bariatric procedures, gastric sleeve
& band have been shown to worsen reflux
symptoms in the postoperative setting.
•Curr Gastroenterol Rep. 2011 Jun, Obesity and GERD:
pathophysiology and effect of bariatric surgery.Tutuian R.
Bern, Switzerland.

45. Gastroesophageal reflux disease and
sleeve gastrectomy USA
•We Know Esophageal Cancer Dangerous
Deadly and Rising Rapidly
•We Know That Acid Reflux (GERD) Is
Most Important Causative Factor in
Esophageal Cancer
•Numerous Studies Including the Sleeve
Consensus Conference Show Band &
Sleeve Cause 20-30% New Onset GE
Reflux
•The Sleeve & Band Pre-cancerous
Lesions In Up To 1/4 -1/3 Patients

46. Imagine; Your Post Op
Sleeve or Band Patient
Post Op Patient Visit"
•
"Dr. I found out the operation that you
•
performed on me may cause cancer,
esophageal cancer.
You did not tell me this."
•
Your answer?
•
We need to warn our patients!
•

47. Fear of Cancer after Bariatric
Surgery
IS APPROPRIATE!
FEAR ESOPHAGEAL CANCER
AFTER SLEEVE AND BAND