Billroth 2: Long Term Studies

 

The risk of oesophageal adenocarcinoma after gastrectomy for peptic ulcer disease
Jesper Lagergren a,b,*, Anna Lindam a
a Upper Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
b Division of Cancer Studies, King’s College London, United Kingdom
EUROPEAN JOURNAL OF CANCER 4 8 ( 2 0 1 2 ) 7 4 9 –7 5 2

The influence of bile reflux in the development of oesophageal adenocarcinomaremains controversial. This was tested in a cohort of patients who had undergonegastrectomy, a procedure often entailed by substantial bile reflux. After exclusion of all person-years the first year after surgery, the final gastrectomy cohort comprised of 19,767 patients. These patients were followed up for a median of17 years, and contributed with a total of 348,231 person-years at risk. The observed number of patients with oesophageal adenocarcinoma (n = 7) was not higher than the expected (n = 11.6), providing a standardised incidence ratio of 0.6 (95% CI 0.2–1.2). There were no clear differences between sexes, age groups or latency intervals after gastrectomy.
To summarise the results of the present study with the available previous research, there is not much support for an association between gastrectomy
and oesophageal adenocarcinoma, why the critical role of bile reflux in the aetiology of this tumour in humans must be questioned.
In conclusion, this population-based and nationwide Swedish cohort study with long-term follow-up of a large gastrectomycohort does not support the hypothesis that gastrectomyincreases the risk of oesophageal adenocarcinoma.

Cancer of the Nongastric Hollow Organs of the Gastrointestinal Tract After Gastric Surgery
Ravi Thiruvengadam, MD; Victoria Hench, MS; L. Joseph Melton III, MD; Eugene P. DiMagno, MD
Arch Intern Med 1988;148:405-407

To estimate the risk of esophageal, gallbladder, small bowel, and colon cancers after gastric surgery for benign disease, all 337 residents of Olmsted County, Minnesota, who had surgical treatment of benign peptic ulcer disease during the years 1935 through 1959, were followed up. The operation was a subtotal gastric resection with a Billroth II anastomosis in 214 patients and a subtotal gastric resection with a Billroth I anastomosis in 60 patients. Gastroenterostomy without resectionwasperformedin57patients,andsixpatientshad various other peptic ulcer operations. Patients were followed up for 6552 person-years of observation.
No esophageal cancers developed (0.8 were expected).
One small-bowel malignant neoplasm (0.2 were expected)
Two gallbladder cancers (1.1 was expected)
Four colon cancers (11.2were expected)
BUT these figures do not reflect a significant increase in the risk of these malignant neoplasms.
In particular, the relative risk of developing colon cancer was only 0.4 when this analysis had 88% power to detect a relative risk of two or more.
When the present investigation and two previous studies of this cohort were taken together, there was no strong evidence for an increased risk of any gastrointestinal cancer following gastric surgery.
In previous studies, no evidence was found of an increased risk of pancreatic cancer or cancer developing in the gastric stump after gastrectomy.
In this present study, we found no increased risk for cancer of the esophagus,gallbladder, small intestine, or colon following gastric surgery.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Risk of gastric cancer after Billroth II resection for duodenal ulcer

A. B. FISCHER, N. GRAM AND 0.M. JENSEN
Br. J. Surg. Vol. 70 (1983) 552-554
In a follow-up study of 1000 patients, who were subjected to Billroth 11resectionfor duodenal ulcer, the incidence and mortality of gastric carcinoma in a 22-30 year follow-up period were determined. Among the 423 survivors traced, 196 underwent gastroscopy and biopsy but carcinomas of the gastric remnant were not seen. Thus the prevalence was 0 , not significantly diflerent f r o m the expected prevalence of 0.3. From all 1000 patients only I3 cases of gastric carcinoma were identified. This is not significantly different from the expected number of 10.6 calculated by the life table method and indirectly standardized
for age, sex, place of residence and time. Even more than 15 years after operation the gastric cancer risk was only slightly increased
(observedlexpected = 7/4.8f I.48), but this was not signijicant statistically. Of522 deaths 13 were due to gastric carcinoma, which was not significantly diflerent from the expected number of 10.2.
These epidemiological data show that individuals subjected to Billroth 11 resection for duodenal ulcer hardly have a higher risk of gastric carcinoma than the general population within the first decades after operation. Thus proplylactic endoscopical monitoring will be unrewarding.


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 III, HIGGINS JA, ILSTRUP DM
N Engl J Med 309:1210-1213, 1983

To determine the long-term risk of gastric cancer in benign peptic ulcer disease, the authors studied 338 residents of Olmsted County, Minnesota, who had surgical treatment for benign peptic ulcer disease in the 25-year period of 1935-1959 and had no evidence of gastric cancer for 5 years after that surgery. The patients were subsequently followed for over 5635 person-years of observation. The risk of development of a gastric cancer in this group was compared with that expected on the basis of gastric cancer incidence rates for the local population. Carcinomas in the gas- tric remnant developed in only two of these patients, as compared with an expected 2.6 primary gastric carcinomas (relative risk, 0.8; 95% confidence interval, 0.1 to 2.7).

The authors conclude that there is no indication for endoscopic surveillance in asymptomatic patients with previous gastric surgery for benign peptic ulcer disease.

Twenty-five Years After Billroth II Gastrectomy for Duodenal Ulcer
Anders B. Fischer, M.D.
World J. Surg. Vol. 8, No. 3, June 1984

One thousand twenty-five patients underwent a Billroth II resection for duodenal ulcer between 1948 and 1956. The operative mortality rate was 2.4%. At follow-up between 22 and 30 years later, 522 had died and 423 patients were traced. Recurrent ulcer appeared in 2.6% of the cases. Postgastrectomy symptoms occurred with the following frequency: dumping 10%, diarrhea 5%, vomiting 7%, and pain 4%. Anemia developed in 18%, hypoalbuminemia and hypocalcemia in 40 and 15%, respectively. Eleven percent had lost more than 10 kg in weight. Tuberculosis was found in 3% of the cases. While 90% of the patients were satisfied with the result, 10% were failures. The overall mortality rate was significantly increased because of suicide.
Gastric carcinoma was the cause of death no more often than expected.
Carcinoma of the esophagus and stomach has attracted special attention [3, 16. 79-82], but like Ross et al. [69], Din and Small [68], and Clark [83], we found no increased risk of dying from carcinoma of the esophagus or the gastric remnant.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Invited Commentary
Lloyd M. Nyhus, M.D.
University of Illinois College of Medicine at Chicago, Illinois, U.S.A.
Cancer in the Retained Stump
Low acidity in the residual gastric stump is the goal of all gastrectomists in the treatment of duodenal ulcer disease. Achlorhydria or hypochlorhydria gives the connotation of increased risk for malig- nancy developing in the residual stomach. Concern has been voiced that after 11 to 20 years, a postgas- trectomy patient would be at increased risk for this eventuality [4].
Note that in the large number of patients reported here, no such long-term complication occurred. This agrees with the report of Schafer et al. [5], who found no increased incidence of gastric stump cancer in reviewing 5,635 person- years following gastrectomy.
Subtotal gastrectomy, ad modum Billroth II, con- tinues to be used extensively throughout the world today [6]. The report of Fischer lends support to the point of view of those who continue this time- honored practice.

The Incidence of Gastric Stump Cancer
Charles G. Clark, M.D., Ch.M., F.R.C.S., Michael W.N. Ward, B.M., F.R.C.S., Alexander M. McDonald, M.B., F.R.C.S., and Frank I. Tovey, M.S., F.R.C.S.
Department of Surgery, Faculty of Clinical Sciences, University College London, The Rayne Institute, London, United Kingdom
World J. Surg. 7, 236-240, 1983

A prospective study, consisting of annual interview, has been carried out on 225 patients who had a partial gastrectomy between 1955 and 1960, a follow-up of between 22 and 27 years. Seventy-seven patients have died during followup, with an accurate cause of death known in 71. One
patient died of gastric stump cancer 17 years after a Polya gastrectomy for duodenal ulcer, representing the only stomach cancer in this series. This is an incidence of 0.44%
as compared to an incidence of 0.1% for the general population of similar age.
We have reviewed the literature with regard to the incidence of gastric stump cancer. This review and our own
data suggest that the incidence is sufficiently low to make annual endoscopy of asymptomatic post-gastrectomy patients unjustified. This conclusion may well need qualification if it becomes possible to define premalignant changes in gastric mucosa from endoscopic biopsy, so that a high-risk subpopulation can be identified.