New Version of My Letter

[Guest guest]

To the Editors:

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

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

side of the body and then being consumed on the venous side. This was the

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

successfully challenged Galen's position showing that a fixed amount of

blood circulated around 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. One example of a well-done study looking at this issue and 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. That is they found that the rate of gastric cancer

in the surgery patients was actually lower than that seen in unoperated

controls.

Numerous 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 analyzed. Five hundred and seven of the group (83.5%) had a

Billroth II procedure. They concluded 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

total 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 there is

a serious flaw in these studies. In the studies that show slight increases

in the rate of gastric cancer following BII, all of these studies include

patients that have had the surgery for ulcer disease. The problem with this

type of study design is the fact that it has been well shown that gastric

ulcer is associated with gastric cancer. For example in a study by Molloy

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

studied among 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 was associated with 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 that ulcer patients have an increased

risk of gastric cancer. In the study by Hansson et. al. from Sweden

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

cancer in a large group of patients with ulcers was analyzed. 57,936

patients were followed for an average of 9.1 years. The rate of gastric

cancer among 29,287 patients with gastric ulcers was increased at 1.8.

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 surgery.

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

stomach cancer seen in the 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? Let us look at these issues to put these

studies in proper perspective.

Hundreds of articles have looked at factors that might affect the

development of gastric cancer. A large number of studies have indicated

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, strong evidence has been provided that high

consumption of fresh fruit and raw vegetables and a high intake of

antioxidants are associated with a reduced risk of gastric cancer. Overall,

it is evident that several factors (including diet, individual

susceptibility and H. pylori infection) interact in a complex multifactorial

process, leading over a long period of time to gastric cancer ([vi]). Now

with all of these factors where is post-gastrectomy positioned as a risk

factor?

Strong evidence 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 hundreds 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 is 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.

Thousands and thousands of patients undergo BII type gastrojejunostomy on a

yearly basis and it would seem his zeal in protecting the public against the

risk of the BII type anastomoses might more profitably be directed

elsewhere, at the thousands of general surgeons that routinely perform the

BII anastomoses on a daily basis. It seems odd for him to focus on this

relatively small subset of BII patients.

In fact it is obvious why he has chosen to misrepresent the medical

literature and or selectively present it in his letter. His real purpose is

revealed in the concluding remarks of his note where he says, " Minimal

invasive surgery . should improve and utilize the experience gained in open

surgery and not re-invent surgical techniques. " His real concern is that

the laparoscopic surgery has modified an open technique. Yet is that not

what all of us actually 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 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 1/3 to ¼ that charged by others. There are

no hernias, pulmonary emboli or episodes of DVT in the series 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.

----------------------------------------------------------------------------

----

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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Re: Please Help.

> In a message dated 8/26/2000 2:15:57 PM Eastern Daylight Time,

> Dr_Rutledge@... writes:

>

> << since these complications are not present in the series of

> MGB patients it should be obvious, even to Dr. Greve, that they are not

be

> the same operation. >>

>

> Dr. Rutledge... I read both letters and found yours to be both informative

> and well thought out. I don't know what kind of suggestions you were

> looking for, but in regards to 'typo's', here's one that I noticed.... "

> ..that they are not be the same operation. " Is the word 'be' an extra

word?

>

> Sorry, I'm a secretary by trade... I look for typos all days. )

>

> Robin

> Wife to Doug

> Mommy to Tyler, 4 yrs., and Brennan, 1 yr.

> Singer, wife, mom, secretary.. and not in that particular order.

>

>

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>