My Letter (Nice)

August 26, 2000

OK Here is the nice version.

To the Editors:

Galen, the great physician and philosopher born in A.D. 129, pronounced his

view that in the body, blood was continuously being created on the arterial

side and then being continuously being consumed on the venous side. This

became the unquestioned medical " truth " for 1,400 years until Harvey

successfully challenged Galen's view showing that a fixed amount of blood

circulated within the body. Like Harvey's transformation of the

science of blood circulation, laparoscopic surgery is revolutionizing many

areas of both General and Bariatric Surgery. Revolutions are by their very

nature inherently disruptive and painful, often requiring a review of

previously held assumptions.

While some embrace the revolutionary aspects of laparoscopic surgery, others

have raised concerns in particular about the laparoscopically performed

" Mini-Gastric Bypass. "

Some have likened the " Mini-Gastric Bypass " (MGB) to the old Mason loop

gastric bypass. A variety of studies have shown the failure of the old loop

bypass [5-7]. But, the Mini-Gastric Bypass is NOT the old loop gastric

bypass, it is a different procedure and the previously well-documented

problems and complications of the old Mason loop gastric bypass have not

occurred in the modern series of 817 MGB patients. Since it is well

recognized that the old Mason loop gastric bypass routinely leads to a

number of well documented complications and since these complications are

not present in the series of MGB patients it is clear, that they can not be

the same operation.

Another concern raised by some is the potential association of the Billroth

II anastomoses and gastric cancer. A casual review of the medical

literature can turn up articles that can to a cursory review seem to raise

concerns about the relation between the Billroth II and gastric cancer. A

more thoughtful review shows this is not a reasonable concern. A number of

the papers showing an association between BII and gastric cancer are out of

date. An example of a well-done study looking at this issue published in the

New England Journal was the article by Schafer et. al. (). In this

study the Mayo Clinic group studied residents of Olmsted County, Minnesota,

who had surgery for ulcer disease from 1935 to 1959. These patients were

followed for over 5,635 person-years. They found gastric cancer in only two

of the patients in the surgical group, as compared with an expected rate of

2.6 persons. That is, they found that the rate of gastric cancer in the

surgery patients was actually lower than that seen in unoperated controls.

Numerous other long-term studies of BII patients have found no evidence of

an increased incidence of gastric cancer. In a recent study by Bassily et.

al. ([ii]) the records of 569 patients who had a partial gastrectomy for

ulcer disease were analysed. Five hundred and seven patients (83.5%) had a

Billroth II procedure. They showed that " the risk of gastric cancer was not

increased after Billroth II partial gastrectomy. "

In another study by Luukkonen et. al. ([iii]) the risk of gastric cancer

after gastric surgery for ulcer in Finland was studied. Six patients of the

285 developed gastric cancer 6, 7, 8, 21, 25 and 27 years after the

operation. The risk of contracting gastric cancer in a control population

(individuals who had no operation) of equal size and age during a similar

follow-up period was 8 cases. That is to say, the operated patients had

lower risk of gastric cancer than nonoperated patients. This study, as well

as many others, shows that the risk of gastric cancer does not significantly

increase after partial gastrectomy for benign peptic ulcer.

It is true that there are some studies that appear to show an increased risk

of gastric stump cancer as compared to the general population. But these

studies are seriously flawed. All of the studies that show slight increases

in the rate of gastric cancer following BII include patients that have had

the surgery for ulcer disease. The problem with this study design is the

fact that it has been well demonstrated that gastric ulcer is associated

with an increased risk of gastric cancer. For example, in a study by Molloy

and Sonnenberg ([iv]) the association between ulcer and gastric cancer was

demonstrated in patients from the US Department of Veterans Affairs. 3,078

subjects with gastric cancer were compared with a 89,082 people without

gastric cancer. This study showed that gastric ulcer patients had an

increased rate of gastric cancer (relative risk 1.53, Note that this

increased risk is similar in magnitude to the increased risk reported in the

studies showing an increased risk of gastric cancer in BII surgical

patients.) Many other studies confirm these findings that ulcer patients

have an increased risk of gastric cancer. In a study by Hansson et. al.

published in the New England Journal of Medicine ([v]) the risk of stomach

cancer in 57,936 patients was analyzed. The rate of gastric cancer among

patients with gastric ulcers was increased at 1.8 times. Again, this value

is very similar to that reported for the increase seen in some studies of

post-gastrectomy patients. They concluded that gastric ulcer disease and

gastric cancer have causative factors in common. Thus the studies that find

small increased rates of gastric cancer in post gastrectomy patients may

simply be identifying gastric ulcer patients that are prone to develop

gastric cancer regardless of the any surgery they may have had.

It is also important to look at the actual size of the increased risk of

stomach cancer reported in the series that seem to find and increased risk

of stomach cancer in post gastrectomy patients. As described above the

majority of studies find no increased risk of gastric cancer in BII

patients, but in the studies that do find an increase in risk, how much of

an increase is seen and how does this compare to other factors involved in

the development of gastric cancer? Analysis of these issues can put these

studies reporting an increased risk of gastric cancer into proper

perspective.

Hundreds of articles have looked at factors that affect the development of

gastric cancer. These studies indicate that salted, smoked, pickled, and

preserved foods (rich in salt, nitrite, and preformed N-nitroso compounds)

are associated with an increased risk of gastric cancer. In contrast, good

evidence has been found that the high consumption of fresh fruit and raw

vegetables and a high intake of antioxidants are associated with reduced

risks of gastric cancer ([vi]). Now with all of these factors where is

post-gastrectomy positioned as a risk factor?

Extensive research shows that gastric cancer has an environmental cause, of

which diet appears to be the most important component ([vii].) Studies show

that there is an approximately a threefold increased risk of gastric cancer

for frequent consumption of fresh and processed meats (relative risk 3.1 and

3.2). Gastric cancer risk rises with increasing intake of smoked and pickled

foods (relative risk 3.7) All of these changes are as much as twice as high

as that seen with the studies showing an effect of gastrectomy on gastric

cancer risk. Many studies also show a decreasing risk of stomach cancer with

increasing frequency of vegetable consumption. Increased intake of citrus

fruits (risk 0.47) and raw-green vegetables (risk 0.56) appear to be

protective. Consumption of salty snacks more than twice per month has been

associated with an 80 percent increased risk ([viii]). These findings are

consistent with many studies around the world that indicate important roles

for salt, processed meats, and vegetable consumption in the risk of gastric

cancer. There are dozens more articles like these but we can summarize

these findings as follows: Billroth II post gastrectomy patients are at

little or no increased risk of gastric cancer. If either they or their

physicians are concerned it about gastric cancer it appears that very simple

dietary modifications can have a much greater impact on the patient's

lifetime risk of gastric cancer than that of the gastrectomy, i.e. avoiding

processed meats, smoked and pickled foods while increasing one's intake of

fresh fruits and vegetables, with or with out supplementation with

additional antioxidant vitamins. Another way to put this is to say that a

regular diet of baloney sandwiches appears to be of greater risk to a

patient for the development of gastric cancer than the Billroth II.

Helicobacter Pylori

Evidence of an association between Helicobacter pylori infection and gastric

cancer risk has been shown by most studies. The increased risk is two- to

threefold increase in risk over normal. Again studies clearly show that H

Pylori not gastrectomy appears to be the risk factor associated with gastric

cancer and physicians who feel this is of concern can provide treatment to

eradiate H. Pylori to patients.

It may also be of value to point out that thousands of general surgeons

routinely perform the BII anastomoses on a daily basis. Tens of thousands of

patients undergo BII type gastrojejunostomy on a yearly basis and there is

no ground swell effort being generated against the risk of the BII type

anastomoses.

Some have called for laparoscopists " not re-invent surgical techniques "

concerned that the laparoscopic surgery might modify an open technique. Yet

is that not what all physicians and surgeons truly hope for, that newer and

better techniques will be devised over time and that these newer techniques

will be put to the service of our patients.

Surgeons have a long history of fighting against change. Surgeons fought

antisepsis, changes in breast cancer surgery, closed suction drainage and

uncounted other improvements in medical care. Rather than welcoming change

surgeons have repeatedly shown themselves instead to be hidebound

conservatives unwilling to see the light of a new day. They have failed to

embrace change so often that it has come to be a defining characteristic of

surgery.

The Mini-Gastric Bypass is a remarkable new development in Bariatric

surgery. It is supported by the most extensive database and data collection

effort ever put forth to document the outcomes of a Bariatric surgical

procedure. To date more than 817 patients have undergone the procedure.

The complication rate is 5.3% over all, the mortality rate is 0.12%, the

operative time averages 38 + 9.2 minutes, the mean hospital stay is 1.1 + 1

day and the hospital charges are 20-30% of that charged by others. In the

series of 817 patients there are no hernias, pulmonary emboli or episodes of

DVT to date. And, the surgery is easily revised or reversed. The weight

loss is comparable or better than any other reported series.

While more work needs to be done, it is clear that rather than calling for

laparoscopic surgeons not to be innovators, all of the members of the

medical community must continually question our past beliefs. If new data

exposes past theories to the harsh light of reality then so be it. We

should all be long past the days of Galen.

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N Engl. J Med 1983 Nov 17; 309(20): 1210-3 The risk of gastric carcinoma

after surgical treatment for benign ulcer disease. A population-based study

in Olmsted County, Minnesota. Schafer LW, Larson DE, Melton LJ 3d, Higgins

JA, Ilstrup DM

[ii] J Gastroenterol Hepatol 2000 Jul;15(7):762-5 Risk of gastric cancer is

not increased after partial gastrectomy. Bassily R, Smallwood RA, Crotty B

[iii] Hepatogastroenterology 1990 Aug; 37(4): 392-4 Decreased risk of

gastric stump carcinoma after partial gastrectomy supplemented with bile

diversion. Luukkonen P, Kalima T, Kivilaakso E

[iv] Gut 1997 Feb; 40(2): 247-52 Relation between gastric cancer and

previous peptic ulcer disease. Molloy RM, Sonnenberg A

[v] N Engl J Med 1996 Jul 25;335(4):242-9, The risk of stomach cancer in

patients with gastric or duodenal ulcer disease. Hansson LE, Nyren O, Hsing

AW, Bergstrom R, fsson S, Chow WH, Fraumeni JF Jr, Adami HO

[vi] J Gastroenterol. 2000; 35 Suppl 12:84-9 Epidemiology of gastric cancer:

an evaluation of available evidence. Palli D

[vii] Cancer 1993 Mar 1; 71(5): 1731-5 Dietary factors and gastric cancer

risk. A case-control study in Spain. Ramon JM, Serra L, Cerdo C, Oromi J.

[viii] Am J Epidemiol 1999 May 15; 149(10): 925-32 Dietary factors and the

risk of gastric cancer in Mexico City. Ward MH, -Carrillo L.

RR

Rutledge, M.D., F.A.C.S.

The Center for Laparoscopic Obesity Surgery

4301 Ben lin Blvd.

Durham, N.C. 27704

Telephone #:

Fax #:

Email: DrR@...

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Imagine a 30 min. Outpatient cure for Obesity

August 27, 2000

In a message dated 08/27/2000 12:00:30 AM Eastern Daylight Time,

Dr_Rutledge@... writes:

<< It is also important to look at the actual size of the increased risk of

stomach cancer reported in the series that seem to find and increased risk

of stomach cancer in post gastrectomy patients. >>

I believe this should read " an. "

Janice

August 27, 2000

In a message dated 08/27/2000 12:00:30 AM Eastern Daylight Time,

Dr_Rutledge@... writes:

<< If either they or their

physicians are concerned it about gastric cancer it appears that very simple

dietary modifications can have a much greater impact on the patient's >>

I think you meant to remove the word " it. "

Janice

August 27, 2000

I loved your letter. It was informative and concise. Even I understood it.

It also made me question my southern tradition of bacon, smoked meats, etc.

Good Luck

Janice

August 27, 2000

Nahhh, I like the other version better. Sorry but they need a sting!

Lissa

August 28, 2000

Hi Dr. R,

I think this version of the letter sounds so much more positive than the last

version. I think it addresses the issue without personally addressing the

author of the original letter, which makes for a stronger response.

- waiting in Chicago