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.

Cell Phones & Fear

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,

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

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.

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.

PRIMITIVE RESPONSE SYSTEMSMODIFY RISK ASSESSMENT:

Fear of Gastric Cancer

Results Six Main Findings: #1

• 1-GCa rates are DECLINING RAPIDLY around the world, > 50%

Six Main Findings: #2Cause & 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.

Six Main Findings: #3Many Large Studies: No Increase Risk GCa after B2

• 3-Many Large Studies • No Increased Risk in GCa after B2.• E.G. Mayo Clinic Study

Six Main Findings: #4Some 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

Six Main Findings: #5Endoscopic 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 Endoscopicfollow up

• “Not Rewarding”

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

Six Main Findings: #6Surgeons 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)

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”

Danger of the Hot Dog!!!

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.

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

Danger of the Hot Dog!!!

• 50 g processed meat = Increased RR Gastric Cancer 2.5

• One Hot Dog = 50 g

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

A B

Danger of the Hot Dog!!!

• One Hot Dog 50 g• Follow-up **6.5 yr** 

• 50 g processed meat = Inc RR 2.5

• Billroth II • Follow up **30 yr**

• Inc RR 1.5

Survey 112 Bariatric Surgeons

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

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)

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.

Fear Gastric Cancer?

• The Hot Dog more Dangerous than BII

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