Sleeve Gastrectomy Specimens Research Articles

Frequency of Clinically Significant Findings in the Surgical Pathology Specimen Following Laparoscopic Sleeve Gastrectomy and Concordance with Preoperative Endoscopy: Insights from a Large Single-Center Experience.

Endoscopy prior to bariatric surgery is not always performed, and in sleeve gastrectomy (SG), the surgical specimen is not always sent for pathological examination. There is limited data on the frequency of clinically significant findings in SG specimens or correlation with preoperative endoscopy. We reviewed 426 consecutive SG patients to determine the concordance of preoperative endoscopy findings in patients with clinically significant postoperative pathology. Preoperative endoscopy was performed on 397 patients (93.2%). Three hundred seventy-three patients had preoperative endoscopy and surgical pathology results available. Then, 20/373 (5.4%) patients had potentially significant postoperative pathology, including intestinal metaplasia, autoimmune metaplastic atrophic gastritis (AMAG), gastrointestinal stromal tumors, and/or gastric cancer. The overall incidence of AMAG in the entire cohort was 2.3%. Preoperative gastric biopsies (to include gastric body) identified AMAG in nearly 1/2 of patients. Patients with clinically significant postoperative pathology results had a median [interquartile range] of 3 [3-5] tissue blocks examined as compared to 3 [1-3] for the remainder of the cohort (p < 0.001). This is one of the largest studies describing clinically significant postoperative pathology after SG. AMAG, in particular, is of particular importance as it is associated with a 3-fivefold increase in risk for gastric cancer. The incidence of significant postoperative pathology in this population is small but potentially clinically significant and requires validation in larger studies. We recommend wider sampling in preoperative endoscopy (body and antrum), especially in patients being planned for gastric bypass, consideration for routine pathological examination of SG surgical specimens, with careful gross examination and targeted sampling.

Gastric Submucosal Fat Accumulation Is Associated with Insulin Resistance in Patients with Obesity

PurposeEctopic fat accumulation plays a significant role in obesity-related metabolic dysfunction, and few studies have reported an association between ectopic gastric fat and metabolic risk factors. We aim to fulfill this need by assessing the degree of gastric submucosal fat accumulation in pathologic sections of 190 sleeve gastrectomy specimens.MethodsStudy patients were divided into two groups (D1 and D2) based on whether fat accumulation exceeded 1/3 of the submucosa of the stomach. Demographic and metabolic risk factors were compared between the two groups. Metabolic risk variables that might be associated with the degree of fat accumulation were screened in the original cohort. After balancing for possible confounders, the robustness of the correlations was assessed using binary and conditional logistic regression analyses.ResultsAll study patients had fat accumulation in the submucosa of the stomach. C-reactive protein (CRP), body mass index (BMI), visceral fat area (VFA), and insulin resistance (IR) were higher in the D2 group than in the D1 group in the original cohort (P < 0.05). Logistic regression analysis showed that BMI and IR may be associated with increased fat accumulation. After balancing variables other than obesity indicators and IR using propensity score matching, BMI and IR remained significantly different between the two groups (P < 0.05). Further analysis of the matched cohort using two logistic regression analyses showed that IR was an independent risk factor for increased fat accumulation.ConclusionThis study indicated that gastric submucosal fat accumulation was prevalent in patients with obesity and was associated with IR.Graphical

Is macroscopic evaluation sufficient in sleeve gastrectomy specimens?

Is macroscopic evaluation sufficient in sleeve gastrectomy specimens?

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

ABSTRACT 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.

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

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. 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. 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. 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.

SJLA_2024_A11: Histopathologic Evaluation of Tissue Resected Postsleeve Gastrectomy, to be done or Not?

Introduction: Obesity is one of the major lifestyle diseases and is associated with multiple comorbidities such as type 2 diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnea, and neoplasms. Bariatric surgeries are the most effective treatment for obesity. The cost-effectiveness of bariatric surgeries has become a major concern, and there is a shift toward avoiding histological evaluation of surgical specimens during routine procedures. Background: It is assumed that similar to other elective surgery specimens, gastrectomy specimens obtained in bariatric surgery would be normal, except for unexpected incidental findings. Here is a lack of published data on histopathological changes in gastric specimens from patients with morbid obesity. There are conflicting reports about the necessity of histopathological examination of bariatric surgery specimens. In Oman, the practice is to send all surgical specimens resected during sleeve gastrectomy for histopathologic evaluation despite in most of the centers, the practice is not to send in normal sleeve gastrectomy operations. Histopathological data are insufficient to describe the most common histopathological findings in laparoscopic sleeve gastrectomy specimens. Methods: All patients who underwent sleeve gastrectomy in Royal and Nizwa hospitals (tertiary hospitals in Oman) from January 2010 to December 2021 were included in the study. The data were collected from the medical records, and it includes baseline characteristics and histopathological findings. The data will be collected in Excel sheet. The analysis includes age, sex, body mass index (BMI), comorbidities, and the histopathological results. Results: The records of 759 patients were reviewed. 34.3% of the specimens were normal. The remaining of the specimens showed benign pathology. The most common benign pathologies were chronic gastritis 58.2%, H. Pylori-associated chronic gastritis 4.6 and chronic gastritis with metaplasia 1.7%. Discussion: This was a cross-sectional retrospective descriptive study. Statistical Package for the Social Science (SPSS) version 26 was used for analysis. Variables included age in years, sex, BMI, and histopathological findings were calculated as frequencies and percentages. Associations were assessed by t-test. P ≤ 0.05 was considered significant. The sample size was calculated using the n Master 2.0 calculator. Based on the expected common finding of chronic gastritis at 60%, 3.5%precision, and 95% confidence interval, we need to study a minimum of 753. The most prevalent histopathological finding is chronic gastritis 58.2%. This study’s results signify the null occurrence of malignancy in resected gastric specimens. There was no association between Helicobacter pylori and advanced age. There was no association between BMI and suspicious findings P value 0.293. Conclusion: The most prevalent histopathological finding is chronic gastritis. This study’s results signify the null occurrence of malignancy in resected gastric specimens. Routine histopathologic examination of all LSG specimens, particularly in the absence of suggestive clinical symptoms is not necessary. Finally, there is no association between BMI, gender, and age with suspicious findings.

Linear Identification of 8 or More Plasma Cells (PCs) in the Interfoveolar Areas (IFAs) of Sleeve Gastrectomies Is Highly Predictive ofHelicobacter pylori (H. pylori) Infection

Abstract Introduction/Objective Bariatric surgery for morbid obesity is dramatically increasing, and large number of sleeve gastrectomies is examined histopathologically. The GIPS guidelines recommend using a visual gestalt to identify substantial inflammation for prompting further ancillary testing for H. pylori microorganisms, and a recent study proposed an “Objective Visual Analog Scale” that justifies additional work-up for H. Pylori infection in gastric biopsies. Our study aims to establish a potential correlation between the number of plasma cells in the IFAs and the presence of H. pylori infection in sleeve gastrectomy specimens. Methods/Case Report We retrospectively reviewed 338 patients who underwent sleeve gastrectomy for morbid obesity at our institution from 2016-2021. Only 105 of 338 cases were included which demonstrated mild to marked lymphoplasmacytic infiltrate in the IFAs of the lamina propria on H&amp;E stain. The number of plasma cells identified in the more expanded IFAs of the lamina propria was assessed by “drawing an imaginary horizontal line” and the number of plasma cells under the “line” were counted. H. pylori immunostain was performed in all cases. Statistical analyses were performed using IBM SPSS statistics Version 26. Results (if a Case Study enter NA) H. pylori like organisms were identified in 49 of 105 cases (20 cases on H&amp;E stain and 29 cases on H. pylori immunostain). Receiver operator characteristic curve (ROC) showed that the identification of 8 or more plasma cells in expanded IFAs is both highly sensitive (93.9%; 46/49) and specific (83.9%; 47/56) for predicting H. Pylori infection with a positive predictive value of 83.6% (46/55) and area under the curve (AUC) of 0.94 (CI:0.89-0.99, p-value= 0.00). Conclusion In the light of above results, we propose that in sleeve gastrectomies specimens, in which H. pylori is not identified on H&amp;E sections, the linear identification of 8 or more plasma in the more expanded IFAs is highly predictive of H. pylori infection and justify additional workup for H. pylori infection.

Laparoscopic clips can be a safe buttressing method for the sleeve gastrectomy operations: An experimental study on resected sleeve gastrectomy specimens

Background/Aim: Laparoscopic sleeve gastrectomy has been accepted in obesity surgery, as it provides rapid weight loss and has low mortality rates. However, because of the long staple line, leakage is a significant problem for these patients. Buttressing methods can be used to reduce the leakage. The aim of this study was to evaluate the efficacy of clips for buttressing the staple line on resected sleeve gastrectomy patients.Methods: The study included 20 patients aged 18–60 years who underwent laparoscopic sleeve gastrectomy surgery in our clinic. Any patients with connective tissue disease or with the removed stomach tissue not intact were excluded from the study. The age, gender, height, weight, and additional disease data were recorded. A manual manometer and inflation mechanism was created, and when the pressure suddenly dropped and a bubble was observed from the staple line, this value was recorded as the leakage pressure. By measuring the leakage pressure in the staple line by inflating the resected and removed stomach, leakage pressure and leakage location were recorded as no-clip leakage pressure. Then, the observed area of leakage was buttressed with laparoscopic clips, and the leakage pressure was measured once more by inflating the stomach; this value was recorded as the clipped leakage pressure. Results: The first pressure value observed had a mean of 43.8mmHg (range, 35–55 mmHg); after application of the clips, the mean was 43.8 mmHg (range (40–50 mmHg) (P = 0.20). The leakage was located in the upper section in 14 (70%) cases, in the mid-section in 5 (25%) cases, and in the lower section in 1 (5%) case. Micro-leakage was observed in 15 (75%) cases, 1-mm leakage in 1 (5%) case, 2-mm leakage in 2 (10%) cases, and 3-mm leakage in 2 (10%) cases. Conclusion: Leakage is the most significant complication following sleeve gastrectomy surgery. The use of laparoscopic clips was described as a buttressing method, but no positive effect of metal clips on leakage pressure was observed in our study. Clarification of the effect of the buttressing with metallic clips is required using in vivo and ex vivo experiments.

Does Gastric Expansibility Affect Weight Loss Success After Laparoscopic Sleeve Gastrectomy?

Reduced excess weight loss (EWL) or regain is a worrying problem after metabolic surgery. Factors attainable from the resected specimen that can predict this outcome are investigated. We retrospectively analyzed 64 patients who had undergone laparoscopic sleeve gastrectomy. We collected demographic data, preoperative gastric emptying measurements, volume, expansion capacity, and 6-dimensional measurements of sleeve gastrectomy specimens. Correlations between EWL, body mass index levels, and gastric specimen measurements related to gastric remnant dimensions were also scrutinized. We found a significant correlation between the gastric specimen and remnant gastric volume, the resection line length in the gastric specimen, and 12th-month EWL%. Antrum expansibility was significantly increased in patients with weight regain. There was also a negative correlation between weight loss and age at postoperative first and third years. Sleeve resection line measurement and resected antrum diameter measurements can be used to predict weight loss, especially in the first year postoperatively.

Is Molecular Analysis Mandatory for Better Post-surgical Outcome in Sleeve Gastrectomy Specimens with Asymptomatic Helicobacter pylori Colonization? A Study from Pakistan

Background: Helicobacter pylori colonizes gastric tissue in obese patients and mostly remains undetected clinically, as histological and molecular analysis is seldom ordered in such cases. Objectives: This study aimed to detect the frequency of H. pylori using different techniques in sleeve gastrectomy specimens of obese patients with minimal or no symptoms suggestive of gastritis. Methods: This longitudinal study was carried out at Farooq Hospital Westwood Lahore, Morbid Anatomy and Histopathology Department and Resource Laboratory at the University of Health Sciences, Lahore, Pakistan, from February 2021 to September 2021. This study selected 80 cases who underwent sleeve gastrectomy within six months. Helicobacter pylori was detected by rapid urease test (RUT), modified Giemsa staining, and polymerase chain reaction (PCR) techniques. Results: Most patients (83.7%) were clinically asymptomatic, while 10% had mild and 6.3% had moderate to severe gastritis symptoms. Of the asymptomatic patients, 56.7% of biopsies showed chronic gastritis. Rapid urease test and modified Giemsa staining showed positive evidence for H. pylori in 47.3% of cases, whereas an additional 13.2% of biopsies that were negative on conventional methods showed the amplification of H. pylori DNA by PCR. Patients were discharged with proton-pump inhibitors therapy (40 mg/day) that showed no adverse post-surgical event over a follow-up of six months. Conclusions: Persistent obesity and other socioeconomic factors may lead to colonizing asymptomatic H. pylori infection. More sensitive techniques for detecting H. pylori may be employed in resource-constrained settings for better patient outcomes and to minimize the complications after sleeve gastrectomy.

Histopathological findings in laparoscopic sleeve gastrectomy specimens: Are pathological examinations necessary?

Histopathological findings in laparoscopic sleeve gastrectomy specimens: Are pathological examinations necessary?

Histopathological findings in laparoscopic sleeve gastrectomy specimens: Are pathological examinations necessary?

Objective: The objective of this study is to determine the prevalence of gastric histopathological findings in patients who underwent laparoscopic sleeve gastrectomy (LSG) in our hospital and to add more data to the published literature on the characteristics of the resected LSG samples. Material and Methods: The pathology reports of the patients were retrospectively analyzed to identify all patients with consecutive morbidly obesity who underwent LSG from January 2015 to December 2019. All patients underwent gastroscopy in the preoperative period. Results: The study analyzed 800 patient reports. No specific pathological finding was observed in 230/800 (28.75%) of the patients, which was reported as normal. Specific pathological findings were present in 570 (71.25%) patients. Cases of chronic inactive gastritis (400 patients [50%] ), chronic active gastritis (134 patients [16.7%] ), intestinal metaplasia (2 patients [0.2%] ), low-grade dysplasia (1 patient [0.12%] ), stromal tumor (7 patients [0.87%] ), Neuroendocrine (NE) cell hyperplasia (7 patients [0.87%] ), fundic gland polyps (3 patients [0.37%] ), granulomatous gastritis (1 patient [0.12%] ), acute gastritis (1 patient [0.12%] ) and ectopic pancreas (1 patient [0.12%] ) were recorded. Conclusion: Surgeons should be aware of the high unexpected histopathological prevalence in bariatric patients. Although our study did not find any malignant pathological result, we believe that routine postoperative pathological examination and preoperative endoscopy are necessary for medicolegal reasons.

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

Laparoscopic sleeve gastrectomy (SG) is a common and effective bariatric surgery, with low postoperative complication rates. It is important to define modifiable risk factors for complications. The possible association of Helicobacter pylori (HP) on SG outcomes is still being investigated. We aimed to examine HP prevalence in SG specimens, the association to early (30-day) complications, and impact of preoperative HP eradication on outcomes. This is a retrospective analysis of all consecutive patients who underwent SG between January 2012 and December 2020 in a single bariatric center. Data were retrieved from our prospectively maintained patient registry database. The 30-day outcomes were compared according to the HP status of the resected specimen: positive and negative, with or without preoperative HP eradication therapy. There were 1985 patients; of them, 179 patients were HP positive and 1806 were HP negative in resected specimens. The overall early complication and major (Clavien-Dindo ≥ 3) complication rates were 8.6% and 3.2% (p = 0.48 and p = 0.21), respectively. A total of 111 patients were HP positive on preoperative endoscopic biopsy and received eradication therapy. All were HP negative on preoperative urea breath test, and 65.45% had HP negative resected specimens. HP eradication did not affect overall and major complications (p = 0.68 and p = 0.48, respectively). The presence of HP does not seem to affect the early outcomes of SG. HP eradication does not change the early postoperative course either. Therefore, the role of routine preoperative HP screening may be limited, and eradication can be completed following SG.

Preoperative Upper Gastrointestinal Endoscopy Prior to Sleeve Gastrectomy: To Do, or Not to Do

AbstractThere is controversy about the requirement of preoperative upper gastrointestinal (GI) endoscopy for sleeve gastrectomy patients. The aim of this study is to understand the necessity of a preoperative upper GI endoscopy before sleeve gastrectomy. In this study, the incidental findings encountered in sleeve gastrectomy pathology specimens of a cohort of patients were analyzed. A total of 270 patients who had sleeve gastrectomy at Ankara Numune Teaching Hospital, General Surgery Clinic, between 2011 and 2016 were evaluated. Histopathological examination of sleeve gastrectomy specimens was performed. Chronic gastritis in 76.6% and intestinal metaplasia in 4.1% of patients were observed. A GI stromal tumor was found in one male patient. Also, an active gastric ulcer was detected in one patient. Only 13 (4.9%) out of 270 patients had a postoperative pathology needing follow-up. None of our findings would have an impact of changing the surgical approach. Therefore, the results of this study suggested that application of a preoperative GI endoscopy is not necessary prior to sleeve gastrectomy in patients without upper GI symptoms.

Management of gastric intestinal metaplasia in patients undergoing routine endoscopy before bariatric surgery.

Routine preoperative endoscopic evaluation for bariatric surgery is controversial; however, for patients undergoing endoscopy, some findings may alter surgical management. Gastric intestinal metaplasia (GIM) is found in up to 11.7% of the general population. When associated with determined risk factors, GIM has a risk of progressing to gastric cancer. The aim of our study was to assess the prevalence of GIM and possible associated factors in those undergoing bariatric surgery. We performed a retrospective chart review of patients who underwent primary sleeve gastrectomy or Roux-en-Y gastric bypass at our institution between January 1, 2016 and June 30, 2020. Baseline characteristics and preoperative endoscopic findings were obtained from all patients. Histopathologic analysis of sleeve gastrectomy specimens was reviewed. We identified 753 patients. Mean (SD) age and body mass index were 49.0 (13.1) years and 43.9 (7.1) kg/m2, respectively. Procedures consisted of 411 (54.6%) gastric bypasses and 342 (45.4%) sleeve gastrectomies. Esophagitis and Barrett esophagus were found in 18.1% and 5.0% of patients, respectively. Preoperative gastric biopsy identified Helicobacter pylori in 6.4% and GIM in 2.7%. Regression analysis found an association of Barrett esophagus (odds ratio 4.60; 95% CI 1.25-16.82) and age ≥ 60years (odds ratio 2.67; 95% CI 1.04-6.90) with preoperative findings of GIM. Histopathologic analysis of sleeve gastrectomy specimens identified H. pylori in 1.8% and GIM in 0.9%. Older age and Barrett esophagus were associated with GIM in preoperative gastric biopsy. This association emphasizes the importance of a diligent examination during preoperative endoscopy.

Intestinal Metaplasia Influencing the Density of Ghrelin Expressing Cells in Morbid Obese Patients.

The aim was to compare the density of ghrelin-expressing cells (GECs) in morbid obese patients with or without intestinal metaplasia (IM). The study included 48 patients out of 244 who underwent laparoscopic sleeve gastrectomy between 2015 and 2019. IM was detected in the sleeve gastrectomy specimens of 24 of these 244 patients. The study group consisted of all of the patients with IM. It was a case matched study. Matching factors were age and gender. Ghrelin was stained with a Leica semiautomatic immunohistochemical-staining machine. Stained preparations with ghrelin were subjected to light microscopic examination. The number of GECs in cases with IM was significantly lower than the cases without IM (p = 0.001). The number of GECs was significantly higher in cases with chronic inactive superficial gastritis than cases with chronic active superficial gastritis (p = 0.033). We found that there was a decrease in the number of GECs in the corpus and fundus of the stomach in cases with gastric IM as a contribution to the literature. IM cause a decrease in the number of GECs in the gastric oxyntic glands. In addition, chronic active superficial gastritis is also associated with a decrease in the number of GECs. We can say that the common feature of all of these factors may be gastric mucosal damage. Consequently, damage to the gastric mucosa appears to reduce the number of GECs.

Post Helicobacter pylori Treatment Histopathological Findings in Laparoscopic Sleeve Gastrectomy Specimens

Background: Obesity nowadays becomes a major medical and social problem in the world. Obesity is a pandemic health problem recognized as a disease of time and is also an important cause of morbidity and mortality. The aim of this study was to investigate the persistent histopathologic changes after Helicobacter pylori (H. pylori) treatment in laparoscopic sleeve gastrectomy (LSG) specimens and correlation between high body mass index (BMI) and histopathological findings. Materials and Methods: Asymptomatic 520 patients were candidate for laparoscopic sleeve gastrectomy (2017-2019) who had not symptom of Helicobacter pylori infection, visually normal endoscopy and had positive H. pylori urease recently. They treated with triple regimen (clarithromycin, amoxicillin for 2 weeks and proton-pump inhibitor (PPI) for 2 month). Eradication was confirmed by urea breath test (UBT). After operation specimens were evaluated histopathologically. Results: Females were 58.3% of the patients. Mean BMI were 44.2 (females) and 46.3 (males). Normal LSG specimens were 58.3%. Most common abnormal histopathology findings were; chronic mild active and inactive gastritis (21.3%), chronic moderate active and inactive gastritis (16.0%), chronic severe active and inactive gastritis (3.3%), had not follicular gastritis, lymphoid aggregates (0.6 %), intestinal metaplasia (0.2%) and PPI effect (0.2%). Significant correlation was observed between the higher patients BMI (BMI>45) with abnormal histopathology findings specially moderate and severe degree of chronic active and inactive gastritis. Conclusion: Patients with higher BMI was at more risk for post H. pylori treatment abnormal pathology like chronic active gastritis which is the risk factor for atrophic gastritis may lead to preventable gastric cancer. Patients with higher BMI (≥45) and H. pylori positive urease test with visually normal endoscopy, mainly candidate for the laparoscopic Roux-en-Y gastric bypass (LRYGB). Permanent endoscopic follow up in these patients are impossible, therefore, endoscopic random tissue mapping even after H. pylori treatment is appropriate.

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

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. To perform a histologic and cost-benefit analysis of gastric remnants post-LSG. 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. 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. 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, Sleeve Gastrectomy, and Gastroesophageal Reflux Disease; Is there a Relation?

Sleeve gastrectomy (SG) is an effective bariatric procedure, yet can be associated with complications as gastroesophageal reflux disease (GERD). The present study aimed to investigate the prevalence of Helicobacter pylori (H. pylori) in SG specimens, its relation with GERD, and its impact on postoperative outcomes. All SG specimens received in the pathology laboratory were reviewed. The prevalence of H. pylori in SG specimens was recorded. Patients with H. pylori infection who received triple therapy were compared with patients without H pylori in terms of baseline characteristics, preoperative GERD and its outcome postoperatively, development of new-onset GERD, staple line complications, and weight loss. The records of 176 patients were reviewed; 69 (39.2%) were positively tested on H. pylori infection. Patients with H. pylori had higher body mass index (BMI) (RR = 1.51), greater incidence of preoperative GERD (RR = 1.67), and complained more of dyspepsia (RR = 1.87). Eradication of H. pylori was achieved in 67 (97.1%) of 69 patients. Postoperative improvement in GERD symptoms (44.4% Vs 19%, p = 0.036) and dyspepsia (85.7% Vs 51.7%, p = 0.007) was higher in patients with H. pylori with confirmed eradication of infection than patients without H. pylori. Both groups had similar operation time, postoperative BMI, excess weight loss, staple line complications, and new-onset GERD. More than one-third of patients with morbid obesity had H. pylori infection. Morbidly obese patients with H. pylori infection may be more prone to develop GERD symptoms; yet after eradication of the infection, they may also experience better improvement in symptoms after SG.

Plasma cells and lymphoid aggregates in sleeve gastrectomy specimens: Normal or gastritis?

Lymphoid follicles/aggregates in gastric biopsies have been traditionally linked to Helicobacter pylori gastritis, and less commonly to other inflammatory and neoplastic conditions. The frequency of such aggregates in normal stomachs has yet to be adequately evaluated. This is especially relevant when it comes to diagnosing non-specific chronic gastritis in biopsy specimens with chronic inflammation but no evidence of H pylori infection. Sleeve gastrectomies represent an opportunity to study adequately preserved gastric mucosa in patients who are otherwise asymptomatic and lack a history of gastric disease.To study sleeve gastrectomy specimens to quantify the amount of lymphoid follicles/aggregates and lymphocytic infiltration in normal stomachs.Sixty-eight bariatric sleeve gastrectomies and 13 control specimens from Whipple resections were examined for multiple histologic features including type, quantity, and distribution of chronic inflammation and lymphoid follicles/aggregates. Presence of H pylori was documented by both Hematoxylin and eosin-stained (H&E) and immunohistochemistry (IHC). Clinical information including age, sex, medication intake, prior endoscopy, and/or H pylori infection was recorded. The patient population was divided in 2 groups, H pylori negative versus H pylori positive, and statistical analysis was performed by a biostatistician.Two hundred sixty three fundic sections from 68 bariatric patients were examined. Fifty three patients were found to be H pylori-negative, compared with 15 who were positive for H pylori. Among the H pylori-negative group, the average number of lymphoid aggregates was 3.33, compared with an average of 6.26 in the H pylori positive group (the difference was statistically significant with a P-value of .008). The average number of plasma cells per high power field was 2.15 in the H pylori negative group, compared and average of 5.07 in the H pylori positive group (the difference was also statistically significant with a P-value <.001). Clinically, 10 of the 53 H pylori-negative patients had esophagogastroduodenoscopy (EGD) that showed endoscopic mild non-erosive gastric erythema. The remaining had no documentation of symptoms or medication intake, including Non-steroidal anti-inflammatory drugs (NSAIDs) and Proton Pump Inhibitors (PPI).Our results suggest that the presence of lymphoid aggregates and plasma cells infiltration can be a normal finding in otherwise normal gastric mucosa, though more pronounced in H pylori infected patients.