a-00020 Dr. Robert RUTLEDGE

Title of Paper: RISK OF GASTRIC CANCER AFTER BILLROTH II IN THE MINI-GASTRIC BYPASS

Nationality: United States of AmericaPosition: Director

Department: SurgeryOrganization: Center For Laparoscopic Obesity Surgery

Tel: +1-702 714 0011E-mail: drr@clos.net

RISK OF GASTRIC CANCER AFTER BILLROTH II IN THE

MINI-GASTRIC BYPASS

Robert RUTLEDGE11Director, Surgery, Center For Laparoscopic Obesity Surgery, United States of America

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. 

Methods:

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

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.

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.)

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

Danger of the Hot Dog!!!

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.

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

Danger of the Hot Dog!!!

• 50 g processed meat = Inc RR Gastric Cancer 2.5

• One Hot Dog 50 g

Danger of the Hot Dog!!!

• 50 g processed meat = Inc RR 2.5• Follow-up of 6.5 yr 

• One Hot Dog 50 g

• Billroth II 20-30 yr FU

• Inc RR 0 - 2

Survey 112 Bariatric Surgeons

• 89% Said:• Hot Dog was More Dangerous Billroth II

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.