OBES SURG (2015) 25:2276–2279
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
Published online: 22 May 2015
# Springer Science+Business Media New York 2015
Abstract
Background In vertical sleeve gastrectomy (VSG), the major-
ity 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 institu-
tion 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 collec-
tion, 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
brownleeandrew@gmail.com
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 follow-
up, 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 man-
agement and natural history of gastritis, peptic ulcer disease, and
gastric cancer. It has been shown to be associated with approx-
imately 50 % of mucosa-associated lymphoid tissue (MALT)
cancers as well as iron and vitamin A, C, E, and B12 deficien-
cies [1, 2]. The prevalence of H. pylori in the developed world
has been estimated to be as high as 85 %. In the general popu-
lation, 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 lympho-
mas [4, 5]. As a result of this, eradication has increasingly be-
come 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 im-
portant member of the microbiome. Its absence has been as-
sociated with an increased prevalence of childhood allergies
and asthma as well as esophageal carcinoma [6–21]. It has
OBES SURG (2015) 25:2276–2279
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 gas-
tric bypass (RYGB), H. pylori has been implicated in the devel-
opment 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, preop-
erative or perioperative identification of H. pylori with treatment
if detected has become standard. In fact, it has become a require-
ment for certification by several insurance companies.
Vertical sleeve gastrectomy (VSG) is the fastest growing
bariatric procedure performed worldwide. It involves the re-
section 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 in-
creased 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 ex-
cluded 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.
Methods
Four hundred and eighty patients who underwent VSG be-
tween January 2011 and April 2013 as a primary procedure
were included in this retrospective study. All patients were
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
Positive 1 1 (1.9 %) 0 1
Negative 0 5 (1.2 %) 2 (0.4 %)
a
Patient admitted for hemorrhoidal bleeding
b
Patient admitted for portal vein thrombosis
2277
18 years of age or older and met the NIH guidelines for bar-
iatric surgery. All patients underwent a preoperative visit, ed-
ucational seminar, preoperative labs, and an upper gastroin-
testinal 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 de-
scribed. 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 bou-
gies, 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 immunohis-
tochemical 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 ac-
cording 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 re-
admission 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.
Results
Of the 480 patients who underwent VSG, 52 were found to be
H. pylori positive based on examination of the pathological
Pain Dehydration Other Total
1 (1.9 %) 1 (1.9 %)a 5
1 3 (0.7 %) 1 (0.2 %)b 12
2278
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 condi-
tions 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 demon-
strated 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 prac-
tice and not treat patients when H. pylori was detected in their
surgical specimen. Now with over 3 years of data and follow-
up, 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 compli-
cations 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 con-
cerns of post-operative ulceration and the need to examine por-
tions of the stomach that would be difficult in post-RYGB
patients, preoperative endoscopy with H pylori detection be-
came a common practice. Despite the absence of data, many
have extrapolated this standard to VSG. Our data suggests that
OBES SURG (2015) 25:2276–2279
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 popula-
tion. 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 prob-
ably 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, regard-
ing 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 ques-
tion, 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 retro-
spective 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 institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
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