Re: “Endoscopic Features of Background Gastritis Associated With Remnant Gastric Cancer: A Multicenter Retrospective Study”

Dear Editor:

We read with great interest the multicenter study by Ohashi et al. [1] on the endoscopic features of remnant gastritis associated with remnant gastric cancer (RGC) after distal gastrectomy. The authors identified anastomotic redness, red streaks, regular arrangement of collection venules (RAC) disappearance, and atrophic gastritis as significant risk factors and proposed a novel risk-scoring system. We commend this contribution to post-gastrectomy surveillance and would like to offer a few observations that may further refine its clinical utility.

One point worth considering is the diagnosis of Helicobacter pylori infection based solely on endoscopic findings according to the Kyoto classification, without confirmatory tests such as histopathology or the urea breath test. While the Kyoto classification performs reasonably well in the general population, its accuracy in the post-gastrectomy setting, where bile reflux and anatomical changes may distort mucosal features, perhaps requires further validation [1,2]. A recent review also reported that the diagnostic accuracy in the remnant stomach warrants additional investigation [3]. Incorporating objective H. pylori testing in future prospective studies may help verify the reliability of the endoscopic criteria in this specific population.

The risk-scoring model does not appear to account for the reconstruction method, although the authors’ own data showed that anastomotic findings were significantly less common after Roux-en-Y (R-Y) than after Billroth I/II. Patients with Billroth II have a relatively higher baseline risk of bile reflux and anastomotic inflammation; however, the scoring system assigns the same points regardless of reconstruction. A randomized controlled trial confirmed that R-Y reconstruction significantly reduced reflux and epigastric pain without compromising survival [4]. It may be beneficial to consider incorporating the reconstruction method as a modifying variable to improve personalized risk stratification.

Furthermore, the timing of H. pylori eradication may influence the risk of atrophic gastritis and RAC disappearance. A 15-year follow-up study demonstrated that eradication after subtotal gastrectomy improves gastric cancer-specific survival, but the benefit appeared most pronounced when performed before the development of advanced atrophic changes [5]. Therefore, capturing a detailed H. pylori treatment history, including eradication timing and success, in future time-to-event analyses may help to better assess risk, as delayed eradication may not fully reverse the risk associated with established atrophy.

Again, we thank the authors for their insightful work and believe that addressing these considerations could enhance the clinical utility of the RGC risk-scoring system.