Abstract
Introduction: Few studies have reported the prevalence and consequences of infection with Helicobacter pylori among obese patients undergoing sleeve gastrectomy. This study reviewed whether infection with H. pylori has any association with postoperative complications. This study also examined whether there was any difference in postoperative percent excess weight loss (%EWL).
Materials and Methods: In this retrospective study, the pathology reports of 400 patients who underwent sleeve gastrectomy between 2008 and 2013 at the authors' institution were reviewed. Data examined included the demographics, perioperative and postoperative complications, and %EWL in the follow-up period.
Results: In 68 of 400 patients (17%), H. pylori was positive in the specimen. In the H. pylori negative group, 332 patients were eligible for follow-up. No perioperative and postoperative (30 days) complications were registered in the H. pylori positive group. There was one postoperative leak in the H. pylori negative group. No other complications were reported in patients during the 36 months follow-up. There were no significant differences between groups in terms of %EWL during postoperative follow-up.
Conclusions: In this study, the prevalence of H. pylori infection among sleeve gastrectomy patient was 17%. H. pylori did not seem to have any influence on postoperative outcomes or %EWL. H. pylori did not increase perioperative complications.
Introduction
Sleeve gastrectomy (SG) has already proved to be a safe and feasible procedure with good postoperative results and improvement in comorbidities.1 Helicobacter pylori infection has been associated with several pathologic changes such as gastritis and ulcers, and has also been implicated in gastric malignancies such as mucosa-associated lymphoid tissue (MALT) lymphoma.2–4
The prevalence of H. pylori infection is 30–50% in the United States.5 Among bariatric surgery patients tested preoperatively, studies report a prevalence ranging from 20% to 50%.6,7 Understanding the effects of H. pylori infection, specifically among the obese population, is of utmost importance. However, there have been few reported studies that have tried to link postoperative complications with H. pylori infection.6,7
The purpose of this study was to analyze the prevalence of infection in the patient population (reported in the histology examination from the gastric specimen), and whether there was any association with postoperative complications (gastritis, ulcers, leaks) after minimally invasive SG and the presence of H. pylori. Secondarily, the authors also examined whether there was any difference in outcome related to postoperative percent excess weight loss (%EWL).
Material and Methods
This study was a retrospective review of a prospectively maintained database with 400 patients who underwent a minimally invasive SG—either laparoscopic or robot assisted—at the University of Illinois Hospital and Health Sciences System between January 2008 and December 2013. This study was conducted under Institutional Review Board approval.
All patients met the standard eligibility criteria for bariatric surgery. Specifically, following the National Institutes of Health, patients had a body mass index (BMI) >35 kg/m2 with weight loss recalcitrant to nonsurgical measures with two or more comorbidities, or had a BMI ≥40 kg/m2 without comorbidities.8 All patients received a medical supervised diet and formal psychological evaluation to assess commitment and potential for adherence.
The following variables were obtained from the electronic medical records obtained from University of Illinois Hospital and Health Sciences System: age, gender, height, weight, BMI, operative time, length of hospitalization, peri- and postoperative complications, Helicobacter pylori test via specimen, and %EWL at 6, 12, 24, 36, and >36 months. Data on comorbidities such as hypertension, type 2 diabetes, gastroesophageal reflux disease (GERD), dyslipidemia, and sleep apnea were also obtained. Patients were divided in two groups regarding the H. pylori testing. Statistical analysis was performed to determine differences between both groups regarding preoperative BMI, peri- and postoperative complications, length of stay, and %EWL at the aforementioned time intervals.
Preoperative evaluation
Patients received a preoperative evaluation by a bariatrician, a medically supervised diet, and a psychological examination. Subsequently, patients were also assessed by the bariatric surgery team to determine eligibility and potential complications. The preoperative evaluation includes a barium swallow test mainly to address anatomy and to rule out large hiatal hernia, large polyps, severe GERD, gastric pathology, and tumors. The preoperative evaluation does not routinely include endoscopy or H. pylori serology.
Intraoperative management
Standard antibiotic and antithrombotic prophylaxis were provided. Either laparoscopic or robotic-assisted SGs were performed.
Postoperative management
Patients started ambulation a few hours after the procedure. On postoperative day 1, an oral tolerance trial was performed with most patients being discharged on postoperative day 2. A postoperative barium swallow test was not routinely performed. In some patients, a barium swallow was used if patients complained of intractable nausea or vomiting after postoperative day 1. This was performed to rule out complication (mainly stricture).
The test for H. pylori was performed on the stomach specimen. If the results were positive, patients were advised in the outpatient clinic to undergo treatment with triple therapy lasting 10 days.
Data analyses
Data analyses were conducted using SPSS Statistics for Windows v22.0 (IBM Corp., Armonk, NY). Comparisons between groups were performed with independent sample Student's t-test for continuous variables and Fisher's test for discrete variables. Confidence intervals were set at 95%, and a two-sided p-value of <0.05 was considered statistically significant.
Results
Demographics and medical characteristics
Data were collected from 330 women (83.7%) and 70 men (16.3%). The mean age was 41 years (range 18–70 years).
Patients were divided in two groups (positive or negative) regarding H. pylori testing. A total of 68 (17%) patients tested positive for H. pylori via the postoperative histopathology report. The mean BMI in H. pylori positive patients was 51.5 kg/m2 (SD 8.1); in the H. pylori negative group, the mean BMI was 50.6 kg/m22 (SD 8.6). In the H. pylori positive group, 68 patients were eligible for follow-up, and 27, 22, 11, 15, and 2 patients were followed up at 6 months, 1 year, 2 years, 3 years, and >3 years respectively. In the H. pylori negative group, 332 patients were eligible for follow-up, and 153, 97, 40, 12, and 19 patients were followed up at 6 months, 1 year, 2 years, 3 years, and >3 years respectively.
There were 10 smokers in the series. The incidence of H. pylori in the smoking population was 10%, showing no correlation with complications in the subgroup. Regarding nonsteroidal anti-inflammatory drugs (NSAIDs), 127 patients in the population had arthritis, and they were prescribed NSAID medication prior to surgery. No association was observed regarding complications after SG with H. pylori and the use of NSAID medications.
There were no significant differences between groups in terms of comorbidities, as summarized in Table 1.
Table 1.
Preoperative Patient Demographics and Comorbidities (N=400)
| Helicobacter pylori positive | H. pylori negative | p-Value | |
|---|---|---|---|
| Gender (female) | 59 | 271 | 0.428 |
| Gender (male) | 9 | 61 | 0.428 |
| Age in years | 42.4 (SD 10.2) | 41.3 (SD 10.8) | 0.437 |
| Initial BMI in kg/m2 | 51.5 (SD 8.2) | 50.6 (SD 8.6) | 0.446 |
| Diabetes | 20 (29.4%) | 122 (36.0%) | 0.299 |
| Hypertension | 32 (47.1%) | 175 (51.3%) | 0.521 |
| Dyslipidemia | 18 (26.5%) | 103 (30.5%) | 0.510 |
| GERD | 9 (15.3%) | 80 (25.6%) | 0.087 |
| Sleep apnea | 24 (35.3%) | 108 (32.0%) | 0.591 |
| Tobacco | 2 (2.9%) | 8 (2.4%) | 0.78 |
BMI, body mass index; GERD, gastroesophageal reflux disease; SD, standard deviation.
There were no perioperative, early postoperative (30 days), or long-term complications registered in the H. pylori positive group. In the H. pylori negative group, there was one complication. One patient had a suture leak on postoperative day 5 that required a reoperation, drainage, and a stent placement. The patient recovered without any further complications. The sole patient with a leak had no history of H. pylori or eradication treatment.
There were no significant differences between groups regarding complications and mortality rate (0%). There were no long-term complications reported in the patients during the time of follow-up (Table 2).
Table 2.
Perioperative Outcomes (N=400)
| H. pylori positive (n=68) | H. pylori negative (n=332) | p-Value | |
|---|---|---|---|
| Mean operative time | 77.5 min (SD 24.1) | 86.2 min (SD 24.6) | 0.41 |
| Early complications (30 days postop) | 0 (n=68) | 1 leak (n=332) | |
| Mortality | 0 | 0 | |
| Mean length of stay | 2.7 days (SD 0.9) | 2.9 days (SD 3.9) | 0.59 |
The mean operative time in the H. pylori positive group was 77.5 min (SD 24.1 min), and in the H. pylori negative group it was 86.2 min (SD 24.6 min) with no significant differences (p=0.41). The mean length of stay in the H. pylori positive group was 2.7 days (SD 0.9), and in the H. pylori negative group it was 2.9 days (SD 3.9) with no significant differences (p=0.59)
There were no significant differences in the mean %EWL at 6, 12, 24, 36, and >36 month follow-up between the two groups. Data are summarized in Table 3.
Table 3.
%EWL in H. pylori Positive Group Versus H. pylori Negative Group at Different Times of Follow-up
| Follow-up | H. pylori positive (n=68) | H. pylori negative (n=332) | p-Value |
|---|---|---|---|
| Mean %EWL at 6 months | 39.6% (27) | 44.0% (153) | 0.346 |
| Mean %EWL at 1 year | 50.1% (22) | 51.4% (97) | 0.102 |
| Mean %EWL at 2 years | 47.8% (11) | 51.3% (40) | 0.304 |
| Mean %EWL at 3 years | 27.6% (15) | 53.9% (12) | 0.068 |
| Mean % EWL at >3 years | 30.2% (2) | 42.6% (19) | 0.243 |
Values are described as percentage of percentage of excess weight loss (number of patients seen).
%EWL, percentage of excess weight loss.
Discussion
The prevalence of H. pylori in the obese population has been reported to be about 20–50%,6,7,9 which is higher than the prevalence in the patient population of this study (17%). The effect of H. pylori on weight loss after bariatric surgery was not significant according to Azuma and Nwokolo.10,11 They correlated the presence of H. pylori and hormones levels (ghrelin and leptin) and showed no significant differences in terms of weight loss.
Although the current study does not involve hormones levels, the presence of H. pylori did not show any difference in %EWL at different times of follow-up (Table 3).
Regarding complications associated with H. pylori, some authors have found that preoperative infection is associated with marginal ulcers in patients undergoing a Roux-en-Y gastric bypass.9,12 Knowing the potential changes that this may cause, it is possible that histological consequences from H. pylori may be related to certain complications after bariatric surgery. A comparison of patients with and without marginal ulcers within 10 months after surgery demonstrated that marginal ulceration was more common among patients who tested positive for H. pylori even when adequately treated.12 Other studies looking at complications following gastric bypass surgery in patients with H. pylori infection also suggest some relation between postoperative complications and the presence of H. pylori.9,13 Although this may imply a benefit to preoperative screening and treatment, there are also conflicting studies. One study found no association with H. pylori seropositivity and postoperative ulcer formation after gastric bypass.14 Similarly, Rawlins et al. looked at complication rates of gastric bypass patients who tested positive for H. pylori preoperatively and found no significant difference with those who tested negative.15
When looking at complications after SG and H. pylori infection there were two reports in the literature that showed no statistically relation.6,7 One study including 89 SG patients demonstrated a prevalence of H. pylori of 44% based on specimen analysis. This series did not demonstrate a statistically significant relationship with regard to postoperative complications.6 In a larger study consisting of 682 patients who underwent SG, 7.8% were found to be H. pylori positive.7 The authors analyzed several complications, including leak, neuropathy, bleeding, and pulmonary embolism. The authors reported five cases (0.8%) of postoperative leak, with only one patient being H. pylori positive, suggesting no relation with H. pylori. Other complications, such as neuropathy (1.2%), were not associated with the presence of H. pylori.7
The present study corroborates these results, demonstrating that complications were not associated with H. pylori. There was no clear association between H. pylori and postoperative complications, especially leaks or ulcers, during the time of follow-up.
Conclusion
The prevalence of H. pylori in this study was 17%, which is lower than that found in previous studies. According to the findings, H. pylori status does not seem to have any influence on postoperative complications and %EWL. This may, however, be due to the limited sample size. Larger studies may therefore be needed in the future. In the authors' experience, preoperative screening of H. pylori is not routinely recommended for patients undergoing a SG.
Acknowledgments
We thank our bariatric team for their patience and support. This paper was presented as a poster at the Obesity Week Conference in Boston, MA on November 2014.
Author Disclosure Statement
No competing financial interests exist.
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