Is Helicobacter Pylori Associated with an Increased Complication Rate after Sleeve Gastrectomy?

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.

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.

Histopathological Findings in Turkish Patients Undergoing Sleeve Gastrectomy: Is Histopathologic Examination of Sleeve Gastrectomy Specimens Clinically Important?

PURPOSE

Sleeve gastrectomy (SG) is a widely used surgical method in the treatment of obesity. This study aimed to reveal the histopathological changes in SG materials and to investigate the prevalence of clinically important lesions requiring follow-up.

MATERIALS AND METHODS

Three hundred five patients' data who underwent SG were analyzed. Cases were divided into three groups as normal, chronic inactive gastritis (CIG), and chronic active gastritis (CAG). Age, gender, and body mass index (BMI) of the three groups and the differences in the gastritis parameters of CIG and CAG groups were compared.

RESULTS

Thirty-three patients (10.8%) were in the normal group, 145 (47.5%) were in the CIG group, and 127 (41.6%) were in the CAG group. Preoperative endoscopic examination was performed in all cases, but Helicobacter pylori (HP) treatment was not applied. HP were detected in 39.3%, atrophy in 3.9%, intestinal metaplasia (IM) in 4.9%, and lymphoid follicle (LF) in 30% of the cases. Inflammation, atrophy, IM, LF, and HP were significantly higher in the CAG group. The proton pump inhibitor (PPI)-related changes were seen in 20 cases and it was more frequent in the CIG group. Intramucosal signet ring cell carcinoma was detected in 1 case. Endocrine cell hyperplasia and dysplasia were present in 7 cases with CAG. Multiple grade 1 neuroendocrine tumors were detected in just 1 case.

CONCLUSION

In our SG specimens, HP and clinically important lesions were significantly higher in the CAG group. Pathological examination should be carefully done as the lesions detected in SG specimens can change patient management.

DO HELICOBACTER PYLORI INFECTION AND ERADICATION THERAPY STATUS INFLUENCE WEIGHT LOSS OUTCOMES AND ENDOSCOPIC FINDINGS AFTER ROUX-EN-Y GASTRIC BYPASS?A HISTORICAL COHORT STUDY

BACKGROUND

Currently, there is conflicting evidence linking Helicobacter pylori (HP) infection with weight loss and endoscopic findings after Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

To identify correlations between HP infection and its eradication with weight loss and endoscopic findings after RYGB.

METHODS

This is an observational retrospective cohort study based on a prospectively collected database of individuals who underwent RYGB from 2018-2019 at a tertiary university hospital. HP infection and the HP eradication therapy outcomes were correlated with post-operative weight loss and endoscopic findings. Individuals were classified according to the status of HP infection into four groups: no infection; successful eradication; refractory infection; and new-onset infection.

RESULTS

Of 65 individuals, 87% were female and the mean age was 39±11.2 years. Body mass index significantly decreased from 36.2±3.6 to 26.7±3.3 kg/m2 one year after RYGB (P<0.0001). The percentage of total weight loss (%TWL) was 25.9±7.2% and the percentage of excess weight loss was 89.4±31.7%. HP infection prevalence decreased from 55.4% to 27.7% (p=0.001); 33.8% never had HP infection, 38.5% were successfully treated, 16.9% had refractory infection and 10.8 % had new-onset HP infection. %TWL was 27.3±7.5% in individuals who never had HP, 25.4±8.1% in the successfully treated, 25.7±5.2% in those with refractory infection, and 23.4±6.4% in the new-onset HP infection group; there were no significant differences among the four groups (P=0.6). Pre-operative HP infection significantly associated with gastritis (P=0.048). New-onset HP infections significantly associated with a lower frequency of jejunal erosions after surgery (P=0.048).

CONCLUSION

No effects of the HP infection on weight loss were identified in individuals undergoing RYGB. A higher prevalence of gastritis was observed in individuals with HP infection before RYGB. New-onset HP infection after RYGB was a protective factor for jejunal erosions.

The evaluation of the relationship between Helicobacter pylori infection and frequency of postoperative complications of laparoscopic sleeve gastrectomy in Shahid Bahonar Hospital in Kerman between 2018 and 2020; a cross-sectional study

Introduction

Among the bariatric surgery procedures, laparoscopic sleeve gastrectomy (LSG) is one of the most common methods for effective and permanent weight loss among patients with severe obesity. Nonetheless, the LSG can be associated with long-term and short-term complications for the patient. The present study is aimed to investigate the effect of Helicobacter pylori on the complications of LSG, to answer the question of whether eradication of Helicobacter pylori in patients undergoing surgery can be effective in reducing postoperative complications.

Methods

In the present analytical-cross sectional study, which has been conducted in Shahid Bahonar Hospital in Kerman during 2018–2020, a total of 100 patients (including 38 males and 62 females) with an average age of 34.8 ± 2.4 years and an average BMI of 41.1 ± 3.1 underwent LSG surgery. After the operation, the gastric mucus specimens were taken from all patients for pathological examination of Helicobacter pylori infection.

Results

According to the results, 28 patients (28%) tested positive for Helicobacter pylori infection (HP positive), and 72 patients (72%) tested negative in this regard (HP negative). The results indicated no significant1 difference between the HP positive and HP negative patients in terms of demographic characteristics (age, gender, BMI). Overall, 11 patients (11%) exhibited postoperative complications of the LSG including 7 cases (7%) of the SSI, 2 cases (2%) of intraoperative2 bleeding, and 2 cases (2%) of leakage [No mortality was reported]. Out of the 11 patients with postoperative complications, 6 patients were HP positive including 4 cases of SSI, 1 case of bleeding, and 1 case of leakage.

Conclusions

As indicated by the obtained results, the HP infection has seemingly no impact on the LSG postoperative complications. Nevertheless, it is necessary to conduct further studies on a larger number of patients with a longer follow-up time focusing on the effect of other parameters, such as BMI and underlying diseases.

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Laparoscopic sleeve gastrectomy (LSG) is one of the most common surgical methods for effective and permanent weight loss among patients with morbid obesity.

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The LSG surgery can be associated with long-term and short-term complications for the patient.

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Approximately 30%–50% of patients are infected by Helicobacter pylori and this can be related to LSG postoperative complications.

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This study reveals no significant difference between the two HP+ and HP- groups in terms of the frequency of short-term postoperative complications of the LSG surgery.

Gastric Histopathologic Findings in South Italian Morbidly Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: Is Histopathologic Examination of All Resected Gastric Specimens Necessary?

BACKGROUND

The value of the routine histopathologic examination of resected gastric remnants following laparoscopic sleeve gastrectomy (LSG) remains to be controversial. This study aimed to determine whether the routine histopathologic examination of gastric specimens is necessary for all patients undergoing LSG if upper gastrointestinal endoscopy (UGIE) plus multiple biopsies are performed routinely during the preoperative work-up.

MATERIALS AND METHODS

Clinicopathologic data of 474 patients who underwent LSG were analysed. Types of histopathologic findings in LSG specimens and the prevalence of these and Helicobacter pylori (HP) infection were estimated. Comparisons were conducted to assess the association of risk factors with the most frequent abnormal and premalignant histopathologic findings.

RESULTS

Chronic gastritis was the most common gastric pathology (63.5%) and premalignant lesions were present in 7.8% of the specimens. The prevalence of HP infection was 36.9%. A statistically significant association was observed between HP infection and chronic gastritis (P = .000), and premalignant lesions (P = .000). Similarly, a statistically significant association was noted between age and premalignant gastric lesions (P = .000).

CONCLUSION

Histopathologic examination of LSG specimens may not be routinely needed and can be performed on selected patients. While we recommend routine preoperative UGIE in all LSG-treated patients, we suggest that histopathologic assessment of the LSG specimens should be mandatory when UGIE biopsies demonstrate HP infection and/or premalignant lesions, in all patients older than 42 years, and in cases of intraoperative detection of incidental tumours or suspicious lesions.

Histologic and Cost-Benefit Analysis of Laparoscopic Sleeve Gastrectomy Specimens Performed for Morbid Obesity

CONTEXT.—

Laparoscopic sleeve gastrectomy (LSG) has quickly become the bariatric surgical procedure of choice for patients with obesity who have failed medical management. Laparoscopic sleeve gastrectomy results in a gastric remnant that is routinely subject to pathologic examination.

OBJECTIVE.—

To perform a histologic and cost-benefit analysis of gastric remnants post-LSG.

DESIGN.—

All LSG cases performed at University Health Network, Toronto, Ontario, Canada, between 2010 and 2019 were reviewed. Specimens that underwent routine histopathologic assessment and ancillary immunohistochemical analysis were analyzed. Baseline patient characteristics and surgical outcomes were obtained from our internal database. The total cost of specimen gross preparation, examination, sampling, and producing and reporting a hematoxylin-eosin slide was calculated.

RESULTS.—

A total of 572 patients underwent LSG during the study period and had their specimens examined histologically. A mean of 4.87 blocks generating 4 hematoxylin-eosin slides was produced. The most common histologic findings reported in LSG specimens ranged from no pathologic abnormalities identified together with proton pump inhibitor-related change. A minority of cases demonstrated clinically actionable histologic findings, of which Helicobacter pylori infection was the most common. The total cost for the complete pathologic analysis of these cases amounted to CaD $66 383.10 (US $47 080.21) with a mean of CaD $116.05 (US $82.40) per case. A total of CaD $62 622.75 (US $44 413.30) was spent on full examination of cases that had no further postoperative clinical impact.

CONCLUSIONS.—

There is a broad spectrum of pathologic findings in LSG specimens, ranging from clinically nonactionable to more clinically actionable. The vast majority of histologic findings had no clinical impact, with only a minority of cases being clinically significant. This study therefore recommends that LSG specimens be subject to gross pathologic examination in the vast majority of cases. However, sections should be submitted for microscopic analysis if grossly evident lesions are present and if there is a clinical/known history of clinically actionable findings.

Helicobacter pylori Prevalence in Laparoscopic Sleeve Gastrectomy Specimen

Introduction

Laparoscopic sleeve gastrectomy (LSG) has become a common surgical procedure. The value of routine histopathologic examination of the LSG specimens remains, however, a controversial issue. Helicobacter pylori was the most prevalent finding in several previous studies, but the overall results were dissimilar. We aim to assess the prevalence of Helicobacter pylori and other histopathologic findings in LSG specimens and the effect of increasing the number of sections for histology, from LSG specimens, on the rates of abnormal findings.

Methods

We retrospectively reviewed the histopathologic data of all patients who had undergone LSG, in a tertiary care center, over a 4-year period (n = 481). Patient characteristics and histopathologic findings were recorded and analyzed.

Results

Inactive chronic gastritis was the most common histopathologic finding (62.16%) followed by Helicobacter pylori gastritis (35.34%). Intestinal metaplasia was identified in 1.66% of the cases. There was no diagnosis of malignancy. Increasing the number of sections submitted for histopathologic examination resulted in a significantly higher rate of H. pylori gastritis detection.

Conclusion

Routine histopathologic examination of LSG specimens may detect H. pylori in a significant proportion of patients, and increasing the number of sections for histology from LSG specimens improves the rate of detection of this bacterium and identifies individuals who may benefit from treatment.

Review of pathological findings in laparoscopic sleeve gastrectomy specimens performed for morbid obesity

BACKGROUND

Bariatric surgical procedures are employed when there is a failure of lifestyle modification in arresting obesity. Laparoscopic sleeve gastrectomy (LSG) is quickly becoming the bariatric surgical procedure of choice. LSG results in a gastric remnant that is subject to pathological examination. The objective of this paper is to review the literature in regard to histological findings identified in gastric remnants post-LSG and identify the most pertinent histological findings.

MATERIALS AND METHODS

A literature search was performed to identify relevant case series. Data gathered from relevant case series then underwent statistical analysis.

RESULTS

The most common histological findings in an LSG specimen were clinically indolent findings such as no pathological abnormalities identified followed by non-specific gastritis. A minority of cases demonstrated clinically actionable findings for which Helicobacter pylori represented the majority of these findings.

CONCLUSION

There is a broad spectrum of pathological findings in LSG specimens, ranging from clinically indolent to clinically actionable. The most common histological findings are clinically indolent and only a small portion are of clinical significance and, hence, actionable.

Does Helicobacter pylori infection influence the major postoperative complication rate after sleeve gastrectomy? A retrospective cohort study in an endemic region

BACKGROUND/AIMS

Helicobacter pylori infection is very common in Eastern countries. Little is known about the impact this infection has on bariatric surgery outcomes. This retrospective cohort study conducted on obese Turkish adults who underwent sleeve gastrectomy at a single center aimed to determine the prevalence of H. pylori infection and the effect of this infection on the rate of early major postoperative complications.

MATERIALS AND METHODS

All consecutive patients who underwent sleeve gastrectomy for obesity between 2014 and 2015 and who had complete data were enrolled. A single surgeon performed all procedures. All resected specimens were sent to pathology for analysis.

RESULTS

Of the 460 patients who met the eligibility criteria, 326 (71%) were female. The average (±standard deviation) age and body mass index were 37.5±10.0 years and 42.7±7.7 kg/m2, respectively. Histology revealed that 150 (33%) patients had H. pylori infection. The H. pylori-infected group developed two complications (leakage and intra-abdominal collection). The uninfected group developed three complications (all bleeding related). The two groups did not differ significantly regarding postoperative complication rates (1.3% vs. 1.0%; p=0.717).

CONCLUSION

H. pylori infection did not affect the rate of early complications after sleeve gastrectomy. This suggests that H. pylori screening or eradication policy is not essential for asymptomatic candidates who have undergone sleeve gastrectomy.

Is it necessary to perform full pathologic review of all gastric remnants following sleeve gastrectomy?

BACKGROUND

This study attempts to determine if enough pathological abnormalities in gastric remnants from sleeve gastrectomy exist to warrant full pathologic evaluation in all remnants.

METHODS

Data was collected on patients undergoing sleeve gastrectomy between 08/01/2011 and 06/30/2014. Significant abnormalities were classified as any pathology that might require follow-up or treatment beyond standard follow-up. Age, comorbidities, gender, and Helicobacter pylori titers were analyzed and compared with pathology specimens using 95% confidence intervals and Phi contingency coefficients.

RESULTS

Full pathologic evaluation was available for 351/387 patients (91.2%). No examples of malignancy or dysplasia were identified. Gastritis was the most common abnormality. There was a statistically significant association between preoperative H. pylori and significantly abnormal pathology (p = 0.003). Other comorbidities had no association.

CONCLUSIONS

These results suggest that full pathologic evaluation of the gastric remnant following sleeve gastrectomy is unnecessary, particularly when gross pathology is not noted at initial operation.