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Mini-Gastric Bypass

Dr Robert Rutledge and the ‘Mini-Gastric Bypass’ (Part 2)

Rutledge argues that the most popular procedure today, the sleeve gastrectomy, has been shown in some studies to have a post sleeve acid reflux rate (GERD) of some 20 to 30%

In the second part of his interview, Dr Robert Rutledge discusses some of the misunderstandings and criticisms of the MGB, specifically the fear of cancer and bile reflux gastritis and oesophagitis…

“While there is no question that when we do the Billroth II loop, there is an increase in bile in the stomach. This is exactly the same as in tens of thousands similar general surgical Billroth II procedures done all around the world every year. The Billroth II is routinely carried out in the abdomen each year for peptic ulcer disease, gastric cancer and trauma. General, trauma and oncologic surgeons are not raising fears about the Billroth II. It seems to odd me that bariatric surgeons are the only ones concerned with the bile of the Billroth II.”

He stated that there is now excess of 100 MGB studies by surgeons from all over the world, which that show that the incidents of bile reflux is very low, about 1%. And when the complication of bile reflux does occur it is almost trivial and so easy to manage by a knowledgeable MGB surgeon.

In comparison, when one looks at the complications from a sleeve, such as a leak or the internal hernia rates of the Roux-en-Y, he thinks the fears and concern about bile reflux is overstated.

Rutledge argues that the most popular procedure today, the sleeve gastrectomy, has been shown in some studies to have a post sleeve acid reflux rate (GERD) of some 20 to 30%. “Since we know that such forms of acid reflux is cause of oesophageal cancer, does this mean we are creating a whole generation of people with a lifetime risk of cancer?” he asks.

As to the surgeons who raise concerns about gastric cancer and the Billroth II, he cited surveys of hundreds of bariatric surgeons that found the less informed a bariatric surgeon was about general surgery, Billroth II and gastric cancer, the greater was the surgeon’s fear of gastric cancer.

“Oncologic gastric cancer surgeons know a little more about the data related to the risk of gastric cancer and the use of the Billroth II, than the average bariatric surgeon,” he stated. “Oncologic gastric cancer surgeons - even in areas of the greatest gastric cancer risk in the world such as China and Korea - routinely use the Billroth II and publish series of subjecting their patients to Billroth II procedures. So my question is, ‘Would cancer surgeons use a procedure that would pose any risk of contributing to the risk of gastric cancer in a gastric cancer patient?’

“I do not mind if my colleagues want to have a discussion about cancer. If you have a MGB patient, you can look for Helicobacter pylori and treat it you are worried about gastric cancer. However, in my opinion the sleeve is creating moderate to severe acid reflux with oesophagitis in a moderate to large percentage of patients. We know that this is a pre-cancerous and a potential cause of oesophageal cancer.”

He acknowledged that in some ways the past fears of gastric cancer are understandable because it is true that some older studies did indeed show a small increase in the risk of gastric cancer in patients who had been operated upon for peptic ulcer with a Billroth II. Notably, there are also a number of studies that showed no increased risk even when followed 20 to 30 years after the Billroth II. Again, confusion can mislead the individual who is not conversant with the details of the medical literature on the subject.

There are a few studies showing a small increased association of patients receiving a Billroth II and later increased risk. But, he said, it is important to remind colleagues that these studies demonstrate an ‘association’ and do not show that the Billroth II is in any way ‘causative’.

“The question we should be asking is, ‘Why were these large groups of patients undergoing the Billroth II in the first place? The answer may be prefaced by a review of recent studies of gastric cancer and its’ relation to the bacteria H. Pylori. In the not too distant past the bacteria H. Pylori was identified as both an etiologic factor in peptic ulcers and, more importantly for this discussion, it has been recognied as a primary cause of gastric cancer. H. Pylori is now known to be a causative factor of both peptic ulcer (especially gastric ulcer) and gastric cancer.”

“At the moment we only have limited data for the sleeve. In 20 years’ time, we could see acid reflux rates as high as the 50%. If bariatric surgeons are worried about cancer, I think they should be much more worried about the long term oesophagitis being reported in sleeve patients, which is an unequivocal precursor to cancer.”

Rutledge explained that those few studies showing a small lifetime increased risk of gastric cancer in Billroth II patients received a Billroth II operation for peptic ulcer disease or for early gastric cancer. Patients were selected because they had a disease that is commonly caused by H. Pylori (a primary cause of gastric cancer). therefore, it is not surprising that patients who were likely infected with a primary cause of gastric cancer, might be at slightly higher long term risk of gastric cancer? It is not the Billroth II, it is the H. Pylori.

“If you compare the slight increased risk of gastric cancer 20-30 years after Billroth II to the increased risk of gastric cancer in patients with an ulcer, they are both the same. So the Billroth II does not seem to be additive, rather it simply identifies patients with ulcer and possibly with H. Pylori.”

He said it seems obvious that if gastric cancer was a significant risk then long term screening of some kind might be recommended to look for early detection of gastric cancer. In fact, this issue has been addressed in several studies in which thousands of post op Billroth II patients were evaluated with post-operative endoscopy. The studies found that a few gastric cancers were identified but the rate was at, or less, than the rate in the general population. So screening endoscopy can be done on post Billroth II patients but the value is no better than simple screening the general population.

“I do not mind if my colleagues want to have a discussion about cancer. If you have a MGB patient, you can look for Helicobacter pylori and treat it you are worried about gastric cancer. However, in my opinion the sleeve is creating moderate to severe acid reflux with oesophagitis in a moderate to large percentage of patients. We know that this is a pre-cancerous and a potential cause of oesophageal cancer. At the moment we only have limited data for the sleeve. In 20 years’ time, we could see acid reflux rates as high as the 50%. If bariatric surgeons are worried about cancer, I think they should be much more worried about the long term oesophagitis being reported in sleeve patients, which is an unequivocal precursor to cancer.”

Click here to read Dr Robert Rutledge and the ‘Mini-Gastric Bypass’ (Part 1)

Click here to read Dr Robert Rutledge and the ‘Mini-Gastric Bypass’ (Part 3)

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