John J Kelly, MD, Richard A Perugini, MD, Lisa Q Wang, MD, Thomas Tomczyk, MD, Julie Flahive, MS. University of Massachusetts Medical Center.
Background
Eradication of H. pylori prior to Roux-en-Y gastric bypass (RYGB) has been advocated as a measure to reduce anastomotic ulceration. However, the evidence to support a correlation between preoperative H. pylori status and postoperative anastomotic ulcer is weak. Our hypothesis is that there is no association between the preoperative presence of H. pylori and post-operative marginal ulcer development and associated complications such as perforation, stricture and pain.
Methods
Consecutive intraoperative antral biopsies were obtained on patients who underwent laparoscopic RYGB at our institution from December 2007 to June 2010. These samples were analyzed by Warthin-Starry stain for H. Pylori organisms. Retrospective chart review was conducted to determine preoperative symptoms of acid dyspepsia and PPI/H2 blocker therapy and post-operative data of ulcer symptoms or ulcer visualization on EGD, perforation, stricture, GI bleed, smoking, NSAID or steroid use, and compliance with ulcer prophylaxis. Presence of marginal ulcer was defined by symptoms, EGD visualization, stricture, or perforation. Fisher’s exact test was used for analyzing associations between discrete groups. Multiple logistic regression was used to assess associations between anastomotic ulcer complications and potential predictors.
Results
A total of 729 patients underwent RYGB, in whom histologic evaluation for H. Pylori organisms was possible in 708. Sixty-seven (9.2%) patients were H. pylori positive; these patients did not receive definitive treatment for eradication. The H. pylori positive group was not different with regards to preoperative age, gender, BMI, diagnosis of GERD or peptic ulcer disease, and postoperative ulcer prophylaxis, usage of steroids, NSAIDs and cigarettes. Marginal ulcers and/or related late complications were seen in 105 (14.8%) patients. Of those, diagnosis of simple ulcer was made in 88 (12.4%) patients based on symptoms and/or seen on EGD, stricture in 31 patients (4.4%) and perforation in 21 patients (2.9%).
| (+) H pylori (n = 67) | (-) H. pylori (n = 641) | P value | |
| Simple ulcer (%) | 1 (1.5%) | 87 (14.4%) | 0.002 |
| Stricture (%) | 2 (3.1%) | 29 (4.6%) | 0.76 |
| Ulcer perforation (%) | 1 (1.5%) | 20 (3.2%) | 0.71 |
| Anastomotic ulcer related complications combined | 4 (6%) | 101 (16.0%) | 0.03 |
Conclusion
This is the largest series in the literature studying tissue biopsy proven H. pylori colonization of the stomach and postoperative anastomotic ulcer complication in RYGB. Rather than a higher incidence, we found a significantly lower incidence of anastomotic ulcer complications in the population positive for H. pylori. This study brings into question efforts to eradicate H. pylori prior to RYGB.