The Association of Helicobacter pylori, Eradication, and Early Complications of Laparoscopic Sleeve Gastrectomy

Long-Term Outcomes of Patients with Staple Line Leaks Following Sleeve Gastrectomy

PURPOSE

The long-term outcomes of patients with staple line leaks (SLL) after SG are under-reported. The purpose of this study is to evaluate the long-term outcomes of patients with SLL after SG.

MATERIALS AND METHODS

A retrospective analysis of a maintained patient registry of patients undergoing SG between January 2012 and December 2020 in a single bariatric center was analyzed and included patients with SLL. Outcomes were compared to a group without SLL.

RESULTS

During this period, 1985 patients underwent SG of which 61 patients (3.1%) developed leak. 26 patients (1.3%) had overt SLL and the rest had organ space infection around the staple line. The mean age and body mass index (BMI) were 39.8 ± 11.3 and 41.5 ± 4.7, respectively. 7 patients (11.4%) underwent concomitant surgery and 12 patients (19.7%) had intraoperative complications. Leak was complicated by Clavien-Dindo ≥ 3 in 31 patients (50.8%). Reoperation rate was 27.8% (n = 17). ≥ 2 interventions were required in 26% of patients (n = 16). Two patients died during hospitalization due to septic complications. Long-term follow-up of median 121 months was available in 78% of the cohort (n = 48). The median total weight loss and BMI were 27% and 30.1 kg/m2, respectively. Weight loss outcomes were higher in comparison to patients without SLL. Seven patients (14.6%) underwent SG revision. All associated medical problems improved during follow-up except for gastroesophageal reflux which was found in 50% of cohort.

CONCLUSION

Long-term outcomes of SG patients with SLL are satisfactory in terms of weight loss, resolution of comorbidities, and requirement for surgical revision.

A comparison of staining methods for Helicobacter pylori in laparoscopic vertical sleeve gastrectomy resections

BACKGROUND

Helicobacter pylori is an important public health concern due to its status as a carcinogenic bacterium. Well adapted to the acidic environment of the human stomach, the variety of strains and virulence factors of the organism when interacting with the host immune system creates an individualistic response. Although estimates suggest that approximately half of the global population is infected with H pylori, the majority of infected persons remain asymptomatic while harboring an increased risk of intestinal metaplasia and gastric cancers. Therefore, appropriate diagnostic testing protocols are imperative.

METHODS

This study compared labeling methodologies, including Wright stain, alcian yellow toluidine blue (AYTB), and immunohistochemistry (IHC) on formalin-fixed paraffin-embedded stomach resections from sleeve gastrectomy patients, to detect H pylori infection.

RESULTS

Although all 3 labeling methods evidenced similar specificity in H pylori detection, the IHC method was significantly more sensitive. However, the IHC cost per test was approximately 5-fold higher than that of the Wright or AYTB stains, and the technical time required per test was at least 6-fold that of Wright or AYTB.

CONCLUSION

Despite the higher cost per test, IHC is the most sensitive and preferred method for determination of H pylori infection.

The presence of H. pylori in laparoscopic sleeve gastrectomy specimens is associated with increased mucosal thickness, presence of secondary follicles, increased chronic inflammation, and intestinal metaplasia

Helicobacter pylori is putatively present in over half of the global human population and is recognized as a carcinogenic agent that increases the likelihood of infected patients developing gastric adenocarcinoma or gastric lymphoma. Although there are several means for testing for H. pylori, the gold standard remains the invasive histologic evaluation. The current most popular form of bariatric surgery is the laparoscopic sleeve gastrectomy (LSG) and is the only bariatric surgery which supplies a specimen for histologic evaluation. While non-invasive testing is effective in diagnosing and monitoring H. pylori infection, histological examination of biopsies and resections is the only way to grade chronic inflammation and evaluate specimens for additional pathologies such as intestinal metaplasia. The investigators evaluated 203 sequential LSG specimens collected from a major metropolitan hospital over the period of one year. Specimens were processed to paraffin, stained with hematoxylin and eosin, alcian blue, and immunohistochemistry to determine the presence of H. pylori, chronic inflammation, presence of secondary lymphoid follicles in the mucosa, mucosal thickness, and presence of intestinal metaplasia. Statistical analyses demonstrated a significant positive correlation among all factors examined. The overall positivity rate of H. pylori in LSG specimens was 18.2% but ranged from 6.9-23.8% depending on whether the treating clinician performed routine pre-surgical endoscopy. The presence of H. pylori was associated with a higher average chronic inflammation grade, intestinal metaplasia, thicker mucosa, and presence of lymphoid follicles with germinal centers in the mucosa.

IMPACT OF HELICOBACTER PYLORI ON EARLY POSTOPERATIVE COMPLICATIONS AFTER SLEEVE GASTRECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

The impact of Helicobacter pylori (HP) on postoperative outcomes after sleeve gastrectomy (SG) is still controversial. A systematic review and meta-analysis were performed to compare the incidence of early complications after SG between HP-positive and HP-negative patients. Eight retrospective comparative studies were included, comprising 4,877 individuals. The prevalence of HP infection in gastric resected specimens ranged from 7.77 to 43.20%. There were no statistically significant differences between groups for overall complications (OR 1.46; 95%CI 0.95-2.23; p=0.08), bleeding (OR 1.35; 95%CI 0.70-2.60; p=0.38), and leak (OR 1.74; 95%CI 0.80-3.81; p=0.17) rates. The need for routine screening and treatment of HP infection before SG remains ambiguous.

Impact of Helicobacter pylori Status on Postoperative Morbidities After Laparoscopic Sleeve Gastrectomy in an Endemic Region (a Retrospective Multicentric Study)

PURPOSE

Studies are still ongoing to determine whether Helicobacter pylori (HP) may affect the results of laparoscopic sleeve gastrectomy (LSG). The main research objectives were HP prevalence in patients with severe obesity and the effects of HP status on outcomes.

PATIENTS AND METHODS

This multicenter retrospective study included patients with severe obesity who had LSG. The patients were grouped into three groups based on the HP status of preoperative endoscopic biopsies and postoperative specimen results: group I (negative HP), group II (eradicated HP), and group III (positive HP). The primary outcome was the overall postoperative morbidities.

RESULTS

One thousand six hundred fifteen patients who underwent LSG for severe obesity were included in this study. Seven hundred fifty (46.4%) patients had negative HP, and 637 (39.4%) patients had eradicated HP, whereas 228 (14.1%) patients had positive HP. The antral and gastric body wall thickness was significantly noticed with positive HP. The groups had no significant differences regarding postoperative complication frequency, severity, and hospital mortality. The rates of gastric leakage in the three groups do not differ significantly. BMI > 50, gastropexy, gastric thickness, and antral resection were found to be independent risk factors for the occurrence of postoperative complications after LSG. There was no statistical significance as regards postoperative %TWL and %EWL among the three groups.

CONCLUSION

The early results of LSG do not appear to be impacted by HP's status. The early postoperative course is unaffected by HP eradication anymore. Therefore, routine preoperative HP testing may not be as necessary, and management can be finished after LSG.

The Impact of Helicobacter pylori on Laparoscopic Sleeve Gastrectomy Postoperative Complications: a Systematic Review and Meta-analysis

We aimed to assess the impact of Helicobacter pylori infection on postoperative outcomes following laparoscopic sleeve gastrectomy (LSG). We searched Cochrane, Scopus, and PubMed databases, reviewed 1026 studies, and thoroughly analyzed 42 of them. Our final analysis included 13 studies comprising 6199 patients. We found that H. pylori infection was correlated with higher rates of risk of overall postoperative complications (OR 1.56; 95% CI 1.13, 2.16; P = 0.007) and staple line leak (OR 1.89; 95% CI 1.05, 3.41; P = 0.03). There were no significant differences in hospital length of stay or postoperative bleeding rates. Despite observed correlations between H. pylori positivity in gastric specimen and postoperative complications in LSG, definitive causation remains elusive, emphasizing the need for prospective randomized studies evaluating the effect of preoperative H. pylori screening and eradication.

The Effect of Revisional One Anastomosis Gastric Bypass After Sleeve Gastrectomy on Gastroesophageal Reflux Disease, Compared with Revisional Roux-en-Y Gastric Bypass: Symptoms and Quality of Life Outcomes

BACKGROUND

Gastroesophageal reflux disease (GERD) is common after sleeve gastrectomy (SG). We aimed to evaluate the effect of revisional one anastomosis gastric bypass (OAGB) on GERD, compared with revisional Roux-en-Y gastric bypass (RYGB) METHODS: A retrospective single-center study of a prospectively maintained patient registry (2018-2022). All patients with GERD undergoing OAGB and RYGB after SG were retrieved and included in the study.

RESULTS

Seventy-eight SG patients had conversion to OAGB (n=31) and RYGB (n=47). Baseline characteristics were similar except age (43.8±11.5 vs. 50.3±13.4 years; p=0.03), body mass index (39.9±8.8 vs. 30.6±6 kg/m2; p<0.001), time interval (8±2.7 vs. 6.4±3.4 years; p=0.01), and sleep apnea (29% vs 8.5%; p=0.01), respectively. There was no significant difference between groups in number of patients consuming proton pump inhibitors (70.1% vs. 72.3%; p=0.66), GERD-health-related quality of life (HRQL) score (9.6±7.2 vs. 13.1±8; p=0.06), and pathological endoscopic findings (48.4% vs. 46.8%; p=0.89). Major complication rates were 0% vs. 8.5% (p=0.09). At 32.4 months follow-up, total weight loss was 22%±12.9 and 4.4%±14.6 (p<0.001), GERD resolution 77.4% and 91.9% (p=0.03), HRQL scoring improved to 1.7±4.5 and 1.7±2.7; p=0.94 for OAGB and RYGB, respectively.

CONCLUSIONS

SG conversion to RYGB provides better chances for definitive treatment of GERD. OAGB results in good symptom resolution and improved quality of life and may be considered for post-SG GERD treatment. The most appropriate solution should be individualized to each patient.

Comparison of One Anastomosis Gastric Bypass and Sleeve Gastrectomy for Revision of Laparoscopic Adjustable Gastric Banding: 5-Year Outcomes

PURPOSE

Laparoscopic adjustable gastric banding (LAGB) is in continuous decline due to low effectiveness and high reoperation rates. This study aims to evaluate outcomes of converting LAGB to one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG) for insufficient weight loss or weight regain.

MATERIALS AND METHODS

Retrospective comparative study, based on prospective registry database of a tertiary center (2012-2019).

RESULTS

In all, 276 LAGB patients were converted to OAGB (n = 125) and SG (n = 151). Body mass index (BMI) at revision was 41.3 ± 6.6 and 42.3 ± 9.6 kg/m2 (P = 0.34) in OAGB and SG patients, respectively. Time interval was longer in OAGB patients (p < 0.001). Major early complication rates were comparable (2.4% and 4%; p = 0.46). At 5-years, OAGB patients had lower BMI (31.9 vs. 34.5 kg/m2; p = 0.002), and a higher total weight loss (25.1% vs. 18.8%; p = 0.003), compared with SG patients. Resolution of type 2 diabetes was higher in OAGB patients (93.3% vs. 66.6%; p = 0.047), while resolution of hypertension was not significantly different (84.6% and 80.5%; p = 0.68). Revision due to delayed complications was required in five (4%) OAGB patients and nine (8.6%) SG patients (p = 0.14).

CONCLUSION

OAGB for revision after LAGB due to insufficient weight loss or weight regain is safe, and has better effectiveness in weight reduction and resolution of type 2 diabetes than SG.

Safety of concomitant cholecystectomy during one anastomosis gastric bypass compared with sleeve gastrectomy and Roux-en-Y gastric bypass

Candidates of metabolic and bariatric surgery (MBS) are prone for gallstone formation. Concomitant cholecystectomy (CC) during MBS is controversial. This study is first to examine the safety of CC during one anastomosis gastric bypass (OAGB), compared with sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Single-center retrospective comparative study of CC (2012-2021) during OAGB, to SG and RYGB. CC was performed in 115 patients during OAGB (n = 50), SG (n = 39), and RYGB (n = 26). All procedures were completed laparoscopically. Baseline characteristics were similar except age, body mass index, gastroesophageal reflux disease, obstructive sleep apnea, and previous MBS (p < 0.05). Intraoperative complications occurred in one OAGB patient (2% vs. 0%, 0%; p = 0.52), which was not cholecystectomy related. There were no differences in total (6% vs. 2.6%, 15.4%; p = 0.13) and major (2% vs. 0%, 3.8; p = 0.50) early-complication rates. Of them, cholecystectomy-related complications occurred in one OAGB, compared with none of SG and one RYGB (2% vs. 0%, 3.8%; p = 0.50). The former was major, and the latter was minor complication. None of the OAGB patients needed re-admission (0% vs. 0%, 11.5; p = 0.04). All CC outcome parameters were similar between asymptomatic and symptomatic gallstones. Previous bariatric procedures were found to be a significant risk for major complications and readmissions (OR = 16.87, p = 0.019). CC during OAGB for gallstones seems safe, as in SG and RYGB. No cholecystectomy-related intraoperative complications occurred, and postoperative complication rates were low and acceptable. Outcomes for asymptomatic gallstones were similar to symptomatic ones, and we cautiously support CC in the presence of gallstones.

One Anastomosis Gastric Bypass Compared with Sleeve Gastrectomy in Elderly Patients: Safety and Long-term Outcomes

BACKGROUND

As life expectancy increases, more elderly patients are being considered for metabolic bariatric surgery. We aimed to assess the safety and long-term effectiveness of one anastomosis gastric bypass (OAGB) compared to sleeve gastrectomy (SG).

METHODS

Single-center retrospective comparative study of OAGB and SG (2012-2019) in patients aged ≥ 65 years.

RESULTS

In all, 124 patients underwent OAGB (n = 41) and SG (n = 83). Mean age was 67.6 ± 2.8 and 67.6 ± 2.6 years (p = 0.89), respectively. Baseline characteristics were comparable, except lower rates of hypertension (HTN) and non-alcoholic fatty liver disease in OAGB than SG patients (43.9% vs. 74.6%; p < 0.001, and 39.0% vs. 89.1%; p < 0.001, respectively). Body mass index (BMI) of OAGB and SG patients decreased from 41.8 ± 7.8 and 43.3 ± 5.9 kg/m² (p = 0.25) to 28.6 ± 4.7 and 33.2 ± 5.3 (p < 0.001), at long-term follow-up, respectively. Excess weight loss (EWL) > 50% was achieved in 80.6% and 43.2% of OAGB and SG patients, with a mean EWL of 67.2% ± 22.3 and 45.8% ± 18.0 (p < 0.001) and a mean total weight loss (TWL) of 30.7% ± 10.4 and 21.9% ± 8.1 (p < 0.001), respectively. Resolution rates of obesity-associated medical problems were similar, except type 2 diabetes (T2D) and HTN, which were 86.6% and 73.3% in OAGB, compared with 29.7% and 36.3% in SG patients (p < 0.001 and p = 0.001), respectively. Major early complication rates were comparable (2.4% vs. 3.6%; p = 0.73, respectively). Revision for late complications was required in two OAGB patients.

CONCLUSIONS

OAGB in the elderly is safe and results in better long-term weight reduction and resolution of T2D and HTN than SG.