irrational fear of gastric cancer:after billroth ii

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FOLLOW UP EFFECT Unbiased Population based studies => Poor Results of RNY Positive Results of RNY reported from RNY centers Suffer from “Follow Up Effect” •Patient Returns to clinic doing well: Greeted Warmly with Great Joy •Patient Returns to clinic doing poorly: Greeted with anger and disapproval Successful pt => Good Follow Up / Failed pt tacitly sent away Now; Center reports excellent results; (30%) follow up Weight Regain, Band Erosion, Death

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Irrational Fear of Gastric Cancer:After Billroth II

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Page 1: Irrational Fear of Gastric Cancer:After Billroth II

FOLLOW UP EFFECT• Unbiased Population based studies => Poor Results of RNY

• Positive Results of RNY reported from RNY centers

• Suffer from “Follow Up Effect”

• Patient Returns to clinic doing well: Greeted Warmly with Great Joy

• Patient Returns to clinic doing poorly: Greeted with anger and disapproval

• Successful pt => Good Follow Up / Failed pt tacitly sent away

• Now; Center reports excellent results; (30%) follow up

• Weight Regain, Band Erosion, Death

• Not Seen, Not Reported

Page 2: Irrational Fear of Gastric Cancer:After Billroth II

Irrational Fear of Gastric Cancer:CHOOSING THE BEST WEIGHT LOSS SURGERY

R Rutledge MD, The Centers for Laparoscopic Obesity Surgery

www.CLOS.netEmail: [email protected]

Page 3: Irrational Fear of Gastric Cancer:After Billroth II
Page 4: Irrational Fear of Gastric Cancer:After Billroth II
Page 5: Irrational Fear of Gastric Cancer:After Billroth II

Dr Rutledge: Training & Background

• Undergrad/Medical School; Teacher Dr. Lester Dragstedt Pioneer / Inventor of the Highly Controversial Vagotomy and Pyloroplasty

• 2 Years Cardiac Surgery National Institutes of Health National Heart Lung Blood Institute

• 20 years University of NC; Professor of Surgery, Associate Chief of Staff, Director of Section Medical Informatics, Director North Carolina Trauma Registry

• Author of 93 papers and articles

Page 6: Irrational Fear of Gastric Cancer:After Billroth II

Dr Rutledge: Training & Background

• Specialty: Trauma, Critical Care, Medical Informatics and Bariatric Surgery (1978-1998 20 years University NC)

• Experience: Trauma Surgery, Director NC Trauma Registry• Peptic Ulcer Surgery; Vagotomy & Pyloroplasty;

Antrectomy & Billroth II

• Bariatric Surgery 33 years: Open RNY & Vertical Banded Gastroplasty

• 1997 one first surgeons laparoscopic RNY • Mini-Gastric Bypass; 14 years, over 6,000 cases

Page 7: Irrational Fear of Gastric Cancer:After Billroth II

Dr. Rutledge

USA 001-702-714-0011 [email protected]

CONSIDERING THE MGB?MGB IS A SUPERB SURGERY BUT…

WARNING: “THERE ARE “TRICKS AND TRAPS”

Page 8: Irrational Fear of Gastric Cancer:After Billroth II

OFFER A SAFE & SUCCESSFUL MGB PROGRAM• Call / Email: Anytime question or advice on any clinical, technical or

patient MGB question

• USA 001-702-714-0011 [email protected]

• Personal Visit: Dr. Rutledge Visiting Professor: France, Turkey, Austria & India, Upcoming visits Greece, Istanbul, United KingdomCzech Republic, Italy, Germany, UAE, Pakistan,

• Please Use the Knowledge of Others Before You Start; Experience; over 14 years, over 6,000 patients

• USA 001-702-714-0011 [email protected]

Page 9: Irrational Fear of Gastric Cancer:After Billroth II

Human Decision Making is FlawedNeed for Decision Making Support

Research: Human Decision Making frequently Flawed & driven by Irrational thinking

Selecting the Best Weight Loss surgery Should be based on a rational review of the data Avoid Emotional or Irrational Bias

Page 10: Irrational Fear of Gastric Cancer:After Billroth II

HUMAN DECISION MAKING ERRORS

Recent Research in Psychology and Neurobiology Shows that:

The Human Brain is a Notoriously Bad Decision Maker

Page 11: Irrational Fear of Gastric Cancer:After Billroth II

Human Decision Making ErrorsVery Common

• Exaggerate Rare Events, Downplay Common Events

• Underestimate risks taken Willingly, (car)Overestimate risks Beyond Control (airplane)

• Overestimate risks Talked About

Page 12: Irrational Fear of Gastric Cancer:After Billroth II

Irrational Illogical Thinking Decision-Making Errors• Confirmation Bias

(favor information that confirms preconceptions)• Herd Behavior

(group think override rational)• “Reptilian Brain”

Amygdala is part "impulsive," primitive system that triggers emotional override rational thinking

Page 13: Irrational Fear of Gastric Cancer:After Billroth II

PRIMITIVE RESPONSE SYSTEMSMODIFY RISK ASSESSMENT

Page 14: Irrational Fear of Gastric Cancer:After Billroth II

THE REPTILIAN BRAIN:EMOTION & DECISION MAKING

• Rational Logical Thinking:Frontal Lobe

• Amygdala Interferes with the Frontal lobe

• Primitive, Impulsive

• Irrational decision-making

Page 15: Irrational Fear of Gastric Cancer:After Billroth II

IRRATIONAL ILLOGICAL THINKING CONFIRMATION BIAS

• Contrary Evidence =>Maintains or strengthens present beliefs

• Overconfidence in present beliefs

• Poor Decision Making

• Especially Present in Organizations, Military, Political & Social Groups

Page 16: Irrational Fear of Gastric Cancer:After Billroth II

REPTILIAN BRAIN POOR DECISIONSFEAR LEADS TO JUDGMENT ERRORS

• Errors in Risk Assessment

• Death Airplane Crash

• Death Car Crash

• 1 in 1,000 patient / 20 years risk of gastric cancer

• Bowel Obstruction from internal hernia +16% in 5 years

Page 17: Irrational Fear of Gastric Cancer:After Billroth II

SURGERYHISTORY OF POOR DECISIONS

JOSEPH LISTER:

AMERICAN SURGEONS DELAYED ADOPTION OF ANTISEPSIS 10 YEARS

Page 18: Irrational Fear of Gastric Cancer:After Billroth II

REPTILIAN BRAINPOOR DECISION MAKING

• Lister published antisepsis

paper:

• 1867

Dr. Gross; Gross Clinic 1875

Page 19: Irrational Fear of Gastric Cancer:After Billroth II

HUMAN DECISION MAKING ERRORS:EXPECTED, NOT RARE

• Realization of FallibilityHuman Decision Making

• Humility

• Socratic Questioning ofAssumptions

• Search for Logical & Rational Decision Making

Page 20: Irrational Fear of Gastric Cancer:After Billroth II

THE PROBLEM

• Obesity Epidemic

• History of Failure of Bariatric Surgical Procedures

• Selecting the “Ideal / BEST” Bariatric Surgical Procedure

Page 21: Irrational Fear of Gastric Cancer:After Billroth II

Problem Definition:Bariatric Surgery: A HISTORY OF FAILURE

Procedure Assessment

Jejuno-ileal Bypass (Failure)

Vertical Banded Gastroplasty (Failure)

Lap Band (Fail?)

RNY Bypass (Fail?)

BPD/DS (Fail?)Sleeve: 1% Leak, 30% GE Reflux, Irreversible, Weight regain (Fail?)

Page 22: Irrational Fear of Gastric Cancer:After Billroth II

1. Low Risk2. Major Weight Loss3. Easily performed4. Short operative times5. Outpatient or short hospital stay6. Minimal Blood Loss7. No Need for ICU Stay8. Minimal Pain9. Very High Patient Satisfaction10. A Good "Exit Strategy"

SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY

Page 23: Irrational Fear of Gastric Cancer:After Billroth II

SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY11. Change Behavior & Preferences; Marked Decrease in Hunger

and Increased Satiety12. Minimal Retching and Vomiting 13. Few adhesions or hernias14. Minimal impact on Heart and Lung Function15. Low Failure Rate16. Low Cost17. Short Recovery Time18. Rapid Return to Work19. Low Risk of Pulmonary Embolus20. Durable weight loss

Page 24: Irrational Fear of Gastric Cancer:After Billroth II

SUCCESS CRITERIA"IDEAL" WEIGHT LOSS SURGERY

21. Low Risk of Ulcer22. Fat Malabsorption; low cholesterol & CV risk 23. No Plastic Foreign Body 24. Easily Verifiable Results; > 10 years of Results25. Low Risk of Bowel Obstruction26. Based upon sound surgical principles 27. Independent confirmation of results28. Healthy life after surgery29. Supported by LEVEL I Evidence; RCT (Controlled Prospective

Randomized Trial)30. Block “Sweet Eater” Failures

Page 25: Irrational Fear of Gastric Cancer:After Billroth II

ALTERNATIVES

• RNY

• Band

• Sleeve

• MGB

Page 26: Irrational Fear of Gastric Cancer:After Billroth II

MINI-GASTRIC BYPASS

• The Mini-Gastric Bypass1997 – 2011 ; >6,000 pts, 10 yr Data; Multiple Centers, R.C.Trials

• Vertical Gastric Tube(Collis Gastroplasty)

• Gastric Bypass(Billroth II Gastro-jejunostomy)

Page 27: Irrational Fear of Gastric Cancer:After Billroth II

MINI-GASTRIC BYPASSBASED SOUND SURGICAL PRACTICE

• Billroth II Performed over 100 years

• 16,000 Billroth II’sUSA in 2007

• Operation of choice: Trauma, Ulcers, Cancer Stomach etc.

Page 28: Irrational Fear of Gastric Cancer:After Billroth II

C: Consequences / Results / Outcomes

RNY Band SG MGB1. Low Risk - + - +2. Major Weight Loss + - - ++3. Easily performed - - + + +4. Short operative times - + + +5. Short hospital stay - - + + +6. Minimal Blood Loss - + + +7. No Need for ICU Stay - + + +8. Minimal Pain - + + +

9. High Patient Satisfaction - - - +

10. A Good "Exit Strategy" - - - + - - +

Page 29: Irrational Fear of Gastric Cancer:After Billroth II

C: Consequences / Results / Outcomes

RNY Band Sleeve MGB11. Decrease Hunger + - + +12. Min Vomiting + + + +13. No Internal hernias - + + +14. Min Heart/Lung - + + +15. Low Failure Rate - - - +16. Low Cost - - - +17. Short Recovery - + + +18. Return to Work - + + +19. Low Risk of PE - + + +20. Durable Weight Loss - - - +

Page 30: Irrational Fear of Gastric Cancer:After Billroth II

C: Consequences / Results / OutcomesRNY Band SG MGB

21. Low Risk of Ulcer - + + -

22. Malabsorption of fat + - - +23. No Foreign Body + - + +

24. Verifiable Results - - - ++

25. Bowel Obstruction - - + + ++26. Sound Surgical + - + +

27. Independent confirm - - - ++28. Healthy life - - - ++

29. RCT; LEVEL I Evidence - - - ++

30. Block Sweet Eater + - - ++

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• Fear of Gastric Cancer \ Bile Reflux

• Rational vs. Reptilian Brain Decision Making

Page 32: Irrational Fear of Gastric Cancer:After Billroth II

STATISTICAL ILLITERACY; "MANY DOCTORS MISUNDERSTAND MEDICAL LITERATURE"

• Example: “In the absence of a Roux limb, the long-term effects of chronic alkaline reflux are unknown.”

• REALLY? Rational vs. Reptilian Brain thinking

• Billroth II >100 years and >1,450 papers on Billroth II

• Collins BJ, Miyashita T, Schweitzer M, Magnuson T, Harmon JW., Gastric Bypass; Why Roux-en-Y? A Review of Experimental Data, Arch Surg. 2007; 142(10):1000-1003.

Page 33: Irrational Fear of Gastric Cancer:After Billroth II

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.

Page 34: Irrational Fear of Gastric Cancer:After Billroth II

BARIATRIC SURGEONS FEAR BILLROTH II;CANCER SURGEONS CHOOSE BILLROTH II

• 1,490 articles on performance of the Billroth II

• General/Trauma/Oncologic surgeons commonly use the Billroth II

• Over 16,000 Billroth II operation performed in USA 2007

• While Bariatric Surgeons Fear the Billroth II General Surgeons use the Billroth II routinely

Page 35: Irrational Fear of Gastric Cancer:After Billroth II

BARIATRIC SURGEONS FEAR BILLROTH IIWHAT IS MAGNITUDE OF THE PROBLEM

• 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

Page 36: Irrational Fear of Gastric Cancer:After Billroth II

BARIATRIC SURGEONS FEAR BILLROTH IIMAGNITUDE 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

Page 37: Irrational Fear of Gastric Cancer:After Billroth II

BARIATRIC SURGEONS FEAR BILLROTH IIMAGNITUDE 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

Page 38: Irrational Fear of Gastric Cancer:After Billroth II

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=

Page 39: Irrational Fear of Gastric Cancer:After Billroth II

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=

Page 40: Irrational Fear of Gastric Cancer:After Billroth II

BARIATRIC SURGEONS FEAR BILLROTH IIGASTROENTEROLOGISTS IGNORE BILLROTH II

• Hundreds of thousands of people with Billroth II’s

• If cancer IS SUCH A BIG RISK…

• Shouldn’t gastroenterologists be looking for these people, screening them with endoscopy?

• No, there is no recommendation for BII follow up screening; Why? THE RISK IS LOW

• 63,000 yrs Follow up 23 cancers = Gen Pop.

Page 41: Irrational Fear of Gastric Cancer:After Billroth II

RISK OF GASTRIC CANCER AFTER BILLROTH II IS LOW

• Follow-up study of 1000 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

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Page 43: Irrational Fear of Gastric Cancer:After Billroth II

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

Page 44: Irrational Fear of Gastric Cancer:After Billroth II

DIET AND CANCER PREVENTION

• 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.

Page 45: Irrational Fear of Gastric Cancer:After Billroth II

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

AA BB

Page 46: Irrational Fear of Gastric Cancer:After Billroth II

CANCER QUIZ: MORE DEADLY Hot Dog or Mini-Gastric Bypass

AA

• American Institute for Cancer Research

• Hot Dog / day • Increase the risk

cancer 21%

Page 47: Irrational Fear of Gastric Cancer:After Billroth II

UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II

• 1. Gastric Cancer Declining Rapidly, > 50%

• 2. Gastric Cancer Cause: Environmental Factors / Easily Prevented

Diet, Lifestyle changes and Rx of H. Pylori

(Avoid Etoh, smoking, processed & salted meats and foods, seek high intake of fruits and vegetables)

Page 48: Irrational Fear of Gastric Cancer:After Billroth II

UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II

• 3. Some studies Slight Increased Risk of gastric cancer after 20 – 30 years (RR 1.5):But: BII to Rx Ulcer => Ulcer => Increased Risk

• (Worried? Rx H Pylori, Eat healthy etc.)

• 4. Many Large Studies: No Increased RiskThousands of patients followed for Decades

Page 49: Irrational Fear of Gastric Cancer:After Billroth II

UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II

• 5. Endoscopic screening of Billroth II patients is Not Recommended. Why? Low Risk!

• 6. General, Trauma and Oncologic surgeons routinely use the Billroth II (Thousands of publications)

• 7. 2007 ~16,000 BII procedures were performed in the USA

Page 50: Irrational Fear of Gastric Cancer:After Billroth II

UNINFORMED FEAR BILLROTH IIEDUCATED USE BILLROTH II

• 8. Billroth II and the Mini-Gastric BypassExcellent, Safe and Effective

• 9. FEAR Gastric Cancer? Avoid ETOH, Tobacco, Processed & Preserved Meats, Rx H. Pylori, Eat Fruits and Veggies, Yogurt and Drink Green Tea

• A Billroth II probably makes NO difference

Page 51: Irrational Fear of Gastric Cancer:After Billroth II

• Rational Review of the Data vs.Fear Gastric Cancer / Bile Reflux

• Rational Thinking vs. Reptilian Brain

Page 52: Irrational Fear of Gastric Cancer:After Billroth II

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

Page 53: Irrational Fear of Gastric Cancer:After Billroth II

FEAR OF GASTRIC CANCER

• FEAR gastric cancer?

• Avoid: Alcohol, Tobacco, Processed & Preserved MeatsRx: H. Pylori, Eat Fruits & Veggies, Yogurt and Drink Green Tea

• Billroth II Probably Makes NO DifferenceBillroth II Probably Makes NO Difference

Page 54: Irrational Fear of Gastric Cancer:After Billroth II

FEAR OF GASTRIC CANCER

A Billroth II Probably Makes No Difference

Page 55: Irrational Fear of Gastric Cancer:After Billroth II

FEAR OF GASTRIC CANCER

A Billroth II Probably Makes No Difference

Page 56: Irrational Fear of Gastric Cancer:After Billroth II

C: Consequences / Results / Outcomes

RNY Band SG MGB

1. Low Risk - + - +

2. Major Weight Loss + - - ++

3. Easily performed - - + + +

4. Short operative times - + + +

5. Short hospital stay - - + + +

6. Minimal Blood Loss - + + +

7. No Need for ICU Stay - + + +

8. Minimal Pain - + + +

9. High Patient Satisfaction - - - +

10. A Good "Exit Strategy" - - - + - - +

Page 57: Irrational Fear of Gastric Cancer:After Billroth II

C: Consequences / Results / Outcomes

RNY Band Sleeve MGB11. Decrease Hunger + - + +12. Min Vomiting + + + +13. No Internal hernias - + + +14. Min Heart/Lung - + + +15. Low Failure Rate - - - +16. Low Cost - - - +17. Short Recovery - + + +18. Return to Work - + + +19. Low Risk of PE - + + +20. Durable Weight Loss - - - +

Page 58: Irrational Fear of Gastric Cancer:After Billroth II

C: Consequences / Results / OutcomesRNY Band SG MGB

21. Low Risk of Ulcer - + + -

22. Malabsorption of fat + - - +

23. No Foreign Body + - + +

24. Verifiable Results - - - ++

25. Bowel Obstruction - - + + ++

26. Sound Surgical + - + +

27. Independent confirm - - - ++

28. Healthy life - - - ++

29. RCT; LEVEL I Evidence - - - ++

30. Block Sweet Eater + - - ++

Page 59: Irrational Fear of Gastric Cancer:After Billroth II

CONCLUSIONS: Rational Choice: Mini-Gastric Bypass

• Choice of Obesity Surgery?

• Criteria for “Ideal” Weight Loss Surgery

• RNY, Band, Sleeve, MGB

• MGB Best Meets Success Criteria

• Fear of Bile Reflux & Gastric Cancer Not Supported by the Data

• Rational Decision Making: Best Choice; Mini-Gastric Bypass

Page 60: Irrational Fear of Gastric Cancer:After Billroth II

WHY CRITICS ONLY CARE FOR MGB?• Why do Critics only care about the

Mini-Gastric Bypass?

• 100,000’s of people already have and are living with and are getting the Billroth II every day

• Why haven’t concerned bariatric surgeons stepped forward to stop all general, trauma and oncologic surgeons from performing this Billroth II surgery?

Page 61: Irrational Fear of Gastric Cancer:After Billroth II

WHY CRITICS ONLY CARE FOR MGB?•Why do Critics only care about the Mini-Gastric Bypass?

•Why haven’t concerned bariatric surgeons stepped forward to start a fund to help suffering Billroth II patients get needed conversions of their surgery to Roux-en-Y?

•Why don’t they write letters to the editor calling for the Billroth II to be declared a operation non-grata?

Page 62: Irrational Fear of Gastric Cancer:After Billroth II

WHY CRITICS ONLY CARE FOR MGB?• Why do Critics only care about the

Mini-Gastric Bypass?

• Why haven’t concerned bariatric surgeons stepped forward to national funding for lifetime endoscopic screening of Billroth II patients to find dreaded gastric cancers?

• It seems odd doesn’t it?

• There is a simple reason

Page 63: Irrational Fear of Gastric Cancer:After Billroth II

WHY CRITICS ONLY CARE FOR MGB?• There is a simple reason

• The critics of the MGB do not do those things because of Cognitive Biases

• Such actions are Not supported by the data

• The Billroth II and the MGB are both good operations

• Published data Does Not support the critics misreading of the medical literature

Page 64: Irrational Fear of Gastric Cancer:After Billroth II

CRITICS OF THE MINI-GASTRIC BYPASS

SHOULD BE EMBARRASSEDFor Forgetting their

General Surgery

Page 65: Irrational Fear of Gastric Cancer:After Billroth II

Dr Rutledge; USA 001-702-714-0011 [email protected]

ARE YOU CONSIDERING THE MGB?

WARNING: THERE ARE “TRICKS AND TRAPS”

Page 66: Irrational Fear of Gastric Cancer:After Billroth II

OFFER A SAFE AND SUCCESSFUL MGB PROGRAM• Please Call / Email: Anytime question or advice on any clinical,

technical or patient MGB question

• USA 001-702-714-0011 [email protected]

• Personal Visit: Dr Rutledge Visiting Prof: Costa Rica, Turkey, France, Austria & India, Upcoming visits Greece, Istanbul, Czech Republic, Italy and Germany

• Please Use the Knowledge of Others Before You Start; Experience; over 14 years, over 6,000 patients

Page 67: Irrational Fear of Gastric Cancer:After Billroth II

THE TIDE BEGINS TO TURNTO THE MINI-GASTRIC BYPASS• “Not too long ago, the bariatric community questioned the

role of the mini-gastric bypass and its appropriateness as a durable operation for obesity.”

• The experience of Lee et al. with a large cohort suggests some answers.”

• Michel M. Murr, M.D.

• “The Journal continues to commit to open, spirited, and balanced discussions that are supported by data and withstand the test of common sense.”

Page 68: Irrational Fear of Gastric Cancer:After Billroth II

A CLARION CALL FOR BETTER BARIATRIC SURGERY

• RNY and VBG FAIL to Lengthen Life!

• Bariatric Surgery; A History of Complications & Failure

• We Need Better Bariatric Surgery

• We Simpler, Safer, More Powerful, More Durable and Revisable and Reversible

• We Need the MGB

Page 69: Irrational Fear of Gastric Cancer:After Billroth II

MGB, 9 YEARS LATER! OUT PERFORMS RNY

• Stunning new results of the MGB:

• “Of the 1,322 patients, 23 (1.7%) had undergone revision surgery during a follow-up of 9 years.”

• Excess weight loss at 5 years after MGB was 72.1%

• No patient had surgery for internal hernia

Page 70: Irrational Fear of Gastric Cancer:After Billroth II

SURVEY: MGB OUT-PERFORMS BAND & RNY

• Follow up survey of bariatric surgery results in 1,500 patients’ friends, family and acquaintances

• Patient Reported Success in Friends Family:

36% RNY,

24% Band and

93% MGB

Page 71: Irrational Fear of Gastric Cancer:After Billroth II

EXAMPLE FEAR & DECISION MAKING SBO VS. GASTRIC CANCER

Which is more Deadly?

• Gastric Cancer or Small Bowel Obstruction?

• Which is more fearsome?

Page 72: Irrational Fear of Gastric Cancer:After Billroth II

11+ RNY STUDIES INTERNAL HERNIA BOWEL OBSTRUCTION• 1 - 16% Internal Hernia /Small Bowel Obstruction

• Follow Up 1-10 years (only 7% F/U at 10 years)

• Note: Dead patients cannot return for follow up

• =15/18 patients, ReOp, failed closure USA=

Page 73: Irrational Fear of Gastric Cancer:After Billroth II

DEATH AFTER SMALL BOWEL OBSTRUCTION

• 877 patients who underwent 1,007 operations for SBO from 1961 to 1995

• Risk of bowel obstruction increases over time• 52 Deaths 6% Death Rate

• Ann Surg. 2000 April; 231(4), Complications and Death After Surgical Treatment of Small Bowel Obstruction A 35-Year Institutional Experience Fevang et.al., Department of Surgery, University Hospital, University of Bergen, Norway

Page 74: Irrational Fear of Gastric Cancer:After Billroth II

FEAR AND DECISION MAKINGSBO VS. GASTRIC CANCER

• Which is more Deadly?

• Gastric Cancer or Small Bowel Obstruction?

• Which is more fearsome?

Page 75: Irrational Fear of Gastric Cancer:After Billroth II

FEAR AND DECISION MAKINGSBO VS. GASTRIC CANCER• 1,000 RNYs, Estimate 20% SBO => 200 operations for

SBO in 5-10 years (? How many more for 20 years?)

Page 76: Irrational Fear of Gastric Cancer:After Billroth II

FEAR?SBO VS. GASTRIC CANCER• 1,000 RNYs, 20% SBO => 200 operations for SBO in

5-10 years (? How many for 20 years?)

• 6% Death Rate => 12 dead before the end of 10 years from SBO

Page 77: Irrational Fear of Gastric Cancer:After Billroth II

FEAR?SBO VS. GASTRIC CANCER• 1,000 RNYs, 20% SBO => 200 operations for SBO in

5-10 years (? How many for 20 years?)

• 6% Death Rate => 12 dead before the end of 10 years from SBO

• 1,000 MGBs After 20 years possibly increased risk of cancer of 1 / 1,000

Page 78: Irrational Fear of Gastric Cancer:After Billroth II

FEAR?SBO VS. GASTRIC CANCER• 1,000 RNYs, 20% SBO => 200 operations for SBO in

5-10 years (? How many for 20 years?)

• 6% Death Rate => 12 dead before the end of 10 years from SBO

• 1,000 MGBs After 20 years possibly increased risk of cancer of 1/1,000

• Deaths at 10 years from Gastric Cancer 0.0

Page 79: Irrational Fear of Gastric Cancer:After Billroth II

FEAR?SBO VS. GASTRIC CANCER• 1,000 RNYs, 20% SBO => 200 operations for SBO in 5-10

years (? How many for 20 years?)

• 6% Death Rate => 12 dead before the end of 10 years from SBO

• 1,000 MGBs After 20 years possibly increased risk of cancer of 1/1,000

• Death at 10 years from Gastric Cancer 0.0

• Death SBO 12/10 years, Deaths Gastric Cancer 10-20 years 0-1

Page 80: Irrational Fear of Gastric Cancer:After Billroth II

WHICH DO YOU FEAR?SBO VS. GASTRIC CANCER

• 1,000 RNYs = 200 SBO operations

• Death from RNY SBO 12 deaths / 10 years

• 1,000 MGB’s 0-1 Gastric Cancer @ 20 yrs

• Deaths Gastric Cancer 10-20 years 0-1?

Page 81: Irrational Fear of Gastric Cancer:After Billroth II

FEAR AND DECISION MAKINGSBO VS. GASTRIC CANCER

• Which is more Deadly?

• Gastric Cancer or Small Bowel Obstruction?

• Which is more fearsome?

Page 82: Irrational Fear of Gastric Cancer:After Billroth II

FOLLOW UP EFFECT• Unbiased Population based studies => Poor Results of RNY

• Positive Results of RNY reported from RNY centers

• Suffer from “Follow Up Effect”

• Patient Returns to clinic doing well: Greeted Warmly with Great Joy

• Patient Returns to clinic doing poorly: Greeted with anger and disapproval

• Successful pt => Good Follow Up / Failed pt tacitly sent away

• Now; Center reports excellent results; (30%) follow up

• Weight Regain, Band Erosion, Death

• Not Seen, Not Reported