Prevalence of Chronic Gastritis or Helicobacter pylori Infection in Adolescent Sleeve Gastrectomy Patients Does Not Correlate with Symptoms or Surgical Outcomes

Patients and Methods

After approval by our Institutional Review Board, we conducted a retrospective analysis of all patients undergoing a laparoscopic sleeve gastrectomy at our children's hospital from January 2010 through July 2014. No patients were excluded from the study, and all patients were followed for at least one year after surgery. We performed a chart review to determine the pre- or post-operative symptoms of GERD or gastritis, as well as any operative complications, including staple line leak, marginal ulcer, surgical site infection, and long-term anti-reflux therapy after surgery. Pre- and post-operative symptoms of GERD include dysphagia, emesis, regurgitation, and abdominal pain. No pre-operative evaluation for H. pylori was conducted in our patients prior to sleeve gastrectomy unless it was required for insurance authorization. There was one patient where the insurance company required negative serum antibody documentation prior to approval. After the procedure, surgical specimens were sent to pathology to evaluate for the evidence of gastritis. Routine hematoxylin and eosin staining was used to determine evidence of gastritis. If there was evidence of gastritis, H. pylori BC7 immunostaining was completed to determine the presence of H. pylori. Anti-H. pylori BC7 is a mouse monoclonal antibody used to detect H. pylori in formalin-fixed, paraffin-embedded tissues. Pathology reports were reviewed for H. pylori status and evidence of gastritis. Patients with symptomatic gastritis were treated pre-or post-operatively with a proton pump inhibitor (PPI). Patients with post-operative symptoms of gastritis were weaned off their PPI by 3 mos after surgery once tolerating solid food. Confirmed H. pylori infections via pathologic testing were treated with triple H. pylori therapy post-operatively.

The study population was described using univariate analysis. Patient demographics and symptoms of GERD and gastritis were analyzed and compared with pathologic evidence of gastritis and H. pylori using a bivariate analysis with Pearson chi square or Fisher Exact test for categorical variables and Student's t-test for continuous data. A p value of<0.05 was considered statistically significant.

Results

A total of 78 adolescents had laparoscopic sleeve gastrectomy from January 2010 through July 2014. The mean age was 17.70±1.60 with a mean body mass index (BMI) of 47.60±6.80 kg/m². The majority of the study population was female (83.3%) and black (57.7%) (Table 1). The prevalence of pathology-proved gastritis was 44.9% (35/78), of those 11.4% (4/35) had H. pylori (Figure 1). Only one patient with H. pylori had pre-operative symptoms of gastritis, but this patient did not have a pre-operative evaluation for H. pylori or pre-operative triple therapy. Of those with pathology-proved gastritis, only 25.7% (9/35) of patients had symptoms. There was no significant difference in age, BMI, gender, and ethnicity when compared between subjects with and without gastritis. Symptomatic patients had an increased prevalence of pathological-proven gastritis (25.7% vs. 9.3% in patients without symptoms), however this difference did not quite reach statistical significance (p=0.0698). Mean patient follow-up was 10 (3–26) mos. There was one patient who had a staple line leak, however this patient did not have any evidence of gastritis on the pathology report and H. pylori immunostaining was negative. All patients with pre-operative gastritis symptoms had resolution of these symptoms by 3 mos post-operatively. No patients required long-term anti-reflux therapy.

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FIG. 1.

Breakdown of presence of pathology proven gastritis and its association with symptoms in 78 adolescents undergoing sleeve gastrectomy.

Discussion

Our study shows there is a sizeable prevalence of gastritis among adolescents with severe obesity undergoing sleeve gastrectomy. However, only a small number of these patients had symptoms or H. pylori infection. In adults undergoing bariatric surgery, some have recommended that a patient routinely undergo pre-operative upper endoscopy to diagnose any upper gastrointestinal tract (GI) abnormalities regardless of symptomatology [7, 10–13]. This would ensure treatment of abnormalities prior to a bariatric procedure that would render parts of the upper GI inaccessible post-operatively. Given the relatively recent increase in bariatric procedures in adolescents, it is important to determine the utility of pre-operative esophagogastroduodenoscopy (EGD) in adolescent patients. Currently there are no published studies on pre-operative EGD in adolescents undergoing bariatric procedures, or any data regarding H. pylori prevalence in severely obese adolescents in general. Al-Akwaa [14] found a high prevalence (85.5%) of H. pylori in Saudi adult patients with active chronic gastritis. Similarly Küper et al. [10] found a high proportion of asymptomatic morbidly obese adults with histopathological findings of but not limited to peptic ulcers, neoplasms, polyps, hiatal hernia, and H. pylori infection. The prevalence of H. pylori infection may be related to endemic colonization in certain regions [14].

In Arkansas, the prevalence of H. pylori infection in children increased with age from 24%–45% [23]. The incidence of H. pylori infection and gastritis in morbidly obese children and adolescents is unknown. In our patients, 44.9% had pathology-proved chronic gastritis. Of these 11.4% had H. pylori. The majority of these patients were asymptomatic. In adults undergoing sleeve gastrectomy, the prevalence of pathology-proven chronic gastritis was 33.3% [24], however the pre-operative BMI in our cohort is greater than in most adult series. It is unclear if the prevalence of gastritis is truly higher in our study population compared with other BMI matched populations, however it may be that we have a greater rate because of the fact that we are routinely evaluating for the presence of gastritis in our gastric specimens. More studies are needed to determine the prevalence of these diseases in this patient population as well as resultant surgical outcomes.

In asymptomatic adults, it is controversial whether a pre-operative EGD is necessary prior to a bariatric procedure [15]. Sharaf et al. [16], concluded that routine preoperative EGD not only has a high diagnostic yield, but also is cost effective. Upper endoscopy is an invasive procedure that requires conscious sedation at a minimum. The performance of EGD is associated with some risk related to passage of the endoscope and anesthesia [17–19]. More recent studies have shown that routine pre-operative EGD is not required [20,21] or does not appreciably alter surgical management [8,9] in adult patients undergoing bariatric surgery. Neither the presence of chronic gastritis nor H. pylori infection correlated with pre- or post-operative symptoms or outcomes in our cohort of obese adolescents undergoing bariatric surgery, which is consistent with the preponderance of the adult literature data [10]. Black et al. [22] found that there was no difference in weight loss for adolescents undergoing bariatric surgery when compared with adults, but that complications were inconsistently reported. Thus, larger studies may be needed to definitively determine whether gastritis or H. pylori infection has any effect on adverse surgical outcomes.

Because our study is a retrospective analysis of adolescents undergoing a bariatric procedure at a single institution, there are obvious limitations to our conclusions. Our study included only 78 adolescents and thus the sample size may be too small to power adequately for outcome measures such as the observed symptoms differences between the H. pylori positive and H. pylori negative gastritis. A randomized controlled trial would be necessary to definitively determine the risks and benefits of pre-operative upper endoscopy, or serum H. pylori evaluation, in adolescents undergoing bariatric procedure. Cost-effectiveness would also need to be evaluated. However a study of that nature is unlikely to occur because it may be unethical to randomize morbidly obese adolescents to undergo a second general anesthesia for a test that seems to have no medical benefit, and certainly families and the patients would be unlikely to enroll to such a study. Although our study did not employ pre-operative EGD or serum H. pylori evaluation in our adolescent patients, we believe these may portend unnecessary added costs and the additional risk of anesthesic and the EGD itself. Furthermore, in the absence of any adverse outcome or predictive symptomatology in those who are infected with H. pylori, we advocate for continued routine pathologic evaluation without the required need for pre-operative determination unless or until H. pylori infection is associated with adverse surgical outcome.