OBES SURG DOI 10.1007/s11695-015-1687-6
ORIGINAL CONTRIBUTIONS
Outcomes in Patients with Helicobacter pylori Undergoing Laparoscopic Sleeve Gastrectomy Andrew R. Brownlee 1 & Erica Bromberg 1 & Mitchell S. Roslin 1,2
# Springer Science+Business Media New York 2015
Abstract Background In vertical sleeve gastrectomy (VSG), the majority of the stomach is resected and much of the tissue colonized with Helicobacter pylori and the bulk of acid producing cells are removed. In addition, the effect of H. pylori colonization of the stomach of patients undergoing stapling procedures is unclear. As a result, the need for detection and treatment of H. pylori in patients undergoing VSG is unknown. Methods Four hundred and eighty patients undergoing VSG are the subject of this study. Three surgeons at a single institution performed the procedures. The remnant stomach was sent to pathology and tested for the presence of H. pylori using immunohistochemistry. All patients were discharged on proton pump inhibitors. Results Of the 480 patients who underwent VSG, 52 were found to be H. pylori positive based on pathology. There was no statistically significant difference in age (p=0.77), sex (p=0.48), or BMI (p=0.39) between the groups. There were 17 readmissions post-op. Five of these were in the H. pylori positive cohort. Six of these complications were classified as severe (anastomotic leak, intra-abdominal collection, or abscess), with two in the H. pylori positive cohort (Table 1). There was no statistically significant difference in the severe complication rates between the two groups (p= 0.67). There were no readmissions for gastric or duodenal ulceration or perforation.
* Andrew R. Brownlee [email protected] 1
Department of Surgery, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10075, USA
2
Northern Westchester Hospital Center, Mt Kisco, NY, USA
Conclusions Our data suggests that there is no increase in early complications in patients with H. pylori undergoing VSG. If these findings are confirmed in a long-term followup, it would mean that preoperative H. pylori screening in patients scheduled for VSG is not necessary. Keywords Helicobacter pylori . Bariatric surgery . Vertical sleeve gastrectomy . Laparoscopic sleeve gastrectomy . Complications . Outcomes . Triple therapy . Microbiome . Lenox Hill Hospital . Obesity . Roux-en-Y gastric bypass . VSG . RYGB
Introduction Since it was first identified in the gastric mucosa by Marshall and Warren in 1982, Helicobacter pylori has altered the management and natural history of gastritis, peptic ulcer disease, and gastric cancer. It has been shown to be associated with approximately 50 % of mucosa-associated lymphoid tissue (MALT) cancers as well as iron and vitamin A, C, E, and B12 deficiencies [1, 2]. The prevalence of H. pylori in the developed world has been estimated to be as high as 85 %. In the general population, treatment of H. pylori is indicated in patients with peptic ulcer disease, low-grade mucosa-associated lymphoid tissue lymphoma, or atrophic gastritis [3]. Antimicrobial eradication has been shown to be effective in 50–80 % [4, 5] of cases and can cause resolution of 60–80 % of low-grade MALT lymphomas [4, 5]. As a result of this, eradication has increasingly become a common practice even in the asymptomatic patient. Recently, this approach has been questioned. A new wave of experts has expressed the opinion that H. pylori is an important member of the microbiome. Its absence has been associated with an increased prevalence of childhood allergies and asthma as well as esophageal carcinoma [6–21]. It has
OBES SURG
also been identified as a suppressor of ghrelin, a hormone that drives the hunger response [22–24]. The treatment of H. pylori infection in some individuals results in increased hunger, food consumption, and BMI [24, 25]. For patients undergoing bariatric surgery, numerous papers have discussed the importance of preoperative detection and eradication of H. pylori. In patients undergoing Roux-en-Y gastric bypass (RYGB), H. pylori has been implicated in the development of marginal ulceration [26]. In addition, because of the anatomy of post-RYGB patients, the stomach remnant is no longer accessible by standard endoscopic evaluation and could theoretically be at increased risk for undiagnosed gastric MALT lymphomas. Furthermore, marginal ulceration remains a source of morbidity following gastric bypass. For these reasons, preoperative or perioperative identification of H. pylori with treatment if detected has become standard. In fact, it has become a requirement for certification by several insurance companies. Vertical sleeve gastrectomy (VSG) is the fastest growing bariatric procedure performed worldwide. It involves the resection of about 85 % of the greater curvature of the stomach. As a result, the majority of tissue potentially colonized or infected with H. pylori is removed. In addition, the majority of acid-producing cells are resected and as opposed to gastric bypass, the risk of marginal ulceration is negated. To date, there is no definitive data on the management of H pylori following VSG. Some have suggested that gastric mucosal inflammation and edema secondary to H. pylori infection may interfere with staple line formation leading to an increased risk of leak, bleed, or infection [27, 28]. On the other hand, it has been shown that despite a high prevalence of H. pylori in found in immunohistochemical staining of excluded stomachs, the post-operative prevalence of H. pylori is low by a urea breath test [28]. As a result, it has become our practice to not treat patients that undergo VSG and are found to have H. pylori in their resected specimen.
18 years of age or older and met the NIH guidelines for bariatric surgery. All patients underwent a preoperative visit, educational seminar, preoperative labs, and an upper gastrointestinal series study (UGIS) as part of the Lenox Hill Hospital Center of Excellence standard of care. No other preoperative H. pylori screening modality was employed. All revisional surgeries were excluded. All surgical procedures were performed at the Lenox Hill Hospital by three surgeons. All were completed laparoscopically. The technique for VSG has been well described. The greater curvature blood supply is taken with a power energy source and transection of the stomach with a stapling device. All cases were performed over 36 French bougies, with transection beginning 3–5 cm from the pyloric valve. Care was taken to preserve the angularis incisura. The staple line is terminated just distal to the gastroesophageal junction, on the gastric side. All sleeves were oversewn with 2–0 PDS suture, and buttress material was not utilized. The remnant stomach was sent to pathology for analysis. The presence of H. pylori was determined using immunohistochemical staining, a widely accepted and highly specific modality. If H. pylori was detected, antibiotic treatment was not commenced. All patients were discharged on a proton pump inhibitor for 30 days. Post-operatively, everyone was followed and monitored according to our standard guidelines for VSG. Any patient who had a post-operative complication or was readmitted within 30 days of surgery was captured using the Lenox Hill Hospital electronic medical record system. Complication or readmission diagnoses were determined based on the imaging and chart review. These diagnoses were separated into major (anastomatic leak, intra-abdominal fluid collection, and abscess) and minor (pain, dehydration, colitis/enteritis, and others). All distributional data was analyzed using the t test and all categorical data was analyzed using the chi squared test.
Methods Results Four hundred and eighty patients who underwent VSG between January 2011 and April 2013 as a primary procedure were included in this retrospective study. All patients were
Of the 480 patients who underwent VSG, 52 were found to be H. pylori positive based on examination of the pathological
Table 1 Reason for readmission post vertical sleeve gastrectomy separated by H. pylori status as determined by pathological examination of the excised gastric mucosa Major
Minor
H. pylori status
Leak
Abscess/collection
Colitis/enteritis
Pain
Dehydration
Other
Total
Positive Negative
1 0
1 (1.9 %) 5 (1.2 %)
0 2 (0.4 %)
1 1
1 (1.9 %) 3 (0.7 %)
1 (1.9 %)a 1 (0.2 %)b
5 12
a
Patient admitted for hemorrhoidal bleeding
b
Patient admitted for portal vein thrombosis
OBES SURG
specimen. The average BMI of the H. pylori negative and H. pylori positive groups were 47.0 and 48.2, respectively. Twenty percent of the patients in the H. pylori positive group were male while 30 % of the H. pylori negative group were male. The average age of the H. pylori negative and H. pylori positive groups were 40.2 and 40.7, respectively. There was no statistically significant difference in age (p=0.77), sex (p= 0.48), or preoperative BMI (p=0.39) between the two groups. There were no complications prior to discharge. There were a total of 17 post-operative readmissions in the first 30 days. Five of these were in the H. pylori positive cohort with the remainder in the H. pylori negative cohort. The reasons for readmission are shown in Table 1. Six of these complications were classified as major, with two in the H. pylori positive cohort and four in the H. pylori negative cohort. There was no statistically significant difference in the severe complication rates between the two groups (p = 0.67). There were no readmissions for gastric or duodenal ulceration or perforation.
Conclusions The discovery of H. pylori and its role in pathologic conditions such as peptic ulcer disease, gastritis, and gastric cancer has caused radical changes in the field of medicine. Treatment of H. pylori has made ulcer surgery and recurrent ulceration far less common. Secondary to these successful outcomes, it has become a widely held belief that H pylori is a pathogen and if detected, should be eradicated. Recent evidence has questioned this practice. Furthermore, as the discovery of the role of H. pylori in disease is recent, we do not know the long-term ramifications of its elimination from the bacterial community. In potential bariatric surgery patients, detection and treatment of H. pylori has become the standard practice. This practice has expanded to the VSG despite the fact that no study has demonstrated that screening and eradication of H. pylori is beneficial in an asymptomatic population. Preoperative detection comes at a cost and can delay surgery. This information combined with the gastric resection that occurs in VSG made us question this practice and not treat patients when H. pylori was detected in their surgical specimen. Now with over 3 years of data and followup, we know of no single case that failure to treat or eradicate H. pylori resulted in complication. Additionally, our study strongly shows no short-term increase in perioperative complications in patients that are colonized. As VSG emerges as the most common bariatric procedure, there may be changes in practice patterns. As a result of concerns of post-operative ulceration and the need to examine portions of the stomach that would be difficult in post-RYGB patients, preoperative endoscopy with H pylori detection became a common practice. Despite the absence of data, many have extrapolated this standard to VSG. Our data suggests that
H pylori surveillance is unnecessary. Even if detected in the operative specimen, treatment is likely not needed. It is our expectation that the prophylactic eradication of H pylori will become less prevalent and treatment is reserved for those with pathologic conditions. Interestingly, our detected rates of H pylori are at the low level of expected prevalence in the general population. It is important to point out that all specimens were examined specifically for the presence of the bacteria with immunohistological stains. Thus, the low prevalence is probably secondary to the impact of eradication in the New York metropolitan area, rather than under detection. Whether or not this practice is beneficial or deleterious may take generations to determine. In this study, we sought to address two different questions. The first is a perioperative management question regarding the effect of the presence of H. pylori colonization in patients undergoing bariatric surgery and whether there is an effect on post-operative outcomes. In this paper, we have shown provocative evidence that H. pylori has no effect on these outcomes. The second is an epidemiological question, regarding the management of H. pylori in the asymptomatic patient population. Our 3-year follow-up shows no adverse outcomes related to H. pylori colonization in the untreated post-sleeve gastrectomy population. To appropriately address this question, however, longer follow-up is required. There were some limitations to this study that must be discussed. The cohort size of 480 patients yielded 52 H. pylori positive patients, which is lower than expected for this sample size, as discussed. The low number of H. pylori positive patients limits the power of this study. With all retrospective studies, there is an inherent risk of the influence of confounding variables.
Disclosures Dr. Roslin is an educational consultant for Johnson & Johnson and Covidien. He is also on the scientific advisory board for SurgiQuest. Dr Brownlee and Ms. Bromberg have no conflicts of interest or financial ties to disclose. Human Rights All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
References 1.
2.
3.
Vitale G, Barbaro F, Ianiro G, et al. Nutritional aspects of Helicobacter pylori infection. Minerva Gastroenterol Dietol. 2011;57(4):369–77. Chey W, Wong CY, et al. Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 2007;102:1808–25. Crowe SE. Helicobacter infection, chronic inflammation, and the development of malignancy. Curr Opin Gastroenterol. 2005;21:32.
OBES SURG 4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14. 15.
Huang JQ, Sridhar S, Chen Y, et al. Meta-analysis of the relationship between Helicobacter pylori seropositivity and gastric cancer. Gastroenterology. 1998;114:1169. Eslick GD, Lim LL, Byles JE, et al. Association of Helicobacter pylori infection with gastric carcinoma: a meta-analysis. Am J Gastroenterol. 1999;94:2373. Matricardi PM, Rosmini F, Riondino S, et al. Exposure to foodborne and orofecal microbes versus airborne viruses in relation to atopy and allergic asthma: epidemiological study. BMJ. 2000;320:412–7. Kosunen TU. Increase of allergen-specific immunoglobulin E antibodies from 1973 to 1994 in a Finnish population and a possible relationship to Helicobacter pylori infections. Clin Exp Allergy. 2002;32:373–8. McCune A, Lane A, Murray L, et al. Reduced risk of atopic disorders in adults with helicobacter pylori infection. Eur J Gastroenterol Hepatol. 2003;15:637–40. Linneberg A. IgG antibodies against microorganisms and atopic disease in Danish adults: the Copenhagen allergy study. J Allergy Clin Immunol. 2003;111:847–53. Jarvis D, Luczynska C, Chinn S, et al. The association of hepatitis A and Helicobacter pylori with sensitization to common allergens, asthma and hay fever in a population of young British adults. Allergy. 2004;59:1063–7. Radon K. Farming exposure in childhood, exposure to markers of infections and the development of atopy in rural subjects. Clin Exp Allergy. 2004;34:1178–83. von Hertzen LC, Laatikainen T, Makela MJ, et al. Infectious burden as a determinant of atopy—a comparison between adults in Finnish and Russian Karelia. Int Arch Allergy Immunol. 2006;140:89–95. Janson C. The effect of infectious burden on the prevalence of atopy and respiratory allergies in Iceland, Estonia, and Sweden. J Allergy Clin Immunol. 2007;120:673–9. Chen Y, Blaser MJ. Inverse associations of helicobacter pylori with asthma and allergy. Arch Intern Med. 2007;167:821–7. Herbarth O et al. Helicobacter pylori colonisation and eczema. J Epidemiol Community Health. 2007;61:638–40.
16.
Shiotani A, Kamada T, Kusunoki H, et al. Helicobacter pylori infection and allergic diseases. Nihon Rinsho. Japanese J Clin Med. 2009;67(12):2352–6. 17. Chen Y, Blaser MJ. Helicobacter pylori colonization is inversely associated with childhood asthma. J Infect Dis. 2008;198(4):553– 60. doi:10.1086/590158. 18. Bodner C, Anderson WJ, Reid TS, et al. Childhood exposure to infection and risk of adult onset wheeze and atopy. Thorax. 2000;55:383–7. 19. Tsang KW, Lam WK, Chan KN, et al. Helicobacter pylori seroprevalence in asthma. Respir Med. 2000;94:756–9. 20. Jun ZJ, Lei Y, Shimizu Y, et al. Helicobacter pylori seroprevalence in patients with mild asthma. Tohoku J Exp Med. 2005;207:287–91. 21. Peek RM, Blaser MJ. Helicobacter pylori and gastrointestinal tract adenocarcinomas. Nat Rev Cancer. 2002;2:28–37. 22. Osawa H. Ghrelin and helicobacter pylori infection. World J Gastroenterol. 2008;14(41):6327–33. 23. Méndez-Sánchez N, Pichardo-Bahena R, Vásquez-Fernández F, et al. Effect of helicobacter pylori infection on gastric ghrelin expression and body weight. Rev Gastroenterol Mex. 2007;72:359–64. 24. Jang EJ, Park SW, Park JS, et al. The influence of the eradication of Helicobacter pylori on gastric ghrelin, appetite, and body mass index in patients with peptic ulcer disease. J Gastroenterol Hepatol. 2008;23 Suppl 2:S278–85. 25. Lane JA, Murray LJ, Harvey IM, et al. Randomised clinical trial: helicobacter pylori eradication is associated with a significantly increased body mass index in a placebo-controlled study. Aliment Pharmacol Ther. 2011;33:922–9. 26. Sapala JA, Wood MH, Sapala MA, et al. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Obes Surg. 1998;8:505–16. 27. Rasmussen JJ, Fuller W, Ali MR. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc. 2007;21(7):1090–4. 28. Keren D, Matter I, Rainis T, et al. Sleeve gastrectomy leads to helicobacter pylori eradication. Obes Surg. 2009;19:751–6.
ORIGINAL CONTRIBUTIONS
Outcomes in Patients with Helicobacter pylori Undergoing Laparoscopic Sleeve Gastrectomy Andrew R. Brownlee 1 & Erica Bromberg 1 & Mitchell S. Roslin 1,2
# Springer Science+Business Media New York 2015
Abstract Background In vertical sleeve gastrectomy (VSG), the majority of the stomach is resected and much of the tissue colonized with Helicobacter pylori and the bulk of acid producing cells are removed. In addition, the effect of H. pylori colonization of the stomach of patients undergoing stapling procedures is unclear. As a result, the need for detection and treatment of H. pylori in patients undergoing VSG is unknown. Methods Four hundred and eighty patients undergoing VSG are the subject of this study. Three surgeons at a single institution performed the procedures. The remnant stomach was sent to pathology and tested for the presence of H. pylori using immunohistochemistry. All patients were discharged on proton pump inhibitors. Results Of the 480 patients who underwent VSG, 52 were found to be H. pylori positive based on pathology. There was no statistically significant difference in age (p=0.77), sex (p=0.48), or BMI (p=0.39) between the groups. There were 17 readmissions post-op. Five of these were in the H. pylori positive cohort. Six of these complications were classified as severe (anastomotic leak, intra-abdominal collection, or abscess), with two in the H. pylori positive cohort (Table 1). There was no statistically significant difference in the severe complication rates between the two groups (p= 0.67). There were no readmissions for gastric or duodenal ulceration or perforation.
* Andrew R. Brownlee [email protected] 1
Department of Surgery, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10075, USA
2
Northern Westchester Hospital Center, Mt Kisco, NY, USA
Conclusions Our data suggests that there is no increase in early complications in patients with H. pylori undergoing VSG. If these findings are confirmed in a long-term followup, it would mean that preoperative H. pylori screening in patients scheduled for VSG is not necessary. Keywords Helicobacter pylori . Bariatric surgery . Vertical sleeve gastrectomy . Laparoscopic sleeve gastrectomy . Complications . Outcomes . Triple therapy . Microbiome . Lenox Hill Hospital . Obesity . Roux-en-Y gastric bypass . VSG . RYGB
Introduction Since it was first identified in the gastric mucosa by Marshall and Warren in 1982, Helicobacter pylori has altered the management and natural history of gastritis, peptic ulcer disease, and gastric cancer. It has been shown to be associated with approximately 50 % of mucosa-associated lymphoid tissue (MALT) cancers as well as iron and vitamin A, C, E, and B12 deficiencies [1, 2]. The prevalence of H. pylori in the developed world has been estimated to be as high as 85 %. In the general population, treatment of H. pylori is indicated in patients with peptic ulcer disease, low-grade mucosa-associated lymphoid tissue lymphoma, or atrophic gastritis [3]. Antimicrobial eradication has been shown to be effective in 50–80 % [4, 5] of cases and can cause resolution of 60–80 % of low-grade MALT lymphomas [4, 5]. As a result of this, eradication has increasingly become a common practice even in the asymptomatic patient. Recently, this approach has been questioned. A new wave of experts has expressed the opinion that H. pylori is an important member of the microbiome. Its absence has been associated with an increased prevalence of childhood allergies and asthma as well as esophageal carcinoma [6–21]. It has
OBES SURG
also been identified as a suppressor of ghrelin, a hormone that drives the hunger response [22–24]. The treatment of H. pylori infection in some individuals results in increased hunger, food consumption, and BMI [24, 25]. For patients undergoing bariatric surgery, numerous papers have discussed the importance of preoperative detection and eradication of H. pylori. In patients undergoing Roux-en-Y gastric bypass (RYGB), H. pylori has been implicated in the development of marginal ulceration [26]. In addition, because of the anatomy of post-RYGB patients, the stomach remnant is no longer accessible by standard endoscopic evaluation and could theoretically be at increased risk for undiagnosed gastric MALT lymphomas. Furthermore, marginal ulceration remains a source of morbidity following gastric bypass. For these reasons, preoperative or perioperative identification of H. pylori with treatment if detected has become standard. In fact, it has become a requirement for certification by several insurance companies. Vertical sleeve gastrectomy (VSG) is the fastest growing bariatric procedure performed worldwide. It involves the resection of about 85 % of the greater curvature of the stomach. As a result, the majority of tissue potentially colonized or infected with H. pylori is removed. In addition, the majority of acid-producing cells are resected and as opposed to gastric bypass, the risk of marginal ulceration is negated. To date, there is no definitive data on the management of H pylori following VSG. Some have suggested that gastric mucosal inflammation and edema secondary to H. pylori infection may interfere with staple line formation leading to an increased risk of leak, bleed, or infection [27, 28]. On the other hand, it has been shown that despite a high prevalence of H. pylori in found in immunohistochemical staining of excluded stomachs, the post-operative prevalence of H. pylori is low by a urea breath test [28]. As a result, it has become our practice to not treat patients that undergo VSG and are found to have H. pylori in their resected specimen.
18 years of age or older and met the NIH guidelines for bariatric surgery. All patients underwent a preoperative visit, educational seminar, preoperative labs, and an upper gastrointestinal series study (UGIS) as part of the Lenox Hill Hospital Center of Excellence standard of care. No other preoperative H. pylori screening modality was employed. All revisional surgeries were excluded. All surgical procedures were performed at the Lenox Hill Hospital by three surgeons. All were completed laparoscopically. The technique for VSG has been well described. The greater curvature blood supply is taken with a power energy source and transection of the stomach with a stapling device. All cases were performed over 36 French bougies, with transection beginning 3–5 cm from the pyloric valve. Care was taken to preserve the angularis incisura. The staple line is terminated just distal to the gastroesophageal junction, on the gastric side. All sleeves were oversewn with 2–0 PDS suture, and buttress material was not utilized. The remnant stomach was sent to pathology for analysis. The presence of H. pylori was determined using immunohistochemical staining, a widely accepted and highly specific modality. If H. pylori was detected, antibiotic treatment was not commenced. All patients were discharged on a proton pump inhibitor for 30 days. Post-operatively, everyone was followed and monitored according to our standard guidelines for VSG. Any patient who had a post-operative complication or was readmitted within 30 days of surgery was captured using the Lenox Hill Hospital electronic medical record system. Complication or readmission diagnoses were determined based on the imaging and chart review. These diagnoses were separated into major (anastomatic leak, intra-abdominal fluid collection, and abscess) and minor (pain, dehydration, colitis/enteritis, and others). All distributional data was analyzed using the t test and all categorical data was analyzed using the chi squared test.
Methods Results Four hundred and eighty patients who underwent VSG between January 2011 and April 2013 as a primary procedure were included in this retrospective study. All patients were
Of the 480 patients who underwent VSG, 52 were found to be H. pylori positive based on examination of the pathological
Table 1 Reason for readmission post vertical sleeve gastrectomy separated by H. pylori status as determined by pathological examination of the excised gastric mucosa Major
Minor
H. pylori status
Leak
Abscess/collection
Colitis/enteritis
Pain
Dehydration
Other
Total
Positive Negative
1 0
1 (1.9 %) 5 (1.2 %)
0 2 (0.4 %)
1 1
1 (1.9 %) 3 (0.7 %)
1 (1.9 %)a 1 (0.2 %)b
5 12
a
Patient admitted for hemorrhoidal bleeding
b
Patient admitted for portal vein thrombosis
OBES SURG
specimen. The average BMI of the H. pylori negative and H. pylori positive groups were 47.0 and 48.2, respectively. Twenty percent of the patients in the H. pylori positive group were male while 30 % of the H. pylori negative group were male. The average age of the H. pylori negative and H. pylori positive groups were 40.2 and 40.7, respectively. There was no statistically significant difference in age (p=0.77), sex (p= 0.48), or preoperative BMI (p=0.39) between the two groups. There were no complications prior to discharge. There were a total of 17 post-operative readmissions in the first 30 days. Five of these were in the H. pylori positive cohort with the remainder in the H. pylori negative cohort. The reasons for readmission are shown in Table 1. Six of these complications were classified as major, with two in the H. pylori positive cohort and four in the H. pylori negative cohort. There was no statistically significant difference in the severe complication rates between the two groups (p = 0.67). There were no readmissions for gastric or duodenal ulceration or perforation.
Conclusions The discovery of H. pylori and its role in pathologic conditions such as peptic ulcer disease, gastritis, and gastric cancer has caused radical changes in the field of medicine. Treatment of H. pylori has made ulcer surgery and recurrent ulceration far less common. Secondary to these successful outcomes, it has become a widely held belief that H pylori is a pathogen and if detected, should be eradicated. Recent evidence has questioned this practice. Furthermore, as the discovery of the role of H. pylori in disease is recent, we do not know the long-term ramifications of its elimination from the bacterial community. In potential bariatric surgery patients, detection and treatment of H. pylori has become the standard practice. This practice has expanded to the VSG despite the fact that no study has demonstrated that screening and eradication of H. pylori is beneficial in an asymptomatic population. Preoperative detection comes at a cost and can delay surgery. This information combined with the gastric resection that occurs in VSG made us question this practice and not treat patients when H. pylori was detected in their surgical specimen. Now with over 3 years of data and followup, we know of no single case that failure to treat or eradicate H. pylori resulted in complication. Additionally, our study strongly shows no short-term increase in perioperative complications in patients that are colonized. As VSG emerges as the most common bariatric procedure, there may be changes in practice patterns. As a result of concerns of post-operative ulceration and the need to examine portions of the stomach that would be difficult in post-RYGB patients, preoperative endoscopy with H pylori detection became a common practice. Despite the absence of data, many have extrapolated this standard to VSG. Our data suggests that
H pylori surveillance is unnecessary. Even if detected in the operative specimen, treatment is likely not needed. It is our expectation that the prophylactic eradication of H pylori will become less prevalent and treatment is reserved for those with pathologic conditions. Interestingly, our detected rates of H pylori are at the low level of expected prevalence in the general population. It is important to point out that all specimens were examined specifically for the presence of the bacteria with immunohistological stains. Thus, the low prevalence is probably secondary to the impact of eradication in the New York metropolitan area, rather than under detection. Whether or not this practice is beneficial or deleterious may take generations to determine. In this study, we sought to address two different questions. The first is a perioperative management question regarding the effect of the presence of H. pylori colonization in patients undergoing bariatric surgery and whether there is an effect on post-operative outcomes. In this paper, we have shown provocative evidence that H. pylori has no effect on these outcomes. The second is an epidemiological question, regarding the management of H. pylori in the asymptomatic patient population. Our 3-year follow-up shows no adverse outcomes related to H. pylori colonization in the untreated post-sleeve gastrectomy population. To appropriately address this question, however, longer follow-up is required. There were some limitations to this study that must be discussed. The cohort size of 480 patients yielded 52 H. pylori positive patients, which is lower than expected for this sample size, as discussed. The low number of H. pylori positive patients limits the power of this study. With all retrospective studies, there is an inherent risk of the influence of confounding variables.
Disclosures Dr. Roslin is an educational consultant for Johnson & Johnson and Covidien. He is also on the scientific advisory board for SurgiQuest. Dr Brownlee and Ms. Bromberg have no conflicts of interest or financial ties to disclose. Human Rights All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
References 1.
2.
3.
Vitale G, Barbaro F, Ianiro G, et al. Nutritional aspects of Helicobacter pylori infection. Minerva Gastroenterol Dietol. 2011;57(4):369–77. Chey W, Wong CY, et al. Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 2007;102:1808–25. Crowe SE. Helicobacter infection, chronic inflammation, and the development of malignancy. Curr Opin Gastroenterol. 2005;21:32.
OBES SURG 4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14. 15.
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16.
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