What Happens When Bariatric Surgeons Forget General Surgery Numerous Examples Where Bariatric Surgeons Make Decisions Based Upon Errors and Misunderstandings of General Surgery Basics Most Bariatric Surgeons Do Not Know: General Surgery Basics Rate of Gastric Cancer Lifetime Risk of Gastric Cancer

1. Bariatric Surgeons vs.
General Surgeons;
Confusion About
General Surgery Basics
What Happens When
Bariatric Surgeons Forget
General Surgery Basics

2. What Happens When Bariatric
Surgeons Forget General Surgery
Numerous Examples Where Bariatric
Surgeons Make Decisions Based Upon
Errors and Misunderstandings of General
Surgery Basics

3. Fear of Cancer
• Numerous Critics Bariatric
Surgeons have raised Fears of
Gastric Cancer after the MiniGastric Bypass
• ERRORS in Understanding Basic
General Surgery

4. Misplaced Understanding
Magnitude
• Most Bariatric Surgeons
Do Not Know:
• General Surgery Basics
• Rate of Gastric Cancer
• Lifetime Risk of Gastric Cancer

5. Lifetime Risk Gastric Cancer
• The projected cumulative lifetime
incidence of gastric cancer in
• H. pylori-infected males is 2.2%
and 0.9% for females;
• This contrasts with
• 0.4 Males & 0.2%, Females, for
those never infected.
• 2 - 4 / 1,000 patients Lifetime Risk

6. Lifetime Risk Gastric Cancer
• Lifetime Risk gastric cancer 2-4%
2 - 4 / 1,000
• Compared to:
• Lifetime risk breast cancer 12%
120 / 1,000
• Prostate cancer risk 16 %
160 / 1,000

7. Most Bariatric Surgeons
Do Not Know:
• Risk of Cancer from CAT Scans
• Computed Tomography (CT)Abdomen and Pelvis, repeated with
and without contrast material
• 20 mSv

8. Most Bariatric Surgeons
Do Not Know:
• Risk of Cancer from 1 CAT Scan
• 2006 report from the National
Research Council has estimated
that 20 mSv
• The approximate dose from 1 CT
Abd+Pelvis w/wo contrast = 20
mSv => Inc Cancer Risk 0.2%
• 2 / 1000

9. Now Having Reviewed
Most Bariatric Surgeons
Do Not Know:
Magnitude of Gastric and Other
Cancers
Risk of Cancer from CT Scan

10. Most Bariatric Surgeons
Do Not Know:
• Bariatric Surgeons
• Fear of Mice & Bile
• Critics of the Billroth II have
referred to mouse studies showing
increased risk of gastric cancer
from "Bile"

11. Fear of Mice & Bile
• Similarly Mouse/Rat Studies have
shown
• Artificial Sweetener cause cancer
• Cell phones cause brain cancer
• Mouse virus causes breast cancer
• Gingko biloba caused thyroid
cancer in mice
• Power Lines

12. Fear of Mice & Bile
• Similarly Mouse/Rat Studies have
shown
• RFID Chips
• Genetically Modified corn
• Fluoride osteosarcoma
• Soy Beans cause Breast Cancer
• Bisphenol A Increases Mammary
Cancer Risk

13. Fear of Mice & Bile
• Mouse/Rat Studies have that there may
be a relation between
• Hundreds of things and cancer
• RFID Chips, Corn, Fluoride, Soy Beans,
plastic, Artificial Sweeteners, Cell
phones, Gingko, Power Lines and
many more...
• and Bile
• Bariatric Surgeons Fear Bile(?)

14. Review of the Basics
General GI Surgery and
Gastric Cancer
What happens when
Bariatric Surgeons Forget
their General Surgery

15. GASTRIC CANCER
RAPIDLY DECLINING
Bariatric Surgeons Do Not
Know

16. *1* GASTRIC CANCER
RAPIDLY DECLINING
• The incidence of gastric
cancer in the United
States has
• Decreased four-fold
since 1930
• Approximately 7 cases
per 100,000 people.

17. *2* WHAT CAUSES GASTRIC CANCER?
ITS NOT BILLROTH II
• Diets rich in fried, salted, smoked or preserved
foods increased cancer risk in many studies.
• Foods contain nitrites and these chemicals can be
converted to more harmful compounds
(carcinogens) by bacteria in the stomach.
• Diets high in fruit and vegetables protects against
Cancer
• Stomach cancer is much more common in
smokers and in those with heavy alcohol intake.
• H. Pylori, No H. Pylori No Cancer

18. DIET CAN PREVENT GASTRIC
CANCER
• Avoid ETOH, Tobacco,
Processed & Preserved
Meats, Salt
• RX H. Pylori,
• Eat Fruits and Veggies,
Yogurt and
• Drink Green Tea
•
Gonzalez CA, Cancer Research, Institut Català d'Oncologia, Av.
Gran Via s/n, km 2.7, 08907 L'Hospitalet, Barcelona, Spain.

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

20. CANCER QUIZ: MORE DEADLY
Hot Dog or Mini-Gastric Bypass
•
•
•
A
American
Institute for
Cancer
Research
Hot Dog / day
Increase the
risk cancer
21%

21. Many Large Studies: No Increased Risk
Thousands of patients followed for Decades

22. Many Large Studies:
No Increased Risk
• 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

23. BARIATRIC SURGEONS FEAR BILLROTH II
MAGNITUDE OF THE PROBLEM
• 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

24. BARIATRIC SURGEONS FEAR BILLROTH II
MAGNITUDE OF THE PROBLEM
• 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

25. There are some HUMAN studies that show an
increased risk of Gastric Cancer after Billroth II
Bariatric Surgeons Forget:
These Billroth II operations were done for ULCERS!
Ulcers => Increased Risk of Gastric Ca!
Both Related to H. Pylori

26. ULCERS INCREASE RISK
CANCER
• Meta-analysis:
7 studies Small increased risk
5 studies No Increased Risk
• Studies with increased Risk; Flawed
• Billroth II = Surgery Rx Ulcers
• ULCERS increase risk of Gastric Cancer!
• Ulcers and Gastric Cancer Common
Etiology
=H. Pylori=

27. ULCERS INCREASE RISK
CANCER
•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
•Ulcers & Gastric Cancer:
•Common Etiology = H. Pylori

28. General, Trauma and Oncologic surgeons routinely
use the Billroth II (Thousands of publications)
UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II

29. UNINFORMED FEAR BILLROTH II
EDUCATED USE BILLROTH II
• Billroth II and the Mini-Gastric Bypass
Excellent, Safe and Effective
• Fear Cancer? CAT Scan much more likely to
cause cancer!
• FEAR Gastric Cancer? Avoid ETOH, Tobacco,
Processed & Preserved Meats, Rx H. Pylori,
Eat Fruits and Veggies, Yogurt
• A Billroth II probably makes NO difference

30. Rational Data Analysis vs.
Irrational FEAR Gastric Cancer
• 1. Gastric Cancer Declining Rapidly
• 2. GC Environmental Causes; Easily Prevented
• 3. Some studies show Small Increased Risk
Probably from Ulcers / H. Pylori
• 4. Many large studies: NO increased risk
• 5. Endoscopic Screening: Not Recommended
• 6. General, Trauma & Oncologic Surgeons Use
Billroth II

31. Bariatric Surgeons Fear of Cancer after MGB
Misplaced!
Fear Cancer After Bariatric Surgery
Fear Esophageal Cancer After
Sleeve, Band and Plication