1. Helicobacter pylori eradication prior bariatric/metabolic surgery
Tadeja Pintar, Tanja Carli, Robert Juvan, Primož Sever
UMC Ljubljana, Clinical department of Abdominal surgery

2. Introduction
H. pylori is an ancient colonizer of the human stomach and represents the main etiological factor in the development of gastritis, peptic ulcer and gastric malignant lesions;
The influence of these factors on H. pylori infection in obesity remains to be ascertained.

3. ● In 80 % of colonised patients no clinical signs of infection is present; ● 40 % of patients are histologically positive for chronic atrophic gastritis; ● 20 % of colonised patients are positive for peptic ulcer disease, duodenal ulcer, MALT lymphoma and gastric cancer; ● Chronic H. pylori colonisation is in correlation to anemia, idiopatic thrombocytopenic purpura and chronic urticaria.
Introduction

4. Introduction
● A possible explanation of these conflicting results can be ascribed to H. pylori-related gastritis patterns; ● The outcome of H. pylori infection differs according to gastritis extension, which generally starts with antritis and subsequently progress to pangastritis, which may be associated with atrophy; ● In chronic gastritis patients the regulation between ghrelin and leptin production is impaired.

5. Obesity can alter innate and adaptive immunity, related to the grade of obesity: ● impaired maturation of monocytes into macrophages; ● diminished polymorphonuclear bactericidal capacity; ● significant decrease in NK cell activity.

6. Detection of risk factors in morbidly obese candidates for surgical treatment
● Venous trombembolism - incidence of 0,34% ;
● Gastrointestinal leak – 1% for LABG to 2% for RYGB and SG;
● Early bleeding, including intraluminal and intraperitoneal bleeds, complicates 1% to 4% of bariatric operations;
● Sepsis resulting from anastomotic dehiscence;
● Respiratory failure;
● Postoperative cardiac events.

7. Detection of risk factors in
Detection of risk factors in morbidly obese candidates for surgical treatment
Delayed complications:
● Marginal ulceration near the gastrojejunal anastomosis of a RYGB or a BPD;
● H.pylori infection .

8. Data
● Data are highly positive that infection with H. pylori has an association with postoperative complications in all type of bariatric surgery procedures.
● Current guidelines are not uniform for the management of H. pylori infection in obese patients who are candidates for bariatric surgery

9. Data
● The prevalence of H.pylori colonisation in Slovenian population is 25%.
● In age group between 20 and 49 years, the prevalence of H.pylori colonisation is 29,6%.
● The incidence of obesity in Slovenia is 52% and morbid obesity 39%.
● The incidence of adolescent obesity is growing, among the numbers those with BMI over 40 kg/m2.

10. Colonization of the stomach by H
Colonization of the stomach by H. pylori might affect gastric expression of an appetite- and satiety-related hormone and patients cured of H. pylori infection gained weight.

11. H. pylori infection plays a special role in obesity for two main reasons:
(1) its possible relationship with BMI;
(2) it is a negative factor in limiting access to bariatric surgery.

12. Study design
● 96 patients of average BMI: 46 kg/m2 (84 female, 12 male);
● Upper endoscopy, gastric biopsy for HUT(quick urease test, sensitivity 65%);
● All positive samples were microbiologically identified (culture);
● Histology for additional mucosal biopsy was performed (100% sensitivity);
● Routine repeated upper endoscopy was performed in all H. pylori positive patients after 1 month free interval;
● Standard 7d treatment protocol according to local sensitivity to H. pylori was
prescribed;
● A combination of esomeprazole, amoxicillin and metronidazole treatment
regimen was used with average elevation dose of 30%.

13. Results
HUT test was positive in 63% of patients in 10 minutes period and in 66% in 24 hours period;
● Histology was positive in 76% of patients (73 patients) candidates for weight loss surgery;
● Repeated upper endoscopy and the same diagnostic protocol revealed 92% H.pylori eradication rate.

14. Standard antibiotic dosage correction to BMI resulted in 100% eradication rate

16. Results ● In 2 of 96 patients (2,1%) H.pylori repeated;
● In EGDS negative patients late postoperative surgical complications were observed (1 sleeve gastrectomy leak and 1 marginal ulcer perforation);
● In 8 of 96 patients (8, 3%) late moderate anemia was present despite feral supplementation.

17. Results
Excellent EWL % (average 50 kg, representing 88% of EWL) was obtained in 1 year period and no other postoperative complications.

18. Conclusions
● Data suggest mandatory highly sensitive methods for H.pylori identification;
● Repeated EGDS in H.pylori positive patients prior any weight loss surgery is highly recommended;
● H.pylori eradication reduces short and long term complications after weight loss surgery.

19. Conclusions
Antibiotic dose correction to BMI and a combination regimen of esomeprazole with antibiotic mono/bivalent therapy according to guidelines was more effective and reduced postoperative complications according to data available in the literature.

20. Thank you for your attention!