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First International Consensus
Conference on the Mini-Bypass / One
        Anastomosis Bypass

     Paris 2012 October 18-19

       Email DrR@CLOS.Net
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
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
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
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
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
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
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
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
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
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!
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
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
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!
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
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:
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;”
"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;”
"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
"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!
Billroth II Further Investigations

• Rather than stop here we probed the
  surgeons opinons and knowledge
  about the Billroth II
• We asked:
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.
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
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
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
• 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!)
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
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
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
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"
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
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
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
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!
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!
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
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
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
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
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"
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.
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
• 99. Most Gastroenterologists DO
  NOT recommend follow up screening
  endoscopy in Billroth II patients
  because of the low risk of gastric
  cancer

• 60% Disagreed
• 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
• 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
• 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
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
• 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
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
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
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
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

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Irrational thinking fear gastric cancer

  • 1. First International Consensus Conference on the Mini-Bypass / One Anastomosis Bypass Paris 2012 October 18-19 Email DrR@CLOS.Net
  • 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