Spectrum of Gastric Histopathologies in Severely Obese American Patients Undergoing Sleeve Gastrectomy

Incidental GIST in Patients Undergoing Bariatric Surgery: A Systematic Review of Incidence and Management

BACKGROUND

There has been a rapid increase in prevalence of obesity, and bariatric surgery is the most effective treatment to reduce all-cause mortality. Gastrointestinal stromal tumors (GISTs) comprise approximately 1% of GI tumors and are the most commonly encountered incidental tumor at the time of bariatric surgery. They have a reported prevalence of approximately 0.5%; however, there are no established guidelines for incidental GISTs.

METHODS

This study performed a systematic literature search using PubMed to identify 100 articles from 2005 to 2023 on incidental GIST tumors found during bariatric operations.

RESULTS

Total prevalence of GISTs was 0.54% with an average size of 7.04 mm. Management of these lesions should prioritize negative margins with the least invasive resection. Tumors able to be resected without alteration to bariatric surgery should be managed with a complete wedge resection prioritizing negative margins. In tumors where resection requires alteration to bariatric surgical plan, the decision to proceed with resection and alteration of bariatric surgical plan should be made only if previous discussions have been made with patient. Lastly, if resection of the GIST precludes the ability to perform the bariatric procedure, consideration to resect the GIST with the goal of negative margins should be prioritized with a plan to discuss future bariatric procedures after.

CONCLUSION

The goal of this paper is to remind bariatric surgeons to be aware of GISTs and provide the possible approaches to management.

Histopathological Examination of 404 Sleeve Gastrectomy Specimens at a Large UK Center and Systematic Review of the Published Literature

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) specimens are histologically analyzed to identify incidental pathologies. However, no guidelines recommend routine histology. This study evaluates the clinical utility of LSG sample analysis and if incidental diagnoses have a significant clinical impact.

METHODS

A single high-volume UK bariatric unit retrospectively gathered LSG data covering a 9-year period. All specimens were sent for histological analysis. Where incidental diagnoses were identified, patient records were reviewed to assess any clinical management alterations. A systematic review (2013-2023) was performed, exploring rates of incidental pathologies post-LSG. Publications were stratified into those performing routine pre-operative endoscopy, or not, and results compared to present data.

RESULTS

From 01/06/2013 to 12/12/2022, 404 patients underwent LSG. 365/404 (90.4%) had no pathology on histopathological analysis. Seven (1.7%) appeared macroscopically abnormal, with histology identifying 3 polyposis and 1 each of GIST, pernicious anaemia, sarcoidosis and gastritis. Ten (2.48%) appeared macroscopically normal but had incidental pathology. All patient management remained unchanged. Twenty-two (5.44%) were H. pylori positive. Forty-eight publications within wider literature reviewed LSG specimen histology. Fifteen, including 9662 patients undergoing pre-operative endoscopy, found pathological diagnoses in 0.5% and 1 malignancy. Thirty-three studies reporting 17,008 patients without pre-operative endoscopy identified pathologies in 0.45% and 7 malignancies.

CONCLUSION

There is little clinical utility in analyzing macroscopically normal gastric samples following LSG. The potential financial and environmental savings from limiting this practice are of great importance to worldwide bariatric teams. The authors recommend selectively sending LSG specimens only if abnormal gastric mucosa is identified when examining the extracted specimen.

Routine Histopathology in Laparoscopic Sleeve Gastrectomy Over 10 Years

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is one of the world's most commonly performed types of bariatric surgery. Routine histopathology of the surgical specimen is undertaken at most institutions, regardless of the lack of clinical suspicion of any sinister pathology. We evaluated the histopathology reports of LSG cases done for morbid obesity at our hospital over 10 years to determine the distribution of gastric changes and the prevalence of Helicobacter pylori infection in these specimens.

METHODS

A retrospective study was conducted. All LSGs performed at Shifa International Hospital, Islamabad, Pakistan, from July 1, 2014, to June 30, 2024, were assessed. A total of 538 cases were included. Histopathology reports were reviewed for all these patients, and the histopathological diagnosis and the presence or absence of H. pylori infection were recorded.

RESULTS

The mean age was 36.9 ± 11.4 years. There were 201 (37.4%) males. No abnormality was found in 105 (19.5%) cases. Gastritis was present in 433 (80.5%) cases. Intestinal metaplasia was present in eight (1.5%) cases in a background of gastritis. There were no cases of gastric atrophy or dysplasia. There was one case of submucosal lipoma (0.2%) and one case of gastrointestinal stromal tumor (GIST) (0.2%). Both cases were associated with gastritis. H. pylori infection was present in 140 (26.0%) cases. All of these were associated with gastritis. Among the gastritis cases, 319 (73.7%) had chronic gastritis, while 114 (26.3%) had both active and chronic gastritis. The severity of gastritis, as designated by the histopathologist in their report, was minimal in 24 (4.5%) cases, mild in 228 (42.4%), moderate in 176 (32.7%), and severe in five (0.9%). There was one case of granulomatous gastritis (non-caseating) (0.2%). There was no difference in the prevalence of gastritis or H. pylori infection based on age or gender.

CONCLUSION

Histopathological examination of the LSG specimen revealed a very high prevalence of gastritis, with normal findings in less than a fifth of all cases. The prevalence of H. pylori infection (26.0%) is much higher in comparison to other studies. Routine histopathology of LSG specimens should continue to be performed in every case.

Evaluating the Necessity of Routine Histopathology in Sleeve Gastrectomy Specimens: A Five-Year Analysis

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is a widely performed bariatric surgery that involves the removal of a portion of the stomach. Routinely, the resected gastric tissue is sent for histopathological examination to screen for malignancies or other significant pathological findings. However, the necessity of this routine practice remains uncertain. This study aims to evaluate the histopathological outcomes of LSG specimens over a five-year period at our institution.

METHODS

We conducted a retrospective analysis of 203 patients who underwent LSG between January 2017 and December 2022 at Heartlands Hospital, University Hospitals Birmingham. Data collected included patient demographics, body mass index (BMI), use of preoperative oesophagogastroduodenoscopy (OGD), and histopathological findings. Patients with incomplete records or those who underwent Roux-en-Y gastric bypass were excluded from the study.

RESULTS

Data were extracted for 310 patients, of whom 107 were excluded. The majority of the 203 patients analyzed were female (83%), with a mean age of 45.7 years and a mean BMI of 45.4 ± 7.3. Preoperative OGD was performed in only 0.5% of cases. Histopathological examination revealed that 81.3% (n=165) of patients had normal gastric mucosa, while 14.3% (n=29) had chronic gastritis. Clinically significant findings were rare, with only 1% (n=2) of patients showing gastrointestinal stromal tumors (GISTs) or focal intestinal metaplasia. None of the patients required additional treatment or follow-up based on these histopathological findings.

CONCLUSION

Most LSG specimens in our study showed normal or non-significant histopathological findings, raising questions about the routine use of histopathological examination in LSG procedures. It remains unclear whether histopathology is necessary following sleeve gastrectomy. While no patients in our cohort required further treatment or surveillance, there are reports in the literature where surveillance or further treatment was necessary, though the incidence remains low. Given the low incidence of clinically significant pathology, further studies with larger sample sizes and multi-center data are needed to establish clear guidelines on this issue.

Can Incidental Gastric GISTs During Bariatric Surgeries Change the Primary Plan of Surgery? A Single Team Experience and a Systematic Review of Literature

As bariatric surgeries (BS) increase, more incidental findings are liable to be discovered. Incidental gastric gastrointestinal stromal tumors (GISTs) during BS can be found in around 0.7% of the cases. In this article, we have performed a systematic review of the literature and added our data to those of the review to review a conceptual treatment strategy to both improve patient outcomes and decrease the risk of overall cancer. With the rise of new bariatric techniques, we have proposed a new classification to BS to enhance our description of the treatment strategy.

A comparison of staining methods for Helicobacter pylori in laparoscopic vertical sleeve gastrectomy resections

BACKGROUND

Helicobacter pylori is an important public health concern due to its status as a carcinogenic bacterium. Well adapted to the acidic environment of the human stomach, the variety of strains and virulence factors of the organism when interacting with the host immune system creates an individualistic response. Although estimates suggest that approximately half of the global population is infected with H pylori, the majority of infected persons remain asymptomatic while harboring an increased risk of intestinal metaplasia and gastric cancers. Therefore, appropriate diagnostic testing protocols are imperative.

METHODS

This study compared labeling methodologies, including Wright stain, alcian yellow toluidine blue (AYTB), and immunohistochemistry (IHC) on formalin-fixed paraffin-embedded stomach resections from sleeve gastrectomy patients, to detect H pylori infection.

RESULTS

Although all 3 labeling methods evidenced similar specificity in H pylori detection, the IHC method was significantly more sensitive. However, the IHC cost per test was approximately 5-fold higher than that of the Wright or AYTB stains, and the technical time required per test was at least 6-fold that of Wright or AYTB.

CONCLUSION

Despite the higher cost per test, IHC is the most sensitive and preferred method for determination of H pylori infection.

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

INTRODUCTION

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.

METHODS

We reviewed 426 consecutive SG patients to determine the concordance of preoperative endoscopy findings in patients with clinically significant postoperative pathology.

RESULTS

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).

CONCLUSION

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.

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

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?

PURPOSE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.

Association of Hypercholesterolemia With Gastric Intestinal Metaplasia, Findings After Sleeve Gastrectomy Pathology Review

BACKGROUND

We evaluated the relationship between comorbidities associated with obesity, body mass index (BMI), and development of intestinal metaplasia (IM) after vertical sleeve gastrectomy (VSG).

MATERIALS AND METHODS

All VSG specimens performed at an academic center between 2011 and 2018 were reviewed. All specimens underwent histopathologic assessment, while those with findings suspicious for IM underwent additional immunohistochemical work up. Baseline patient characteristics and demographic data were obtained from Iran National Obesity Surgery Database by retrospective review.

RESULTS

A total of 862 adult individuals underwent VSG during the study period and specimens were histopathologically examined. All patients had preoperative upper endoscopy. The most common histopathologic diagnosis was miscellaneous findings (57.8%) followed by no pathologic finding (36.7%). The minority of patients (5.5%) had IM. Although 40.5% of patients had positive Helicobacter pylori infection preoperatively, just 13.8% had still positive infection postoperatively. A significant association was found between IM and hypercholesterolemia (odds ratio: 1.95; 95% confidence interval: 1.1, 3.5).

CONCLUSION

This study found a correlation between histopathologic changes in patients with IM and hypercholesterolemia. Prospective research studies are recommended to further examine this correlation.

Routine histopathologic examination of the resected specimen after laparoscopic sleeve gastrectomy - what can be expected?

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) is nowadays an established bariatric procedure. Although preoperative gastroscopy is recommended to rule out severe pathologies, there is little evidence about the role of routine histopathologic examination of resected specimens. We sought to identify the prevalence of histopathological relevant findings in patients undergoing LSG and to evaluate their impact in clinical practice.

METHODS

A retrospective analysis on a prospectively collected dataset on patients undergoing LSG between August 2009 and May 2018 in two bariatric centers was performed. Demographic and clinical data and histopathological results were analyzed.

RESULTS

Sixhundred-thrirteen patients were identified, mean age was 43.1 years (14-75), average body mass index was 44.8 kg/m² (34.4-73.9). Histopathology revealed abnormal findings in 47.97% of the patients, most common pathology was chronic non-active or minimally to moderate active gastritis (n = 202;32.95%). Among others, Helicobacter-associated gastritis (n = 33;5.38%), intestinal metaplasia (n = 13;2.12%), micronodular enterochromaffine-like cell hyperplasia (n = 2; 0.33%) and gastrointestinal stromal tumors (n = 6; 0.98%) were present. No malignancies were found. Histopathological results required a change in the postoperative management in 48 patients (7.83%). The costs of histopathological assessment ranged between 0.77% and 2.55% of per-case payment.

CONCLUSION

A wide range of histopathological findings occur in specimens after LSG, requiring a relevant number of patients additional therapies or surveillance. Therefore, routine histopathological examination after LSG is recommendable.

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

CONTEXT.—

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.

OBJECTIVE.—

To perform a histologic and cost-benefit analysis of gastric remnants post-LSG.

DESIGN.—

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.

RESULTS.—

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.

CONCLUSIONS.—

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 Prevalence in Laparoscopic Sleeve Gastrectomy Specimen

Introduction

Laparoscopic sleeve gastrectomy (LSG) has become a common surgical procedure. The value of routine histopathologic examination of the LSG specimens remains, however, a controversial issue. Helicobacter pylori was the most prevalent finding in several previous studies, but the overall results were dissimilar. We aim to assess the prevalence of Helicobacter pylori and other histopathologic findings in LSG specimens and the effect of increasing the number of sections for histology, from LSG specimens, on the rates of abnormal findings.

Methods

We retrospectively reviewed the histopathologic data of all patients who had undergone LSG, in a tertiary care center, over a 4-year period (n = 481). Patient characteristics and histopathologic findings were recorded and analyzed.

Results

Inactive chronic gastritis was the most common histopathologic finding (62.16%) followed by Helicobacter pylori gastritis (35.34%). Intestinal metaplasia was identified in 1.66% of the cases. There was no diagnosis of malignancy. Increasing the number of sections submitted for histopathologic examination resulted in a significantly higher rate of H. pylori gastritis detection.

Conclusion

Routine histopathologic examination of LSG specimens may detect H. pylori in a significant proportion of patients, and increasing the number of sections for histology from LSG specimens improves the rate of detection of this bacterium and identifies individuals who may benefit from treatment.

The use of nonsteroidal anti-inflammatory drugs after sleeve gastrectomy

BACKGROUND

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is discouraged after bariatric surgery. The effect of NSAIDs on patients who have undergone sleeve gastrectomy (SG) is not well studied. Moreover, the rate of NSAID use after SG is unknown.

OBJECTIVES

To determine the rate of NSAID use after SG, and its associated complications.

SETTING

A single institution, multi-surgeon, academic, tertiary care hospital.

METHODS

We performed a retrospective review of patients who underwent SG between January 1, 2014, and November 1, 2017. A phone interview was conducted with identified patients. The inclusion criteria were any patient who had undergone SG during the study period, and there were no exclusion criteria.

RESULTS

We identified 421 SG patients for inclusion. There were 231 phone surveys completed, with 64.5% of respondents reporting some NSAID use after SG. Of the respondents who used NSAIDs, 40.3% reported that they used the drugs often (>once/wk), 28.2% reported occasional use (>once/mo but <once/wk), and 31.5% reported rare use (<once/mo). Nearly 26% of phone interview respondents regularly used NSAIDs after SG. A retrospective review of the 421-patient cohort revealed 0 cases of sleeve complications secondary to NSAID use when searching for incidences of bleeding, ulceration, gastritis, gastropathy, perforation, leak, or stenosis.

CONCLUSION

NSAID use in our bariatric surgery population is high despite an institutional policy to prohibit their use across all bariatric patients. Despite the high incidence of NSAID use in our patient population, we could not identify a single case of an NSAID-induced gastrointestinal complication in our retrospective review. NSAID use after SG may be a safe and viable pain management strategy that needs further evaluation.

Trends in bariatric surgery and incidentalomas at a single institution in Saudi Arabia: a retrospective study and literature review

BACKGROUND

Data are lacking on trends in bariatric surgery and the frequency of incidental findings in Saudi Arabia.

OBJECTIVE

Report on trends in bariatric surgery as well as our experience in incidental findings along with a literature review (mainly on gastrointestinal stromal tumor).

DESIGN

Retrospective chart and literature review.

SETTINGS

Academic tertiary care center.

PATIENTS AND METHODS

We conducted a retrospective study at King Khalid University Hospital and analyzed the data collected from 2009 to 2019. We collected data on age, body mass index (BMI), H pylori infection, type of bariatric surgery performed, and type and location of incidental findings.

MAIN OUTCOME MEASURES

Incidental findings during or after bariatric surgery (in pathology specimen).

SAMPLE SIZE

3052 bariatric surgeries, 46 patients with incidentalomas.

RESULTS

The mean and standard deviation for the age of the 46 patients with incidentalomas was 42.1 (13.9) years and the mean (SD) preoperative BMI was 43.4 (6.4) kg/m². Of 3052 bariatric surgeries performed, the most common type was sleeve gastrectomy (93.9%), followed by gastric bypass surgery (4.58%) and gastric banding (1.47%). The total frequency of incidentalomas was 1.5%; 10.8% of patients had gastrointestinal stromal tumors (GIST), with the stomach being the commonest site for incidental findings. Eighty percent of the patients with GIST were positive for H pylori (P=.01 vs negative patients).

CONCLUSION

The number of incidentalomas and other findings were consistent with other reports. All these findings suggest that bariatric surgeons should take special care before, during, and after a laparoscopic operation in obese patients.

LIMITATIONS

Since this is a single-center, retrospective study, we did not collect data on important variables such as gender, socioeconomic status of the patient, and family history of obesity, and we did not perform a preoperative esophagogastroduodenoscopy.

CONFLICT OF INTEREST

None.

Laparoscopic sleeve gastrectomy performed in a morbidly obese patient with gastrointestinal stromal tumor: a case report and literature review

Background

Gastrointestinal stromal tumor (GIST) is the most frequent submucosal tumor, and with advancements of diagnostic modalities, the incidence of GIST cases diagnosed have increased. Similarly, prevalence of morbid obesity has also rapidly increased over the past decade. Notably, the incidence of GIST in obese patients was reported to be more frequent as compared to the general population. Despite local resection being the first choice for GIST treatment, extensive surgery should also be considered depending on the tumor size and location. Laparoscopic sleeve gastrectomy (LSG), the most popular bariatric procedure, could also be a concomitant treatment option for both morbid obesity and GIST when the tumor is contained within LSG the excision range. There are, however, few reports about LSG planned for GIST preoperatively.

Case presentation

A morbidly obese 46-year-old Japanese male (body weight of 105.4 kg, body mass index (BMI) of 36.6 kg/m²) was diagnosed with an intramural GIST in the gastric fundus. Because of his extreme visceral fat dominated obesity (visceral fat area of 386 cm²), in addition to the size and location of the tumor, we determined that it would be difficult to perform local resection. We planned LSG as a concomitant treatment for both GIST and morbid obesity. After the preoperative examination and 6 months of weight control, the patient lost enough weight to undergo LSG safely. Keeping enough distance away from the tumor, which we observed with an endoscope, we performed LSG to successfully resect the tumor. The patient was discharged uneventfully. Weight loss was successful as his BMI was 21.0 kg/m² at 3 months post-surgery.

Conclusion

We successfully performed LSG in a morbidly obese patient with a large GIST. This is the largest GIST concomitantly resected with LSG reported within current literature.

Review of pathological findings in laparoscopic sleeve gastrectomy specimens performed for morbid obesity

BACKGROUND

Bariatric surgical procedures are employed when there is a failure of lifestyle modification in arresting obesity. Laparoscopic sleeve gastrectomy (LSG) is quickly becoming the bariatric surgical procedure of choice. LSG results in a gastric remnant that is subject to pathological examination. The objective of this paper is to review the literature in regard to histological findings identified in gastric remnants post-LSG and identify the most pertinent histological findings.

MATERIALS AND METHODS

A literature search was performed to identify relevant case series. Data gathered from relevant case series then underwent statistical analysis.

RESULTS

The most common histological findings in an LSG specimen were clinically indolent findings such as no pathological abnormalities identified followed by non-specific gastritis. A minority of cases demonstrated clinically actionable findings for which Helicobacter pylori represented the majority of these findings.

CONCLUSION

There is a broad spectrum of pathological findings in LSG specimens, ranging from clinically indolent to clinically actionable. The most common histological findings are clinically indolent and only a small portion are of clinical significance and, hence, actionable.

Compared to What? Is BMI Associated with Histopathological Changes in Laparoscopic Sleeve Gastrectomy Specimens?

BACKGROUND

Obesity is a risk for many different cancers. Laparoscopic sleeve gastrectomy (LSG) is common, and benign or pre-malignant histopathology types are reported in the removed gastric specimens. We assessed whether higher BMI was associated with certain benign or pre-malignant histopathological changes.

METHOD

Retrospective chart review of all primary LSG patients (N = 1555). Demographic, clinical, and LSG histopathology data were retrieved. BMI of patients with specific benign or pre-malignant conditions in their gastric specimens was compared with the BMI of the rest of the patients with abnormal histopathology specimens and also compared with the BMI of patients with normal control specimens.

RESULTS

Females comprised 70% of the patients. Mean BMI were 46.3 (females) and 48 (males). Normal LSG specimens comprised 52%. Most common abnormal histopathologies were chronic inactive gastritis (33%), chronic active gastritis (6.8%), follicular gastritis (2.7%), lymphoid aggregates (2.2%), intestinal metaplasia (1.4%) and GIST (0.7%). After controlling for confounders (age, gender, H. pylori, diabetes mellitus type 2, hypertension), no significant association was observed between the BMI of patients with specific benign or pre-malignant histopathology compared with the BMI of the rest of the patients with abnormal histopathologies and compared to the BMI of patients with normal histopathologies.

CONCLUSION

When confounders were taken into account, there appeared no significant associations between the BMI of patients with specific benign or pre-malignant histopathology compared with the BMI of the rest of the patients with abnormal histopathologies and compared to the BMI of patients with normal histopathologies of their gastric specimens. There was a very weak correlation between BMI and other covariates.

Gastric Histopathologic Findings in South Italian Morbidly Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: Is Histopathologic Examination of All Resected Gastric Specimens Necessary?

BACKGROUND

The value of the routine histopathologic examination of resected gastric remnants following laparoscopic sleeve gastrectomy (LSG) remains to be controversial. This study aimed to determine whether the routine histopathologic examination of gastric specimens is necessary for all patients undergoing LSG if upper gastrointestinal endoscopy (UGIE) plus multiple biopsies are performed routinely during the preoperative work-up.

MATERIALS AND METHODS

Clinicopathologic data of 474 patients who underwent LSG were analysed. Types of histopathologic findings in LSG specimens and the prevalence of these and Helicobacter pylori (HP) infection were estimated. Comparisons were conducted to assess the association of risk factors with the most frequent abnormal and premalignant histopathologic findings.

RESULTS

Chronic gastritis was the most common gastric pathology (63.5%) and premalignant lesions were present in 7.8% of the specimens. The prevalence of HP infection was 36.9%. A statistically significant association was observed between HP infection and chronic gastritis (P = .000), and premalignant lesions (P = .000). Similarly, a statistically significant association was noted between age and premalignant gastric lesions (P = .000).

CONCLUSION

Histopathologic examination of LSG specimens may not be routinely needed and can be performed on selected patients. While we recommend routine preoperative UGIE in all LSG-treated patients, we suggest that histopathologic assessment of the LSG specimens should be mandatory when UGIE biopsies demonstrate HP infection and/or premalignant lesions, in all patients older than 42 years, and in cases of intraoperative detection of incidental tumours or suspicious lesions.

Histopathological Findings in Morbid Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: Does H. pylori Infection Effective on Pathological Changes?

AıM: To determine the prevalence of histopathological findings requiring clinical follow-up in morbidly obese patients undergoing laparoscopic sleeve gastrectomy (LSG) and evaluate the relationship between these findings and Helicobacter pylori as well as to add more data to the published literature in this regard. MATERıAL AND METHODS: Overall, 161 morbidly obese patients with body mass index (BMI) > 40 kg/m² who underwent LSG between May 1, 2014 and May 31, 2017 were retrospectively included in the study. The findings of the histopathological evaluation of the resected gastric material and the relationship between these findings and histopathologically detected H. pylori infection were investigated.

RESULTS

The study included 114 women (70.8%) and 47 men (29.2%). The mean age of the patients was 36.82 ± 10.41 years, and the mean BMI was 46.05 ± 3.76 kg/m². H. pylori infection was detected in 103 (64%), chronic gastritis in 156, chronic active gastritis in 47, intestinal metaplasia in eight, and atrophy in seven patients. The rate of H. pylori-associated chronic gastritis was 64%, that of chronic active gastritis was 24.2%, that of lymphoid aggregation was 62.2%, and that of intestinal metaplasia and atrophy was 3.1%. There was a significant relationship between H. pylori infection and chronic gastritis, chronic active gastritis, and lymphoid aggregation; however, no significant relationship was found between intestinal metaplasia and atrophy. CONCLUSıON: Clinicians should be aware of the histopathological findings requiring clinical follow-up for LSG-treated patients. Given the complications of H. pylori infection such as lymphoma and malignancy, periodic follow-up of patients and eradication therapy may be a suitable approach for treating intestinal metaplasia and atrophic changes.

Histopathology Findings in Patients Undergoing Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has gained popularity in the last 10 years for its good results in weight loss and comorbidity control. However, guidelines on the pathological examination of the specimen are lacking. The aim of this retrospective study was to determine the usefulness of the routine specimen examination when presurgery endoscopy (upper gastrointestinal endoscopy, UGIE) and multiple gastric biopsies are part of the preoperative work-up.

METHODS

A retrospective review of records of the patients submitted to LSG between January 2012 and August 2017 was carried out. Sex, age, histopathology findings in the presurgery endoscopy biopsies and surgical specimen, and the prevalence of Helicobacter pylori infection were analyzed.

RESULTS

A total of 925 patients entered the study group (mean age = 44.1 years, Females = 80.3%, BMI = 44.58 kg/m²). The most common histopathology pattern in the endoscopy biopsies and in the surgical specimens was inactive chronic gastritis (64.4 and 55.6%, respectively). Helicobacter pylori infection was 24.6 and 2.48%, respectively. Ninety-nine percent (n 796) of patients with non-significant endoscopy biopsy findings showed the same patterns in specimen analysis. Only three patients (0.3%) who had intestinal presurgery metaplasia were positive in the specimen analysis, and two cases of gastric stromal neoplasms (gastrointestinal stromal tumor and gastric leiomyoma) were found intraoperatively.

CONCLUSION

Most of the findings are non-significant and can be predicted if UGIE plus multiple biopsies is routinely included in the bariatric work-up with significant cost reduction. In those patients who had a significant finding prior to the surgery or intraoperatively, the pathological examination of the specimen is recommended.

Histopathological findings in laparoscopic sleeve gastrectomy specimens

Objective: To study the demographic data and histopathological specimen findings of patients who have undergone laparoscopic sleeve gastrectomy. Design: A retrospective descriptive study. Setting: Pathology and Laboratory Medicine Department, Al-Ahli Hospital, Doha, Qatar. Methods: Data of patients who underwent laparoscopic sleeve gastrectomy between January 1, 2009 and December 31, 2016 were retrospectively collected from the laboratory information system of Al-Ahli Hospital. Results: A total of 342 patients underwent laparoscopic sleeve gastrectomy. Among these patients, 294 (86%) were Qatari and 241 (70%) were female. The patient age ranged from 13 to 72 years, and most patients were in the 31-40-year age group. Histological examination of specimens showed that lymphocytic aggregates in the lamina propria were the most frequent histopathological finding (171, 50%), followed by no remarkable pathological finding (98, 28.6%). The other pathological findings were follicular gastritis, fundic gland polyps, and acute and chronic gastritis. Conclusion: Our findings clearly indicate the need for routinely performing histopathological examination of laparoscopic sleeve gastrectomy specimens. The study also highlights lymphocytic aggregates as the most common histopathological finding.

Pathologic findings of the removed stomach during sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the preferred surgical intervention to treat morbid obesity. Despite the rising popularity of LSG, little is known on the histopathologic findings of the resected partial stomach specimens. Our study aims to identify prevalent pathologic findings of the removed stomach and explore the association between patient characteristics and abnormal findings.

METHODS

A retrospective analysis was conducted using a prospectively maintained database of 649 patients who underwent LSG between November 1, 2013 and December 31, 2015 at our institution. Patient characteristics included age, body mass index, gender, and preoperative comorbidities (diabetes, hyperlipidemia, depression, gastroesophageal reflux, hypertension, and sleep apnea). Statistical analysis was performed using descriptive analysis and logistic regression models.

RESULTS

Abnormal pathologic findings were identified in approximately one-fifth (n = 142, 21.9%) of the patients. The most common find is non-specific chronic gastritis (9.7%), followed by Helicobacter pylori gastritis (4.9%). Approximately 15% of patients had significant histopathological alterations that might require further investigation, treatment, or follow-up, including non-specific chronic gastritis, H. pylori gastritis, autoimmune atrophic gastritis, and gastrointestinal stromal tumor. The odds of abnormal findings in patients without hyperlipidemia was 0.09 times the corresponding odds in those with hyperlipidemia (95% CI 0.03-0.29), controlling for factors including age, body mass index, gender, and other preoperative comorbidities.

CONCLUSION

Patients with gastroesophageal reflux and hyperlipidemia might suggest higher incidence rate of gastric histopathologic abnormalities. Routine preoperative screening may not be beneficial for patients undergoing sleeve gastrectomy.

Histopathological examination of tissue resected during bariatric procedures - to be done or not to be done?

INTRODUCTION

Obesity is one of the major lifestyle diseases and provokes various comorbidities, such as hypertension, type 2 diabetes mellitus, obstructive sleep apnea, and even neoplasms. Bariatric surgery is the most effective treatment of obesity. Since cost-effectiveness has become a major concern, there is a tendency to avoid general histological evaluation of surgical specimens during routine procedures.

AIM

To evaluate the necessity of histopathological investigation of tissue excised during bariatric surgery and to verify whether the operation should be continued in the case of suspicious macroscopic findings.

MATERIAL AND METHODS

From January 2013 to December 2016, 1252 patients with obesity were qualified for bariatric procedures. The qualification was performed according to the current European recommendations. Every operation started with an inspection of the peritoneal cavity performed once the abdomen was insufflated. If a macroscopic pathology was found, the specimen was secured for histopathological investigation.

RESULTS

Out of 81 (6.47%) patients from whom histopathological samples were collected, 39% (n = 32) showed negative results, and 61% (n = 49) cases showed abnormalities.

CONCLUSIONS

As it is impossible to exclude the existence of gastric tumors only in preoperative gastroscopy and ultrasonography, especially as there is a higher risk in obese patients, routine histological examination of tissue excised during bariatric procedures should be considered. Since most of the neoplasms were found to be benign, there is no need to abandon the bariatric procedure if a pathology is found and resected. Bariatric surgeons should always focus on thorough examination of the abdominal and the pelvic cavity, especially in female patients.

Histopathological Changes in Laparoscopic Sleeve Gastrectomy Specimens: Prevalence, Risk Factors, and Value of Routine Histopathologic Examination

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a common surgical therapeutic option for obese patients, with debate about the value of routine histopathologic examination of LSG specimens. We assessed the following: prevalence of different histopathologic changes in LSG specimens, risk factors associated with premalignant and with frequent histopathologic changes, and whether routine histopathologic examination is warranted for LSG patients with nonsignificant clinical history.

METHODS

Retrospective review of records of all LSG patients operated upon at Hamad General Hospital, Qatar (February 2011-July 2014, n = 1555), was conducted. Risk factors (age, BMI, gender, and Helicobacter pylori) were assessed in relation to specific abnormal histopathologic changes.

RESULTS

Mean age and BMI of our sample were 35.5 years and 46.8, respectively. Females comprised 69.7% of the sample. Normal histopathologic specimens comprised 52% of the sample. The most common histopathologic changes were chronic inactive gastritis (33%), chronic active gastritis (6.8%), follicular gastritis (2.7%), and lymphoid aggregates (2.2%). We observed rare histopathology in 3.3% of the sample [e.g., intestinal metaplasia and gastrointestinal stromal tumor (GIST)]. Older age was associated with GIST and intestinal metaplasia (P = 0.001 for both). Females were associated with chronic active gastritis (P = 0.003). H. pylori infection was associated with follicular gastritis, lymphoid aggregates, GIST, intestinal metaplasia, and chronic active gastritis (P < 0.001 for each).

CONCLUSION

Older age, H. pylori, and female gender are risk factors for several abnormal histopathologic changes. Histopathologic examination of LSG specimens might harbor significant findings; however, routine histopathologic examination of all LSG specimens, particularly in the absence of suggestive clinical symptoms, is questionable. The association between female gender and chronic active gastritis; and the association between H. pylori infection and GIST are both novel findings that have not been previously reported in the published literature.

The pathological findings seen in laparoscopic sleeve gastrectomies for weight loss

Sleeve gastrectomy specimens are increasingly common surgical specimens received for examination following bariatric surgery for weight loss. The spectrum of pathological changes seen in these cases is not well documented. Retrospective examination was undertaken of 1463 consecutive sleeve gastrectomy specimens received at Envoi Specialist Pathologists. Most cases showed no pathological changes (80.2%). The most common changes seen were non-specific, non-Helicobacter associated chronic gastritis (7.2%), Helicobacter associated gastritis (6.8%) and benign fundic gland polyps (4.0%). Other, rarer changes were lymphocytic gastritis, autoimmune atrophic gastritis, chronic gastritis with intestinal metaplasia, hyperplastic polyps, pancreatic heterotopia, gastrointestinal stromal tumours (GISTs) and a leiomyoma. A wide range of pathological changes are seen in resection specimens following sleeve gastrectomies for weight loss. Many cases will require further treatment or ongoing investigation and surveillance.