Fear of Gastric Cancer after MGB
Surgeons who repport Fear of Gastric Cancer after MGB
Show evidence of limited knowledge of
Gastric Cancer, General Surgery and Bariatric Surgery
2. Fear of Gastric Cancer
• Surgeons who repport Fear of
Gastric Cancer after MGB
• Show evidence of limited knowledge
of
• Gastric Cancer, General Surgery and
Bariatric Surgery
3. Irrational Thinking in Surgeons that
Fear Gastric Cancer after the Mini-
Gastric Bypass
An Analysis of Knowledge of the
use of the Billroth II and Gastric
Caner in Surgeons that Express
Fear of Gastric Cancer after MGB
4. Survey Results
• As part of a Pre-Conference survey
for the MGB/OAB Consensus
Conference we asked Expert
Surgeons a variety of questions
related gastrointestinal surgery,
bariatric surgery and gastric and
esophageal cancer
5. 74. I Fear that MGB patients can have
an increased risk of gastric cancer from
bile reflux
• As part of our survey asking over
120 questions of 118 surgeons from
23 countries and 6 continents we
asked the question above and 23%
Agreed with this Fear of Gastric
Cancer following the Billroth II used
in the Mini-Gastric Bypass
6. Surgeons Who Fear Gastric Cancer after
Billroth II
• We investigated these surgeons
knowledge and opinions on a variety
of topics related to gastrointestinal
surgery, gastric cancer, esophageal
cancer and bariatric surgery to
determine if these surgeons had a
logically consistent thinking on this
topic
7. Primary Hypothesis
• Our primary hypothesis was that surgeons
who had an expressed fear of gastric
cancer following the Billroth II used in the
Mini-Gastric Bypass
• Have limited knowledge of Billroth II and
Gastric Cancer
• Show conflicting and paradoxical and
illogical opinions
• Have trouble making a logical case for
their belief
8. Are You Knowledgable About Gastric
Cancer
• Our first issue was whether the fear
of gastric cancer was based uon
knowledge of the subject or on
incomplete information, ignorance or
misinformation misremembered
from past experiences and education
9. Are You Knowledgable About Gastric Cancer
• We asked:
• Do you agree or disagree with the
following statement:
• 85. I have recently reviewed the
literature on gastric cancer and am
very knowledgeable about the risk of
gastric cancer
10. Are You Knowledgable About Gastric Cancer
• 85. I have recently reviewed the
literature on gastric cancer and am
very knowledgeable about the risk of
gastric cancer
• Only 24% of surgeons felt they were
"very knowledgeable" about the risk
of gastric cancer
11. Are You Knowledgable About Gastric Cancer
Answer NO
• So before we go any further with
this study we can conlude that
surgeons that fear gastric cancer
after Billroth II used in Mini-Gastric
Bypass appear to have limited
knowledge about the risk of gastric
cancer by their own admission!
12. Fear of Gastric Cancer
• Surgeons that Fear Gstric Cancer
• Have By Their Own Admission
• Limited Knowledge about the risk of
gastric cancer
• This is very common in Humans and
in Human Decision Making
• We fear what we do not understand
13. Fear of Gastric Cancer
• We can determine the scientific
understanding of these surgeons by
asking about their understanding of
assocaition and causation
• so we asked: "76. I understand the
difference between "Association" and
"Causation" "
• Surprisingly 15% disagreed
14. Knowledge of Association and Causation
• We gave and example of association as opposed
to causation
• 77. In a study from the Netherlands of 58,279
patients 162 stomach cancers were detected.
• A higher risk for stomach cancer was found for
men with the lowest level of education
• (RR lowest/highest level = 2.0, p = 0.02)
• i.e. Lower education = higher risk of stomach
cancer
• Do you think less education "CAUSES"
stomach cancer?
• Again surprisingly 15% said the less education
causes gastric cancer!
15. Fear of Gastric Cancer
• Fear of Gastric Cancer Driven by
Lack of Understanding
• We can go further and investigate
these surgeons knowledge about the
details of the gastrointestinal
surgery, bariatric surgery and gastric
and esophageal cancers
• We asked the following questions
16. Fear of Billroth II
• While it can be assumed that these
surgeons are aware that there are
some articles in the medical
literature that show and increased
risk of gastric cancer after Billroth II
there are many published studies
showing no such increase
• We wanted to know if these
surgeons were aware of these
studies s we asked:
17. Agree or Disagree
• “75. There are many large scale studies
that show no increased risk of gastric
cancer after Billroth II:
• i.e.: 30 yr f/u, over 500 pts
• "Risk of gastric cancer is * Not *
increased after partial gastrectomy."
• Bassily R, Dept Gastroent., Victoria,
Australia.J Gastroent Hepatol. 2000
15(7):762;”
18. "Some Studies Show NO Gastric Cancer
Increase after Billroth II" (True)
• We even included a reference to one
such study in the body of the
question:
• i.e.: 30 yr f/u, over 500 pts
"Risk of gastric cancer is * Not *
increased after partial gastrectomy."
• Bassily R, Dept Gastroent., Victoria,
Australia.J Gastroent Hepatol. 2000
15(7):762;”
19. "Some Studies Show NO Gastric Cancer
Increase after Billroth II" (True)
• Inspite of providing them with a
reference still
• 60% of these surgeons disagreed
with the demonstrable fact that
there are many such studies
20. "Some Studies Show NO Gastric Cancer Increase
after Billroth II" (True)
• How can we explain the 60% of
surgeons who erroneous reported
that they disagreed with the
statement "Some studied show no
increase in gastric cancer after
BillrothII"
• One possibility is ignorance
• But there was a Reference Provided!
21. Billroth II Further Investigations
• Rather than stop here we probed the
surgeons opinons and knowledge
about the Billroth II
• We asked:
22. 78. There are some studies showing a slight
increased risk of gastric cancer 20-30 years after
Billroth II.
But these patients had the Billroth II overwhelmingly
for Ulcer Disease and Ulcer and Gastric Cancer have
a common etiology; H. Pylori.
• Again Somewhat surprisingly
• 100% of surgeons that fear gastric
cancer after Billroth II,
• Agreed with this statement,
correctly so.
23. 79. Unoperated Gastric Ulcer patients
have double the risk for Gastric Cancer
• We then asked about their knowledge of
the association between ulcer disease and
gastric cancer and included a reference:
• Am J Gastroenterol. 2007 Long-term risk of
gastric cancer by subsite in operated and
unoperated patients hospitalized for peptic ulcer.
Bahmanyar S, et al, Department of Medical
Epidemiology and Biostatistics, Karolinska
Institutet, Stockholm, Sweden
24. 79. Unoperated Gastric Ulcer patients
have double the risk for Gastric Cancer:
• Again surprisingly
• While 61.5% correctly agreed
• 38.5% Disagreed with this
statement
25. Fear
• To try and get the surgeon's
impression of the magnitude of the
risk of gastric cancer
• Because the issue here is fear
• So we compared the risk to the risk
of eating a hot dog
26. • 80. Which is more deadly a Hot Dog or a Billroth
II?
• Processed meats (bacon, sausage, hot dogs, sandwich
meat, packaged ham, pepperoni, salami, etc.)
• have been shown to be associatesd with gastric cancer.
• An increase intake of 100 g of processed meat per day
• Increases the risk of Gastric Cancer by 3.5 times
• = Natl Cancer Inst. 2006 Mar 1;98(5):345-54. Meat intake and
risk of stomach and esophageal adenocarcinoma within the
European Prospective Investigation Into Cancer and Nutrition
(EPIC).
• = J Natl Cancer Inst. 2006 2;98(15):1078 "Processed meat
consumption and stomach cancer risk: a meta-analysis" The
Karolinska Institutet
• (Hint: A Hot Dog weight 3.7 oz = 100 g = INCREASED
RISK 3.5!)
27. 80. Which is more deadly a Hot Dog or
a Billroth II?
• A daily serving of processed meat
(bacon, sausage, hot dogs, sandwich
meat, packaged ham, pepperoni,
salami, etc.)
• Was chosen by 92.3%
• What this does is show that 92% of
these sugeons judge that the dietary
intake of common foods are more
dangerous than the Billroth II
28. Fear
• How fearful can the Billroth II be if
• Eating a hot dog is more dangerous
• 92% of these surgeons judged the
cancer risk of processed meats as
more dangerous than Billroth II
29. The Causes of Gastric Cancer
• These surgeons expressed fear that the
Billroth II led to or "Causes" Gastric
Cancer
• So this question is designed to assess the
surgeon's knowledge of the Major causes
of gastric cancer
• Smoking, Helicobacter pylori, Diet: high
salt intake, processed meats, salted,
pickled, or smoked foods & low intake of
green leafy vegetables and fruit
30. The high rates of Gastric Cancer are
from Environmental Causes.
• 81. Gastric Cancer is Most Common Cancer in
Korea & Japan Rates in Japan 69/100,000 men &
29/100,000 women.
• Moving from Japan/ Korea to USA Drops Risk to
Low USA Rates.
• The high rates of Gastric Cancer are from
Environmental Causes.
• (Smoking, Helicobacter pylori, Diet: high salt
intake, processed meats, salted, pickled, or
smoked foods & low intake of green leafy
vegetables and fruit)
• World J Gastroenterol 2006 Jan 21;12(3):354 "Epidemiology of
gastric cancer"
31. The high rates of Gastric Cancer are from
Environmental Causes.
• 100% of these surgeons agreed
• Gastric Cancer is caused by these
Environmental Factors:
• Smoking, Helicobacter pylori, Diet: high
salt intake, processed meats, salted,
pickled, or smoked foods & low intake of
green leafy vegetables and fruit
32. Do Surgeons Who Fear Gastric Cancer
after Billroth II Know What They are
Talking About?
• What is the rate of Gastric Cancer
after MGB And in the Population
• 50% 1 out of 10,000 after 20 years
in the General Population and
• 40% 1 out of 10,000 after 20 years
after MGB
33. Do Surgeons Who Fear Gastric Cancer
after Billroth II Know What They are
Talking About?
• What is the rate of Gastric Cancer
after MGB And in the Population
• 27.3% 1 out 1000 in the General
Population and
• 30.0% 1 out 1000 after MGB
34. Do Surgeons Who Fear Gastric Cancer
after Billroth II Know What They are
Talking About?
• In other words:
• Surgeons that fear gastric cancer
predicted the
• Risk of gastric cancer after MGB was
• EQUAL to the risk of Gastric Cancer
in the General Population!
35. Do Surgeons Who Fear Gastric Cancer
after Billroth II Know What They are
Talking About?
• In other words:
• Surgeons who fear that the risk of gastric
cancer is higher after MGB than the risk in
the general population predicted that the
• Risk of gastric cancer after MGB was
• EQUAL to the risk of Gastric Cancer in the
General Population!
36. H. Pylori and Gastric Cancer
• The next 2 questions were designed
to assess the surgeon's knowledge
of the relation between H. Pylori and
Gastric Cancer
37. 86. The association between H pylori infection
and the development of gastric cancer is well
established
In 1994, the International Agency for
Research on Cancer classified H pylori as a
Type I (definite) carcinogen in human beings.
• 100% of these surgeons agreed
38. 87. 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
• 100% Agreed
39. H. Pylori and Gastric Cancer
• So according to the surgeons'
answers on these questions
• They all agreed that H. Pylori is
primary cause of Gastric Cancer and
• That Treament of H.Pylori can
normalize the risk of gstric cancer
• Yet the still reportedly fear gastric
cacner after the MGB
40. Gastric Cancer Prevention
• 90% of Surgeons Agreed that:
• "88. Gastric cancer can be prevented
by treating H. Pylori, eating a diet of
fresh fruit and vegetables and
avoiding smoking, alcohol and
nitrates in preserved foods"
41. Billroth II in Oncologic Surgery
• The Billroth II is used routinely in
general surgery
• Since distal gastrectomy and Billroth
II Gastrojejunostomy is a routine
procedure in gastrc cancer patients
we thought it would be interesting to
see what these surgeons thought
about this fact.
42. 98. Oncologic Surgeons
Use the Billroth II
• Oncologic Surgeons have reported
over 800 articles recently of
• Distal Gastrectomy and Billroth II for
Distal Gastric Cancer,
• Including more than 20 in the first 3
month 2012. (True)
• 43% DISAGREED
43. • 99. Most Gastroenterologists DO
NOT recommend follow up screening
endoscopy in Billroth II patients
because of the low risk of gastric
cancer
• 60% Disagreed
44. • 100. There were approximately 40 deaths
from stomach cancer per 1,000,000
population in USA 2009.
• = Median age at death for cancer of the
stomach 73 years
• = 2/3 stomach cancer patients are > 65
• Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Altekruse SF,
Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR,
Chen HS, Feuer EJ, Cronin KA (eds). 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.
• 24% Disagreed
45. • 102. According to the National Inpatient
Sample from USA, over 16,000 Billroth II
operations were performed in 2007 in the
USA. (True)
• 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,
quality, and outcomes.
• 10% Disagreed
46. • 103. Korea has the Highest Risk of Gastric
Cancer in the World.
• In April 2012 two different papers by Oncologic
Surgeons from Korea (379 cases) and China (70
cases) reported on 2 series of Laparosocpic
Antrectomy & Billroth II for distal Gastric Cancer.
• In the first 3 months of 2012 there 20 other
similar papers. (True)
• Antrectomy & Billroth II by these surgeons was a
*reasonable and acceptable* surgical choice.
• 14% Disagreed
47. Question Basic General Surgery
• 104. A Billroth II gastro-jejunostomy
is a common and accepted
reconstruction after antretomy;
• A BII * IS NOT * an acceptable
reconstruction following total
gastrectomy because of bile reflux
into the esophagus.
• 81.5% Agreed;
But 18.5% DISAGREED
48. • 105. Billroth II with anastomosis at the
junction of the body and the antrum of
the stomach in the Mini-Gastric Bypass /
One Anastomosis 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.
• 83.3% Agreed
49. Surgeons Who Reported
Fear of Gastric Cancer
After Mini-Gastric Bypass
Performed Significantly Worse
on 12 out of 20
GI Surgery Questions
In no question did Surgeons with
Fear of Gastric Cancer
Outperform Surgeons
Who Did Not Report
Fear of Gastric Cancer
50. Tesst Performance & Patient Outcomes
• If, as other studies have shown
• There is an association between test
performance and patient outcomes
• This study raises concerns about the
knowledge levels and potentially
patient outcomes in surgeons who
have Fear of Gastric Cancer
51. Fear of Gastric Cancer
• Surgeons who repport Fear of
Gastric Cancer after MGB
• Show evidence of limited knowledge
of
• Gastric Cancer, General Surgery and
Bariatric Surgery
52. The Mini-Gastric Bypass is an Excellent Operation
with Results Reported on Thousands of Patients
Over the Past 10-15 years
• Survey Shows:
• Short, Simple, Effective, Durable,
• 30 min Operation with 1 day Hospital Stay
• Lower Leak rate than Sleeve or RNY
• Better / Best Weight Loss
• Leaks easily identified and easily managed
• Easily Reversible, Revisable
• MGB Marginal Ulcer / Gastritis = RNY