Prevalence of Helicobacter pylori infection in gastric remnant after distal gastrectomy for primary gastric cancer

Role of New Anatomy, Biliopancreatic Reflux, and Helicobacter Pylori Status in Postgastrectomy Stump Cancer

Distal gastrectomy for benign gastroduodenal peptic disease has become rare, but it still represents a widely adopted procedure for advanced and, in some countries, even for early distal gastric cancer. Survival rates following surgery for gastric malignancy are constantly improving, hence the residual mucosa of the gastric stump is exposed for a prolonged period to biliopancreatic reflux and, possibly, to Helicobacter pylori (HP) infection. Biliopancreatic reflux and HP infection are considered responsible for gastritis and metachronous carcinoma in the gastric stump after oncologic surgery. For gastrectomy patients, in addition to eradication treatment for cases that are already HP positive, endoscopic surveillance should also be recommended, for prompt surveillance and detection in the residual mucosa of any metaplastic-atrophic-dysplastic features following surgery.

13C-Urea Breath Test for the Diagnosis of H. pylori Infection in Patients after Partial Gastrectomy: A Systematic Review and Meta-Analysis

BACKGROUND

The ¹³C-urea breath test (¹³C-UBT) is a kind of safe, noninvasive, and reliable measure for Helicobacter pylori (H. pylori) infection diagnosis in patients with complete stomach. Nevertheless, the test has not indicated fully precision in people who have had a gastrectomy. So, we made the use of a systematic review of plentiful published resources and research and meta-analysis. There are prominent research achievements regarding of utilizing ¹³C-UBT for H. pylori infection patients diagnosis with the residual stomach.

METHOD

We searched publications available on Cochrane, PubMed, and Embase databases, and on the web of science. The last search was performed in May 2021. The basis model for this meta-analysis was fixed-effect through Metadisc Beta 1.4 software (Universidad Complutense, Madrid, Spain). When measuring the precision of ¹³C-urea breath test, we utilized the ratio analysis such as Ratio of diagnostic odds ratio (DOR) and its corresponding 95% confidence interval (95%CI).

RESULTS

Ten associated researches were analyzed with a total of 1065 patients. In general, the sensitivity of included studies ranged from 0.40 to 1.00 (I² = 81.2%), whereas the specificity ranged from 0.59 to 1.00 (I² = 90.1%). The pooled sensitivity, specificity were 0.83 (95% CI, 0.79-0.86; P < 0.001), 0.79 (95% CI, 0.76-0.83; P < 0.001) respectively. The accuracy ranged from 71 to 99. The positive predictive values ranged from 45 to 100. The negative predictive values ranged from 53 to 100. The combined DOR was 36.02 (95%CI 15.65-82.92; I² = 65.8%; P = 0.0018). The corresponding AUC for the SROC curve was 0.92 and the Q value was 0.85.

CONCLUSION

In conclusion, the outcomes of meta-analysis indicate that during the period of patients' diagnosis in H. pylori infection, who undergoes partial gastrectomy, has high accuracy.

Incidence of Multiple Metachronous Gastric Cancers After Pyloric-Preserving Gastrectomy

AIM

Pylorus-preserving gastrectomy (PPG) is widely used for early gastric cancer located in the middle third of the stomach. The minimization of the extent of gastrectomy may increase the risk of metachronous multiple gastric cancer (MGC). We report the findings of a study that was conducted to evaluate the prevalence of MGC after PPG.

METHODS

The clinical data of 533 patients who underwent PPG for gastric cancer between 1993 and 2018 were reviewed. The clinicopathological characteristics at the time of the primary treatment that were predictive of the development of MGC were explored. The median (range) observation period was 112.4 (8.1-290.7) months.

RESULTS

Metachronous MGC was diagnosed in 33 of the 533 patients. The cumulative 5-year and 10-year event rates were 3.3% and 6.2%, respectively. The patient gender, presence/absence of synchronous MGC and the macroscopic type of the primary gastric cancer were significantly associated with the risk of development of metachronous MGC. Multivariate analysis identified the presence of synchronous MGC (hazard ratio [HR]: 4.828, 95% confidence interval [CI]; 1.611-12.30, p = 0.004) and Type 0-IIa primary gastric cancer (HR 2.810, 95% CI; 1.113-7.090, p = 0.029) as independent factors associated with the risk of development of MGC. All the patients could be treated by surgical or endoscopic resection for the metachronous MGC. Recurrence was observed in one patient.

CONCLUSIONS

There was quite a few incidence of development of metachronous MGC after PPG. Nevertheless, PPG remains reasonable treatment option, if adequate postoperative surveillance can be ensured.

The Different Clinicopathological Features of Remnant Gastric Cancer Depending on Initial Disease of Partial Gastrectomy

Background: The incidence of gastric cancer increases in the remnant stomach after partial gastrectomy; however, its pathogenesis remains controversial. The clinicopathological features and immunohistochemical subtype were evaluated in patients with remnant gastric cancer considering the initial cause of partial gastrectomy. Methods: We categorized 59 cases of remnant gastric cancer who underwent curative surgery between 2001 and 2016 according to initial pathologies of benign (n = 24) or malignant (n = 35). Histological changes including pyloric metaplasia and intestinal metaplasia in the mucosa around the anastomosis site and the background mucosa of carcinomas were compared between the groups. Results: In the malignant group, the proportion of male patients was substantially lower, with a shorter interval. In background mucosa around the carcinomas, incidence of high-grade pyloric metaplasia was significantly higher in the benign group (13/20, 65.0% vs. 10/28, 35.7%), while high-grade intestinal metaplasia was only observed in the malignant group (0/20, 0% vs. 7/28, 25.0%). Conclusions: The cancers in the initial benign disease are mainly associated with pyloric metaplasia at the anastomosis site, reflecting reflux, but not with intestinal metaplasia. On the other hand, in the initial malignant disease group, intestinal metaplasia has an equally important role as reflux-associated pyloric metaplasia.

Efficacy of Low Dose Proton Pump Inhibitor-Based Therapy to Eradicate Helicobacter pylori in Patients with Subtotal Gastrectomy

Proton pump inhibitor (PPI)-based therapy is standard to eradicate Helicobacter pylori (H. pylori). Gastric acidity is lowered after gastrectomy because of bile reflux and impaired mechanism of acid secretion. Therefore, low-dose PPI may be effective for H. pylori eradication in the remnant stomach after gastrectomy. In this study, we compared the efficacy of low-dose PPI with standard double-dose PPI to eradicate H. pylori in patients who underwent subtotal gastrectomy. A total of 145 patients who were treated for eradication after gastrectomy was analyzed. They were treated with PPI-based triple regimen (PPI, clarithromycin and amoxicillin) for 14 days. We compared the eradication rate in the low-dose PPI group (lansoprazole 15 mg once daily) with that in the standard double-dose PPI group (lansoprazole 30 mg twice daily). The H. pylori eradication rate was 79.1% in the low-dose PPI group and 85.3% in the standard double-dose group; the difference was not significant statistically (p = 0.357). In the multivariate analysis, low-dose PPI (odds ratio (OR) = 1.79, 95% confidence interval (CI), 0.68–4.69) was not associated with eradication failure, while Billroth II anastomosis (OR = 4.45, 85% CI, 1.23–16.2) was significantly associated with eradication failure. Low-dose PPI-based triple regimen was as effective as standard double-dose PPI-based regimen for H. pylori eradication in patients with subtotal gastrectomy. Further study is needed to confirm the effect of low-dose PPI on H. pylori eradication in patients with gastrectomy.

DNA methylation genome-wide analysis in remnant and primary gastric cancers

BACKGROUND

Although primary (PGC) and remnant gastric cancers (RGC) both originate from the same gastrointestinal organ, they have very distinct clinicopathological behaviors. We hypothesized that there would be distinct differences in DNA methylation patterns that would occur during carcinogenesis of RGC and PGC, and that the differences in methylation patterns may help identify the primary factor contributing to chronic inflammation in patients with RGC.

METHODS

We investigated the genome-wide DNA methylation patterns of PGC and RGC tissues from 48 patients using the Infinium HumanMethylation450 Beadchip assay. The results were validated by quantitative methylation-specific PCR (qMSP) in separate, independent cohorts.

RESULTS

We found that in our training cohort of 48 patients, the most variable genes from the gastric cancer tissues identified by the Infinium HumanMethylation450 Beadchip clustered the resultant heatmap into high and low methylation groups. On multivariate analysis, PGCs contributed significantly to the high methylation group (p = 0.004, OR 12.33), which suggested that the promoter methylation status in PGC is higher than that in RGC. Supporting this conclusion was the finding that in a separate qMSP analysis in a test cohort, the EPB41L3 gene, chosen because of its high β value on microarray analysis in the gastric cancer tissues, had significantly higher DNA promoter methylation in cancer tissues in the validation PGC tissues than in RGC.

CONCLUSIONS

This study demonstrated that promoter methylation status in PGC is higher than in RGC. This result may reflect the effects of the absence of Helicobacter pylori on the reduced DNA methylation in the remnant stomach.

Clinicopathological Features of Remnant Gastric Cancer (RGC): Detection of RGC after Five Years of Follow-Up Was Associated with a Poor Prognosis

The purpose of this study was to evaluate the clinicopathological features and prognosis of patients who underwent surgery for remnant gastric cancer (RGC) during/after the regular five-year follow-up period after initial distal gastrectomy for gastric cancer that is recommended by the Japanese gastric cancer treatment guidelines. Between January 2007 and December 2017, 40 patients underwent surgery for RGC after distal gastrectomy. Twenty-eight of the 40 patients underwent initial gastrectomy for cancer. We divided the 28 patients into two groups: patients who were diagnosed with RGC during/after the five-year follow-up period after initial gastrectomy, and analyzed their retrospectively collected data. Among the 28 patients, 15 patients were diagnosed with RGC within five years and 13 patients were diagnosed with RGC after five years. There were significant differences in the reconstruction of the initial operation, curative resection, pathological depth of the tumor, and pathological stage of the two groups. Multivariate analyses revealed that the interval between initial gastrectomy and RGC and the pathological TNM stage were significant risk factors for shorter cancer-specific survival. Kaplan-Meier analyses demonstrated that patients with RGC after the five-year follow-up period had a significantly worse prognosis in terms of cancer-specific survival than those who developed RGC within five years. This study suggested surveillance by using the annual endoscopy might be necessary beyond the initial five-year period for patients who underwent gastrectomy for gastric cancer.

Dynamic Changes in Helicobacter pylori Status Following Gastric Cancer Surgery

Background/Aims

Helicobacter pylori eradication is recommended in patients with early gastric cancer. However, the possibility of spontaneous regression raises a question for clinicians about the need for "retesting" postoperative H. pylori status.

Methods

Patients who underwent curative gastrectomy at Seoul National University Bundang Hospital and had a positive H. pylori status without eradication therapy at the time of gastric cancer diagnosis were prospectively enrolled in this study. H. pylori status and atrophic gastritis (AG) and intestinal metaplasia (IM) histologic status were assessed pre- and postoperatively.

Results

One hundred forty patients (mean age, 59.0 years; 60.7% male) underwent subtotal gastrectomy with B-I (65.0%), B-II (27.1%), Roux-en-Y (4.3%), jejunal interposition (0.7%), or proximal gastrectomy (4.3%). Preoperative presence of AG (62.9%) and IM (72.9%) was confirmed. The mean period between surgery and the last endoscopic follow-up was 38.0±25.6 months. Of the 140 patients, 80 (57.1%) were found to be persistently positive for H. pylori, and 60 (42.9%) showed spontaneous negative conversion at least once during follow-up. Of these 60 patients, eight (13.3%) showed more complex postoperative dynamic changes between negative and positive results. The spontaneous negative conversion group showed a trend of having more postoperative IM compared to the persistent H. pylori group.

Conclusions

A high percentage of spontaneous regression and complex dynamic changes in H. pylori status were observed after partial gastrectomy, especially in individuals with postoperative histological IM. It is better to consider postoperative eradication therapy after retesting for H. pylori.

Current status in remnant gastric cancer after distal gastrectomy

Remnant gastric cancer (RGC) and gastric stump cancer after distal gastrectomy (DG) are recognized as the same clinical entity. In this review, the current knowledges as well as the non-settled issues of RGC are presented. Duodenogastric reflux and denervation of the gastric mucosa are considered as the two main factors responsible for the development of RGC after benign disease. On the other hand, some precancerous circumstances which already have existed at the time of initial surgery, such as atrophic gastritis and intestinal metaplasia, are the main factors associated with RGC after gastric cancer. Although eradication of Helicobacter pylori (H. pylori) in remnant stomach is promising, it is still uncertain whether it can reduce the risk of carcinogenesis. Periodic endoscopic surveillance after DG was reported useful in detecting RGC at an early stage, which offers a chance to undergo minimally invasive endoscopic treatment or laparoscopic surgery and leads to an improved prognosis in RGC patients. Future challenges may be expected to elucidate the benefit of eradication of H. pylori in the remnant stomach if it could reduce the risk for RGC, to build an optimal endoscopic surveillance strategy after DG by stratifying the risk for development of RGC, and to develop a specific staging system for RGC for the standardization of the treatment by prospecting the prognosis.

Endoscopic and oncologic outcomes according to indication criteria of endoscopic resection for early gastric cancer: a systematic review and meta-analysis

BACKGROUND

The criteria for endoscopic resection for early gastric cancer (EGC) have been expanded recently, and it has become acceptable to use techniques that are regarded as having equivalent technical and pathological outcomes to absolute indication (AI). However, the long-term oncological outcomes of expanded indication (EI) have yet to be clarified. This meta-analysis aimed to assess the long-term outcome of EI versus AI, to identify the endoscopic feasibility and safety according to the indication, and to provide the appropriate recommendations for each indication.

METHODS

Electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and KoreaMed were searched for articles published between January 2000 and October 2014. After screening, the reviewers extracted the information from 12 retrospective cohort studies. A total of 9635 EGC lesions, 4150 lesions in the EI group and 5485 lesions in the AI group, were included in this study.

RESULTS

Meta-analyses showed that the local recurrence rate [risk ratio (RR) 1.34; 95% CI 0.67-2.70] was not significantly higher in the EI group compared with the AI group, although the metachronous recurrence rate was higher in the EI group than in the AI group (RR 1.60; 95% CI 1.22-2.10). The rates of en bloc resection [odds ratio (OR) 0.57; 95% CI 0.41-0.78), complete resection (OR 0.37; 95% CI 0.25-0.57), and curative resection (OR 0.34; 95% CI 0.20-0.58) were significantly inferior in the EI group than in the AI group, whereas overall bleeding risk (RR 1.47; 95% CI 1.19-1.82) and procedure-related perforation rate (OR 2.04; 95% CI 1.56-2.68) were significantly higher in the EI group than in the AI group.

CONCLUSIONS

This meta-analysis suggests that the EI group showed acceptable long-term outcomes with local recurrence rate that was not significantly inferior, although the metachronous recurrence rate was higher compared with that in the AI group.

Surgical Resection of Remnant Gastric Cancer Following Distal Gastrectomy: A Retrospective Clinicopathological Study

BACKGROUND

Remnant gastric cancer (RGC) is one of the less prevalent gastric cancers. The purpose of this study was to explore the clinicopathological characteristics and results of the operation of RGC following distal gastrectomy. In particular, we examined factors related to prognosis.

METHODS

Between January 1970 and December 2012, 122 patients with RGC following distal gastrectomy underwent further surgery and were analyzed retrospectively.

RESULTS

Initial gastric diseases included benign (49 patients, 40.2 %) and malignant diseases (73 patients, 59.8 %). Reconstructions by initial surgery included Billroth I (80 patients, 65.6 %) and Billroth II (42 patients, 34.4 %). Tumors were located at anastomotic (44 patients, 36.1 %) and nonanastomotic sites (78 patients, 63.9 %). There were 59 patients (48.4 %) classified with pathological (p) stage I, 19 as p stage II (15.6 %), 22 as p stage III (18.0 %), and 22 (18.0 %) as p stage IV. A total of 100 patients (82.0 %) underwent curative resection, and 22 underwent noncurative resection. The number of cases of postoperative morbidity, 90-day mortality, and adjuvant chemotherapy were 23 (18.9 %), 3 (2.5 %), and 20 (16.4 %), respectively. Univariate and multivariate analyses were performed to identify the prognostic factors of RGC. Multivariate analysis revealed historical periods, pathological venous invasion, curative resection, and postoperative morbidity to be independent prognostic factors.

CONCLUSIONS

The prognosis of patients with RGC can be improved by aggressively performing curative resection without causing complications.

The diagnostic validity of the (13)c-urea breath test in the gastrectomized patients: single tertiary center retrospective cohort study

BACKGROUND

This study was conducted to evaluate the diagnostic validity of the (13)C-urea breath test ((13)C-UBT) in the remnant stomach after partial gastrectomy for gastric cancer.

METHODS

The (13)C-UBT results after Helicobacter pylori eradication therapy was compared with the results of endoscopic biopsy-based methods in the patients who have received partial gastrectomy for the gastric cancer.

RESULTS

Among the gastrectomized patients who showed the positive (13)C-UBT results (≥ 2.5‰, n = 47) and negative (13)C-UBT results (< 2.5‰, n = 114) after H. pylori eradication, 26 patients (16.1%) and 4 patients (2.5%) were found to show false positive and false negative results based on biopsy-based methods, respectively. The sensitivity, specificity, false positive rate, and false negative rate for the cut-off value of 2.5‰ were 84.0%, 80.9%, 19.1%, and 16.0%, respectively. The positive and negative predictive values were 44.7% and 96.5%, respectively. In the multivariate analysis, two or more H. pylori eradication therapies (odds ratio = 3.248, 95% confidence interval= 1.088-9.695, P = 0.035) was associated with a false positive result of the (13)C-UBT.

CONCLUSIONS

After partial gastrectomy, a discordant result was shown in the positive (13)C-UBT results compared to the endoscopic biopsy methods for confirming the H. pylori status after eradication. Additional endoscopic biopsy-based H. pylori tests would be helpful to avoid unnecessary treatment for H. pylori eradication in these cases.

Gastric cancer arising from the remnant stomach after distal gastrectomy: A review

Gastric stump carcinoma was initially reported by Balfore in 1922, and many reports of this disease have since been published. We herein review previous reports of gastric stump carcinoma with respect to epidemiology, carcinogenesis, Helicobacter pylori (H. pylori) infection, Epstein-Barr virus infection, clinicopathologic characteristics and endoscopic treatment. In particular, it is noteworthy that no prognostic differences are observed between gastric stump carcinoma and primary upper third gastric cancer. In addition, endoscopic submucosal dissection has recently been used to treat gastric stump carcinoma in the early stage. In contrast, many issues concerning gastric stump carcinoma remain to be clarified, including molecular biological characteristics and the carcinogenesis of H. pylori infection. We herein review the previous pertinent literature and summarize the characteristics of gastric stump carcinoma reported to date.

Incidence of metachronous gastric cancer in the remnant stomach after synchronous multiple cancer surgery

BACKGROUND

In the preoperative evaluation for gastric cancer, high-resolution endoscopic technologies allow us to detect small accessory lesions. However, it is not known if the gastric remnant after partial gastrectomy for synchronous multiple gastric cancers has a greater risk for metachronous cancer. The purpose of this study was to determine the incidence of metachronous cancer in this patient subset compared with that after solitary cancer surgery.

METHODS

Data on a consecutive series of 1,281 patients gastrectomized for early gastric cancer from 1991 to 2007 were analyzed retrospectively. The 715 gastric remnants after distal gastrectomy were periodically surveyed by endoscopic examination in Shikoku Cancer Center. Among those surveyed cases, 642 patients were pathologically diagnosed with solitary lesion (SO group) and 73 patients with synchronous multiple lesions (MU group) at the time of the initial surgery.

RESULTS

In the follow-up period, 15 patients in the SO group and 3 patients in the MU group were diagnosed as having metachronous cancer in the gastric remnant. The cumulative 4-year incidence rate was 1.9 % in the SO group and 5.5 % in the MU group. The difference did not reach the significant level by the log-rank test.

CONCLUSIONS

The incidence of metachronous cancer is higher after multiple cancer surgery; however, the difference is not statistically significant.

A rapid continuous-real-time 13C-urea breath test for the detection of Helicobacter pylori in patients after partial gastrectomy

INTRODUCTION

Before the development of efficient medications for peptic ulcer disease many patients were treated surgically by partial gastrectomy. The pathogenetic role of Helicobacter pylori was also not known yet. Some of these patients may therefore still harbor H. pylori in their remnant stomach as a carcinogenic agent for gastric cancer. This could be even more relevant for patients who were operated for tumors in the stomach. The efficacy of the urea breath test (UBT) is not clear in this population.

AIMS

To study the prevalence of H. pylori and to evaluate the sensitivity and specificity of the continuous UBT (BreathID) in postgastrectomized patients in Israel. In this system, the pH of the stomach is lowered by the addition of citric acid that may be beneficial in the smaller and more alkalic stomach.

METHODS

We compared retrospectively the results of our continous UBT with a rapid urease test (RUT) and the histology in all our patients who underwent gastroscopy for any clinical indication, and had a history of partial gastrectomy during the years 2002 to 2010. Only patients in whom H. pylori was tested by all the 3 methods during the same day were included in the study. We identified 76 such patients older than 18 years and performed a statistical analysis of all possibly related clinical data. The 3 methods were compared with each other.

RESULTS

H. pylori was positive in 14/76 (18.4%) patients when histology was considered as the gold standard method. The positive predictive value of the continuous UBT and the RUT was 0.64 and 0.35, respectively. The negative predictive value was high by both the methods, 0.92 and 0.95, respectively. Weight loss was correlated with positivity for H. pylori (P=0.032) and a longer gastric stump was marginally related to H. pylori (P=0.071). There was no difference for H. pylori positivity between patients with Billroth I or Billroth II operations. Prevalence of H. pylori was not lower in patients who had partial gastrectomy several years earlier.

CONCLUSIONS

The prevalence of H. pylori is considerable even several years after partial gastrectomy. The BreathID is reliable to exclude H. pylori after partial gastrectomy. The positive predictive value of the UBT is not very high but better than the RUT. We suggest that all positive patients found by the breath test should be treated. Our results support the view that alternative noninvasive methods, such as the stool antigen test should be further studied and compared with the BreathID in larger populations.

Risk factors for metachronous gastric cancer in the remnant stomach after early cancer surgery

BACKGROUND

Early gastric cancer patients have a good prognosis after radical resection. However, if the patients have a gastric remnant after the surgery, the risk of metachronous gastric cancer remains. The aim of this study was to clarify the risk factors for metachronous gastric cancer after partial gastrectomy for early gastric cancer.

METHODS

Data on a series of 1281 consecutive gastrectomy patients with pathologically confirmed early gastric cancer from 1991 to 2007 in Shikoku Cancer Center were analyzed retrospectively.

RESULTS

The gastric remnants of 868 patients were periodically surveyed by endoscopic examination. Among those surveyed cases, 26 patients were diagnosed as having metachronous gastric cancer in the gastric remnant. They underwent curative resection by remnant gastrectomy (n = 13 patients) or endoscopic mucosal resection (n = 13 patients). Multivariate analysis showed that male sex, older age, submucosal invasion, and proximal gastrectomy were independent risk factors.

CONCLUSIONS

Our data suggested that more intensive endoscopic follow-up is needed for the remnant stomach in patients with these risk factors to detect metachronous gastric cancer at its early stage.

Evaluation of the efficacy of triple therapy regimen for Helicobacter pylori eradication in gastrectomized patients with gastric adenocarcinoma

BACKGROUND

The cause of cancer in the gastric stump is multifactorial, and Helicobacter pylori is one of these factors. Its eradication has been recommended; however, there are few studies about of H. pylori eradication in gastrectomized patients.

METHODS

Twenty gastrectomized patients with gastric adenocarcinoma and Roux-en-Y reconstruction (study group) infected by H. pylori were compared with nongastrectomized patients (control group) also infected by H. pylori. The presence of H. pylori was determined by the ultra-quick urease test and from a histological sample obtained by endoscopy. Both groups received the same triple therapy regimen.

RESULTS

The rate of eradication of H. pylori in the study group was 90% and in the control group, it was 85%. Sex, age, and postoperative time did not influence the rate of eradication.

CONCLUSION

There were no differences in the efficacy of H. pylori eradication between the two groups; therefore, the triple therapy regimen is effective for the eradication of H. pylori in gastrectomized patients with a Roux-en-Y reconstruction.

Le reflux biliaire duodéno-gastrique et gastro-œsophagien

This study reviews current data regarding duodenogastric and gastroesophageal bile reflux-pathophysiology, clinical presentation, methods of diagnosis (namely, 24-hour intraluminal bile monitoring) and therapeutic management. Duodenogastric reflux (DGR) consists of retrograde passage of alkaline duodenal contents into the stomach; it may occur due to antroduodenal motility disorder (primary DGR) or may arise following surgical alteration of gastoduodenal anatomy or because of biliary pathology (secondary DGR). Pathologic DGR may generate symptoms of epigastric pain, nausea, and bilious vomiting. In patients with concomitant gastroesophageal reflux, the backwash of duodenal content into the lower esophagus can cause mixed (alkaline and acid) reflux esophagitis, and lead, in turn, to esophageal mucosal damage such as Barrett's metaplasia and adenocarcinoma. The treatment of DGR is difficult, non-specific, and relatively ineffective in controlling symptoms. Proton pump inhibitors decrease the upstream effects of DGR on the esophagus by decreasing the volume of secretions; promotility agents diminish gastric exposure to duodenal secretions by improving gastric emptying. In patients with severe reflux resistant to medical therapy, a duodenal diversion operation such as the duodenal switch procedure may be indicated.

Simple and accurate (13)C-urea breath test for detection of Helicobacter pylori in the remnant stomach after surgery

BACKGROUND

The efficacy of the (13)C-urea breath test (UBT) for diagnosis of Helicobacter pylori (H. pylori) infection in the remnant stomach after surgery is a matter of controversy. We report a simple and accurate method of (13)C-UBT for diagnosis of H. pylori infection in the remnant stomach after gastrectomy.

METHODS

Eighty patients who had undergone gastrectomy with or without subsequent H. pylori eradication therapy were examined a total of 134 times for H. pylori infection by the (13)C-UBT. (13)C-Urea, 10mg per test, was used in powdered form or in the form of film-coated tablets. Breath samples were collected before and 10, 20, and 3 min after ingestion. Mucosal biopsy specimens for bacterial culture and histological examination of the remnant stomach were collected endoscopically after each (13)C-UBT test.

RESULTS

Factors that confounded the (13)C-UBT results in the remnant stomach were oral bacteria, posture, and residual food. Lying horizontally on the left side was the best position, and film-coated tablets indicated no necessity for use of mouthwash. The method of anastomosis had no significant effect on the results of the (13)C-UBT. Thirty minutes and a cutoff of 4.5 per thousand were optimal conditions for detection of H. pylori in the remnant stomach. Under these conditions, sensitivity, specificity, and accuracy were 79.4% (27/34 cases), 95.7% (44/46 cases), and 88.8% (71/80 cases), respectively, in ordinary H. pylori diagnosis, and 100% (2/2 cases), 93.3% (14/15 cases), and 94.1% (16/17 cases), respectively, in evaluating eradication at 4 weeks after treatment of H. pylori.

CONCLUSIONS

Having the patient lie horizontally on the left side, using a film-coated (13)C-urea tablet without using mouthwash, and measurement at 3 min provided a simple and accurate method of (13)C-urea breath test for detection of H. pylori in the remnant stomach after gastrectomy.

[Late follow-up of gastrectomized patients for peptic ulcer: clinical, endoscopic and histopathological aspects]

BACKGROUND

The gastrectomy is an uncommon procedure because the proton bomb inhibitors associated to the antibiotic outlines used to eradicate the Helicobacter pylori changed the focus of the peptic ulcer treatment.

AIMS

Later evaluation on those patients who underwent partial gastrectomy as a treatment for peptic ulcer, at that time when any drug to eradicate the Helicobacter pylori was not used. The clinical evaluation included the late postoperative symptoms and postgastrectomy syndromes like dumping, diarrhea, alkaline gastritis and nutritional aspects. The upper digestive endoscopy analysed the surgery reconstruction and the gastric stump, the duodenum and the jejunum mucosa aspects. The histopathological evaluation included looking for Helicobacter pylori by using two different methods: histology and urease test.

CASUISTIC AND METHODS

Fifty-nine patients, 44 (74.6%) male, median age 55.5 years old (range from 31 to 77 years old), who underwent a clinical interview and an upper digestive endoscopy. Paraffin blocks from the surgical specimen were reviewed in order to find out if the patients did have or did not have Helicobacter pylori before surgery.

RESULTS

The final results show that most of the patients had very good and good clinical evolution (Visick I e II) in 96%. The most common symptoms on late postoperative are mild dyspepsia with or without Helicobacter pylori, and diarrhea, anemia and dumping occurred in, respectively, 11 (18.6%), 2 (3.4%) and 2 (3.4%) cases. The Billroth I reconstruction had the best clinical results on statistical rate. The endoscopic finding showed normal results in the most number of cases, and reflux alkaline gastritis or erosive gastritis in a few cases. Ulcer recurrences were diagnosed in two patients (3.4%), and both had positive Helicobacter pylori. Most of the patients had Helicobacter pylori (86%) before surgery and also in the postoperative time (89.9%).

CONCLUSIONS

The patients had a very good clinical evolution after the gastrectomy. The Billroth I reconstruction had the best clinical results. The Helicobacter pylori is still present on gastric stump in late postoperative time, and we believe that it does not bring any negative influence to surgical results.

Efficacy of triple therapy plus cetraxate for the Helicobacter pylori eradication in partial gastrectomy patients

In the present study, we aimed to establish an additional standardized protocol with a higher H. pylori eradication rate in the remnant stomach. Fifty-five H. pylori-positive patients were randomly allocated to one of three regimens: LAC--lansoprazole, amoxicillin, and clarithromycin b.i.d. for 7 days (n = 17); LAC+CET--LAC b.i.d. plus cetraxate q.i.d. for 7 days (n = 20); and LEFT--LAC for 7 days in a horizontal body position on the left side for 30 min (n = 18). Patient compliance and side effects were checked via interviews. H. pylori eradication was successful in 75, 72, and 41% in LAC+CET, LEFT, and LAC, respectively. The eradication rate was significantly higher in LAC+CET than in LAC (P = 0.024) but not in LEFT (P = 0.058). Adverse events that occurred in each group were almost all mild ones. Cetraxate plus LAC for 1 week is a safe and effective regime for the eradication of H. pylori in patients after partial gastrectomy.

Diagnostic value of culture, histology and PCR for Helicobacter pylori in the remnant stomach after surgery

BACKGROUND

Diagnosis of Helicobacter pylori infection in the remnant stomach has not been established.

AIMS

To investigate the diagnostic value of culture, histology, PCR and serum IgG against H. pylori (ELISA) with and without eradication therapy in the remnant stomach, compared with the unoperated stomach.

METHODS

Biopsy samples for bacterial culture and histological diagnosis of H. pylori were taken from the stoma and upper corpus of the remnant stomach and gastric juice was used for PCR assay.

RESULTS

Bacterial culture-based diagnosis in the remnant stomach, sensitivity and specificity of culture were 95.1%, 100%; histology 89%, 92.3%; PCR 66%, 89.7%; and ELISA 100%, 50%, respectively, in cases without H. pylori eradication therapy. In assessment of the results of therapy for the remnant stomach, sensitivity and specificity of culture were 100%, 100%; histology 80%, 96.8%; PCR 80%, 91.7%; and ELISA 100%, 0%, respectively.

CONCLUSION

Bacterial culture had the highest diagnostic value in the remnant stomach as well as unoperated stomach. Sensitivity by histology and PCR was lower in the remnant stomach than the unoperated stomach, but specificity values were equal. Serum ELISA assay was not suitable for the remnant stomach.