1. The German “S3-Guidelines of the German Society of Digestive and Metabolic Diseases” from 2009 (4) recommend the following protocol for HP associated gastroduodenal ulcer disease: Triple-treatment (Clarithromycin plus Metronidazole plus PPI) for one week followed by PPI for six weeks, then testing (urea breath test or fecal antigen test) not earlier than 4 weeks after the end of eradication respectively not earlier than 2 weeks after the end of PPI- therapy. In case of positive test results eradication and testing should be repeated. These guidelines do not comment on preoperative screening for bariatric patients but may delay bariatric surgery for several months. This may demotivate patients or stimulate them to address to other bariatric institutions with less strict protocols. In our own experience we did preoperative endoscopy in 158 of 200 bariatric patients and found HP positive in 19 cases (12,0 %). Taking into account that more than 90 % respond well to HP eradication therapy, both urea breath test as well as fecal antigen test for HP can be performed correctly even after gastric bypass procedures and a second eradication can successfully be performed postoperatively, we altered our own protocol as follows (see our algorithm on the left): All bariatric patients have preoperative upper endoscopy with HP testing. In case of a positive result we demand eradication with standard triple therapy for one week but do not delay surgery any further. Our patients routinely have 3 months of postoperative PPI therapy. We recommend re-testing for HP with either breath or stool testing 4 weeks after the end of PPI-course (to avoid false negative results). Should this reveal a positive result then second line eradication can be performed and re-tested for success. A NEW PROTOCOL FOR THE PREOPERATIVE MANAGEMENT OF H. PYLORI IN BARIATRIC SURGICAL PATIENTS IN GERMANY Introduction As the role of routine upper endoscopy prior to bariatric surgery remains controversial, this applies even more for routine preoperative diagnostic and treatment of Helicobacter pylori (HP) infection (1, 2). 1. Chan T, Patel S, Mehran A. Routine Preoperative EGD, UGI, and H. pylori Screening: Are They Necessary? Bariatric Times. 2011;8(3):8–10 2. Papasavas PK, Gagne DJ, Donnelly PE, et al. Prevalence of Helicobacter pylori infection and value of preoperative testing and treatment in patients undergoing laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2008; 4(3):383–388. 3. Runkel N, et al. Evidence-based German guidelines for surgery for obesity.Int J Colorectal Dis. 2011 Apr;26(4):397-404. 4. Fischbach W et al. S3 Leitlinie Helicoacter pylori und gastroduodenale Ulkuskrankheit. Z Gastroenterol 2009; 47: 68-102 5. Forman D, Newell DG, Fullerton F et al. Association between infection with Helicobacter pylori and risk of gastric cancer: evidence from a prospective inverstigation. Bmj 1991; 302(6788): 1302-1305 6. Xue Fb, Xu YY, Wan Y et al. Association of H. pylori infection with gastric carcinoma : a Meta analysis. World J Gastroenterol 2001; 7(6): 801-804 7. Levi F, Lucchini F, Gonzalez JR et al. Monitoring falls in gastric cancer mortality in Europe. Ann Oncol 2004(15): 338-345 8. Graham DY, Malaty HM, Evans DG et al. Epidemoplogy of Helicobacter pylori in an asymptomatic population in the United States. Effect of age, race and socioeconomic status. Gastroenterology 1991; 100(6): 1495-1501 9. Loewen M, Giovanni J, Barba C (2008) Screening endoscopy before bariatric surgery: a series of 448 patients. Surg Obes Relat Dis 4: 709-712 10. Khitin L, Roses RE, Birkett DH. Cancer in the gastric remnant after gastric bypass: a case report. Curr Surg 2003 Sep-Oct; 60(5): 521-523 11. Inoue H, Rubino F, Shimada Y, Lindner V, Inoue M, Riegel P, Marescaux J. Risk of Gastric Cancer After Roux-en-Y Gastric Bypass. Arch Surg. 2007;142(10):947-953 Methods The current literature was studied. This included the national bariatric guidelines of the German Association for General and Visceral Surgery concerning bariatric surgery (3) as well as the guidelines of the German Society for Digestive and Metabolic Diseases concerning HP associated gastroduodenal ulcer disease (4). Furthermore, the authors discussed the topic in (non-systematic) interviews with several German bariatric colleagues of other bariatric centres and with a bariatric expert from the US (Dr. R. Rutledge). On this basis and taking into account the own bariatric experience of 7 years of bariatric activity, a new protocol was developed. Conclusions Results HP is proven to be a very important cause for the development of distal gastric cancer as well as gastric MALT-lymphoma (5, 6). With current medical treatment of HP associated gastritis, duodenitis and gastroduodenal ulcers as well as with better controlled food quality the incidence of gastric cancer diminished tremendously within the last decades (7). About 25 % of western adult populations are positive for HP (1, 8). Many bariatric experts recommend some kind of HP screening prior to bariatric surgery and eradication therapy in case of possible results (1). HP positive gastritis seems to be a risk factor for postoperative marginal ulcer following gastric bypass surgery (9). The German “S3-Guideline for Surgery of Obesity” from 2010 does not clearly recommend testing for HP prior to bariatric surgery (3). It neither comments on whether a routine eradication should be performed nor whether the success of eradication should be controlled preoperatively. Interviewing german fellows (not systematically, personal discussion with collegues during bariatric meetings and congresses) revealed that there seems to be no general practice among german bariatric surgeons regarding this issue. Some even do not perform neither endoscopy nor screening for HP systematically prior to bariatric surgery. Many do this only in the presence of strong clinical suspicion (reflux symptoms, patients under antiacid treatment, previous history of gastroduodenal ulcers). Some perform routine upper endoscopy themselves on the operation table a few minutes prior to surgery without any testing for HP. Others are satisfied with an ambulatory normal gastroscopy result even without any HP testing. Ambulatory upper endoscopies in Germany are avoided by gastroenterologists because (in contrast to colonoscopies) the reimbursement by the health insurances – even without HP testing - is not enough to compensate at least the expenses of the practitioner. The compromise of preoperative upper endoscopy with routine testing for H.pylori infection in every bariatric patient followed by one course of eradication in case of positive result seems to us a very reasonable and sufficient solution for the problem of Helicobacter pylori in bariatric patients. We believe that re-testing after one course of eradication therapy preoperatively would be exaggerated and causes unnecessary delay of the bariatric surgery. The elaborated protocol simplifies checking for and treatment of HP infection prior to bariatric surgery. Taking into account that appearance of gastric cancer in the endoscopically not accessible remnant stomach after bypass procedures is an extremely rare condition (10), we think that proving the success of one course of eradication therapy preoperatively is not compulsory and will unnecessarily delay the bariatric surgery. Anyway bariatric surgery should be considered as a prophylactic measurement concerning development of gastric cancer in the remnant stomach (stop of afflux of potentially cancerogenic alimentary agents, less production of chlorine acid) (11). Under socio-economic and ethical aspects the question should be allowed why bariatric patients should have a far better prophylaxis against gastric cancer than the average population? Discussion References Patient to be planned for bariatric surgery Negative for HPPositive for HP Preoperative upper endoscopy with testing for HP Eradication (triple therapy with Clarithro- mycin, Metronidazol and PPI for 7 days) Bariatric surgery Re-testing (urea breath test or fecal antigen test) not earlier than 2 weeks after end of postoperative PPI- prophylaxis (normally after 3 months) Positive result Negative result 2 nd line eradication and re- testing until negative result Algorithm for diagnosis and treatment of possible HP infection prior to bariatric surgery HP is held responsible for several gastric diseases (electron micrographs courtesy of Nycomed, Germany) Rheinwalt KP¹, Plamper A¹, Kolec S¹, Kleimann E¹, van Lessen IM¹, Rutledge R² ¹Department for Bariatric and Metabolic Surgery St. Franziskus-Hospital Cologne Schoensteinstrasse 63 50825 Cologne, Germany ²Center for Laparoscopic Obesity Surgery 98E Lake Mead Parkway 302, Henderson, NV, USA P 112