1. Irrational Fears of Cancer General Surgeons Use the Billroth II Bariatric Surgeons FEAR the Billroth II (Mini-Bypass) At WORST Lifetime Risk Billroth II is Less Risky than 2 CATScans or Eating a Hot Dog! Surgeons with Greatest Fear => Least Well Informed

2. Fear of Mini-Bypass Numerous studies now confirm that the Mini-Gastric Bypass (MGB) is Short, simple, highly effective, very safe, very durable and easily revised surgery In almost every way the MGB out performs the Sleeve, Band and RNY

3. Lack of Knowledge and Patient Outcomes Studies Show Correlation Between Surgeon's knowledge in there areas of expertise and patient outcomes Survey Data Showed : Surgeons who FEAR GCa after MGB were much less knowledgeable about GCa and Billroth II and General Surgery than other Bariatric Surgeons

4. Fear of Gastric Caner after Mini-Bypass Purpose: Education 1 Gastric Cancer (GCa) 2 Declining Risk 3 Causes Prevention GCa 4 H Pylori GCa 5 Billroth II and GCa 6 General Surgeons Routine Use of BII 7 Incidence/Frequency of GCa 8 Studies showing NO Increased Risk of GCa Post BII 9 Some Studies DO show Increased Risk of GCa after BII...BUT in these studies BII Done for ULCERS! 10 Reminder Ulcers and GCa CAUSED by H Pylori! 11 Gastroenterologists DO NOT recommend endo F/U for BII patients; Why? BECAUSE THE RISK IS TOO LOW 12 Irrational Fears: Hot Dogs, CATScans and Cognitive Biases in Humans and Bariatric Surgeons

5. Human Decision Making Numerous Studies show that Human Decision Making is far from the ideal logical and rational skill that many of us imagine Cognitive Biases Foundation of Good Decision Making is a Clear understanding of the data

6. Survey 102 Bariatric Surgeons Experience with over 39,000 cases Surgeons who expressed Fear of GCa after MGB Significantly LESS Knowledgeable about GCa, General Surgery, outcomes of BII and MGB

7. Begin with Education

8. Gastric Cancer (GCa) Studies Show just the Word "Cancer" engenders an inordinate amount of fear in study participants Example what's more deadly cancer or bowel obstruction To judge the right response to a risk we need to look at the actual data...

9. Gastric Cancer (GCa) Declining Risk There has been a long-term decline in incidence of stomach cancer in virtually all countries worldwide This is linked to falling rates of infection with H. pylori, and the use of refrigeration instead of salting to preserve foods,

10. Gastric cancer is declining in Japan and all over the world The incidence of gastric cancer is declining in Japan and all over the world. In a study conducted in Osaka prefecture, the age-adjusted mortality rate for gastric cancer decreased from 84 (196365) to 41 (198789) for males and from 41 to 18 for females during the same period

11. Gastric Cancer (GCa) Declining Risk Researchers at Harvard School of Public Health CGA declined 60% between 1978 and 2008 H. pylori infection and smoking accounted for 47% Predicted 2008-2040, U.S. CGA rates will fall an additional 47%, and H. pylori and smoking will contribute to more than 80% of the decline.

12. Gastric Cancer (GCa) Declining Risk What to KNOW 1. Worldwide Massive Decline of GCa 2. Why? = Decline in Smoking = Refrigeration => Decrease in Nitrate in Preserved Foods/More Fresh Fruit and Veges AND = Decline in H.Pylori 3. NOT Billroth II

13. Causes/Prevention GCa H Pylori: H. pylori can cause peptic ulcers. cause of stomach cancer Smoking: Heavy smokers are most at risk. Diet: Smoked, Salted, Or Pickled increased risk Diet high in fresh fruits & vegetables lower risk Sedentary and Obesity Increase Risk

14. Fear Gastric Cancer? Rx H Pylori STOP Smoking Diet: DO NOT EAT Smoked, Salted, Or Pickled foods * DO Eat * fresh fruits & vegetables Be Active and Rx Obesity

15. H Pylori GCa H. pylori infection is a major cause of gastric (stomach) cancer "Helicobacter pylori causes gastric cancer in human and in experimental animals. " Many surgeons who fear GCa in MGB did no seem to be clear on this fact

16. Fear Gastric Cancer? Rx H Pylori STOP Smoking Diet: DO NOT EAT Smoked, Salted, Or Pickled foods * DO Eat * fresh fruits & vegetables Be Active and Rx Obesity

17. Billroth II and GCa Many Surgeons who fear the GCa Association with MGB were not clear on the research on this topic

18. Billroth II and GCa Studies showing NO Increased Risk of GCa Post BII Many Surgeons who fear the GCa Association with MGB do not know that Many Studies of BII and GCa Show NO ASSOCIATION Studies showing NO Increased Risk of GCa Post BII

19. BARIATRIC SURGEONS FEAR BILLROTH II Many Studies Show NO Association 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

20. 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

21. BARIATRIC SURGEONS FEAR BILLROTH II No Association of Billroth II and Gastric Ca 338 Billroth II pts, Followed 25-yrs 5,635 person-years Only 2 Cancers in 5,000 pt yrs follow up Lifetime Risk GCa after BII 0.04% RATE of Gastric Cancer is Declining 24 - 50% Expected Decrease from 1983 Future risk ~1 patient / 5,000 pt years

22. BARIATRIC SURGEONS FEAR BILLROTH II No Association of Billroth II and Gastric Ca Only 2 Cancers in 5,000 pt yrs follow up Lifetime Risk GCa after BII 0.04% Remember! RATE of Gastric Cancer is Declining This was Published in 1983! 24 - 50% Expected Decrease from 1983 Future risk GCa: ~1 pt / 5,000 pt yrs Lifetime Risk of GCa after 5,000 pt yrs FU 0.02% Less than the risk for the rest of the population!

23. BARIATRIC SURGEONS FEAR BILLROTH II No Association of Billroth II and Gastric Ca Remember! RATE of Gastric Cancer is Declining This was Published in 1983! 24 - 50% Expected Decrease from 1983 Future risk GCa: ~1 pt / 5,000 pt yrs Lifetime Risk of GCa after 5,000 pt yrs FU 0.02% Less than the risk for the rest of the population!

24. Billroth II and GCa Many Surgeons who fear the GCa Association with MGB do not know that Many Studies of BII and GCa Show NO ASSOCIATION

25. Remember If You Fear Gastric Cancer? Rx H Pylori STOP Smoking Diet: DO NOT EAT Smoked, Salted, Or Pickled foods * DO Eat * fresh fruits & vegetables Be Active and Rx Obesity

26. Some Studies DO show Increased Risk of GCa after BII...BUT in these studies BII Done for ULCERS! Meta-analysis: 7 studies show Small increased risk 5 studies No Increased Risk

27. Some Studies DO Show Association Billroth II and GCa Ulcers associated with increased risk of GCa Why? Because H.Pylori Infection H. Pylori causes GCa (RR = 1.53)

28. Some Studies DO Show Association Billroth II and GCa Meta-analysis: 7 studies show Small increased risk 5 studies No Increased Risk Some Studies DO Show Association Billroth II and GCa (RR = 1.5) similar to ulcers BUT...

29. Reminder Ulcers and GCa CAUSED by H Pylori!

30. Some Studies DO Show Association Billroth II and GCa 7 studies show Small increased risk BUT... Studies increased Risk; Flawed Why Billroth II? Rx Ulcers Ulcers = H. Pylori Infection H. Pylori Infection => GCa

31. Some Studies DO Show Association Billroth II and GCa Some Studies show increased Risk of GCa after BII; Flawed Billroth II performed to Rx Ulcers Ulcers = H. Pylori Infection H. Pylori Infection => GCa Effect of Increased GCa more from H Pylori than BII

32. BII and GCa Many Studies Show No Association between BII and GCa Some studies DO show an association But In the studies that do show an association the BII was done for Ulcers Ulcers = H. Pylori H. Pylori causes GCa Billroth II probably has little or nothing to do with RR of GCa

33. General Surgeons Routine Use of BII Bariatric Surgeons Fear Billroth II; General Surgeons Choose Billroth II Trauma Surgeons Choose Billroth II Oncologic Surgeons Choose Billroth II

34. 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

35. BARIATRIC SURGEONS FEAR BILLROTH II; CANCER SURGEONS CHOOSE BILLROTH II Studies from Oncologic Surgeons from Korea and China Location of some of the highest rates of GCa in the world Routinely report the use of Billroth II reconstructions in GCa patients

36. Incidence/Frequency of GCa

37. Incidence/Frequency of GCa From Cancer.org USA Lifetime Risk of stomach Cancer * 0.5% * MD India * 0.51% * Declining Rates of Stomach Cancer

38. Cancer from CAT Scans Additional Cancer Risk(%) Abd/Pelvis CT Additional Cancer Risk(%) ++0.14% 2 Abd/Pel CtScan + Contrast 40mSv Additional Cancer Risk(%) ++0.28%

39. Lifetime Risk of Gastric Cancer & Predicted Increased Risk from WORST Billroth II Studies (RR1.5) Baseline Lifetime Risk of GCa 0.50% Using Worst Billroth II studies Predicted Additional Cancer Risk(%) + +0.25%

40. Lifetime Risk of Gastric Cancer & Predicted Increased Risk from WORST Billroth II Studies (RR1.5) Baseline Lifetime Risk of GCa 0.50% Using Worst Billroth II studies Predicted Additional Cancer Risk(%) + +0.25%

41. Declining Rates of Stomach Cancer Stomach cancer incidence rates have decreased overall since the mid1970s For males, European AS incidence rates decreased by *59%* between 1975-1977 and 2008-2010. The decline is slightly bigger for women, with rates decreasing by *64%* between 1975-1977 and 20082010.

42. Comparison of Risk of Worst Predicted Outcomes of BII Compared to 1 or 2 CT Scans 1 or 2 CT Scans vs BII (as predicted by the worst BII risk studies, published in the 60's80's) CT Scan 0.78% vs BII 0.75% Lifetime risk cancer

43. Fear CTScans? Many studies show no increased risk of GCa after BII Of the old studies that do show an increased risk the magnitude of the risk is about the risk see with one or two CT Scans Fear CT Scans?

44. Fear the Hot Dog?

45. Fear the Hot Dog? 100 g increment the association between processed meat increased risk of gastric cancer (** RR 5.0 **) One Hot Dog = 100g

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

47. CANCER QUIZ: MORE DEADLY Hot Dog or Mini-Gastric Bypass A Answer Hot Dog Do you Fear Hot Dog or a CAT Scan? Remember Many Studies of Billroth II Show No increased Risk of GCa

48. UNINFORMED FEAR BILLROTH II EDUCATED 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)

49. UNINFORMED FEAR BILLROTH II EDUCATED 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 Risk Thousands of patients followed for Decades

50. UNINFORMED FEAR BILLROTH II EDUCATED 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

51. UNINFORMED FEAR BILLROTH II EDUCATED USE BILLROTH II 8. Billroth II and the Mini-Gastric Bypass Excellent, 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

52. Rational Review of the Data vs. Fear Gastric Cancer / Bile Reflux Rational Thinking vs. Reptilian Brain

53. 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

54. FEAR OF GASTRIC CANCER FEAR gastric cancer? Avoid: Alcohol, Tobacco, Processed & Preserved Meats Rx: H. Pylori, Eat Fruits & Veggies, Yogurt Billroth II Probably Makes NO Difference

55. FEAR OF GASTRIC CANCER A Billroth II Probably Makes No Difference