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 Table of Contents  
Year : 2018  |  Volume : 16  |  Issue : 3  |  Page : 296-299

Evaluation of the importance of histopathology of all gastric remnants following sleeve gastrectomy

1 Department of General Surgery, Faculty of Medicine, Al-Azhar University, Assuit, Egypt
2 Department of General Surgery, Faculty of Medicine, Al-Azhar University, Egypt
3 Department of General Surgery, Faculty of Medicine, Al-Azhar University, Assuit Branch, Assuit, Egypt

Date of Submission24-Sep-2018
Date of Acceptance10-Feb-2019
Date of Web Publication15-Apr-2019

Correspondence Address:
Abd Al-Kareem Elias
Department of General Surgery, Faculty of Medicine, Al-Azhar University, Assuit, 33515
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AZMJ.AZMJ_108_18

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Background This study attempts to determine the importance of histopathology of all gastric remnants after sleeve gastrectomy (SG).
Patients and methods Data were collected on patients undergoing SG between 8 January 2017 and 6 June 2018 in Al-Azhar University Hospitals. Significant abnormalities were classified as any pathology that might require follow-up or treatment beyond the standard follow-up. Age, comorbidities, sex, and Helicobacter pylori titers were analyzed and compared with pathology specimens.
Results Full pathologic evaluation was available for 60 patients. No examples of malignancy or dysplasia were identified. Gastritis was the most common abnormality. There was a statistically significant association between preoperative H. pylori and significantly abnormal pathology. Other comorbidities had no association.
Conclusions These results suggest that full pathologic evaluation of the gastric remnant following SG is unnecessary, particularly when gross pathology is not noted at initial operation.

Keywords: morbid obesity, sleeve gastrectomy, weight-loss surgery

How to cite this article:
Al-Tokhy AA, Morsi AE, Elias AA. Evaluation of the importance of histopathology of all gastric remnants following sleeve gastrectomy. Al-Azhar Assiut Med J 2018;16:296-9

How to cite this URL:
Al-Tokhy AA, Morsi AE, Elias AA. Evaluation of the importance of histopathology of all gastric remnants following sleeve gastrectomy. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Jul 6];16:296-9. Available from: http://www.azmj.eg.net/text.asp?2018/16/3/296/255850

  Introduction Top

The most successful long-term treatment for obesity, and the obesity-related comorbid diseases, remains bariatric surgical intervention. Recommendations by the National Institutes of Health, and reviewed by the American Bariatric Society [1], state that patients are suitable for bariatric surgery if they have a BMI of at least 40.0 kg/m2, or a BMI of between 35.0 and 39.9 kg/m2 with one or more obesity-related comorbidity, or a BMI of between 30.0 and 34.9 kg/m2 and either uncontrolled type 2 diabetes or metabolic syndrome. Of the bariatric surgical options available, sleeve gastrectomy (SG) has been gaining in popularity [2],[3]. SG offers the advantage of being easily performed laparoscopically and is associated with a relatively quick recovery and short postoperative hospital stay. Also, it is less complex compared with the Roux-en-Y gastric bypass or biliopancreatic diversion while maintaining the native gastrointestinal pathway, thereby minimizing chronic malabsorption problems. Moreover, it has been proven to be a safe operation with low mortality [4]. While SG was thought to be effective via calorie restriction, changes in incretins, alterations in the microbiome, and modulation of the hormone ghrelin [5],[6] all appear to contribute to weight loss. When performing SG, many institutions and surgeons send the resected gastric remnant for full pathologic analysis. Full pathologic analysis includes macroscopic evaluation, microscopic evaluation, and any associated staining necessary by the pathologist performing the evaluation. This study attempts to determine whether the incidence of pathological abnormalities in a given population warrants full pathologic evaluation in all patients.

  Patients and methods Top

A retrospective review of consecutive patients presenting for SG between January 2017 and June 2018. All final pathology reports were reviewed. Any abnormality reported by the pathologist was documented. Significant abnormalities, defined as those abnormalities or findings on pathology requiring continued follow-up or treatment, were analyzed separately. All procedures were performed laparoscopically. Statistical analyses were performed comparing preoperative comorbidities and Helicobacter pylori titers of patients whose remnants showed any pathological findings. The incidence of multiple remnant pathological classifications was further defined using exact 95% two-sided confidence intervals for the incidence of abnormal, significantly abnormal, and urgently abnormal pathology outcomes as well as for the incidence of each pathology outcome category. Phi contingency coefficients were used to isolate any statistically significant association (P≤0.05) that might exist between Abnormal and Significantly Abnormal outcomes (present/absent) and pre-existing medical statistically significant correlations (P≤0.05) between Abnormal and Significantly Abnormal outcomes (present/absent) and pre-operation Age, BMI and Antibody (AB) Titer measurements using a continuous metric Analyses were conducted using the StatXact Software [v.11.0.0 (cytel India, Pune, India)] and the NCSS software [v.10 (NCSS, LLC., Utah, USA)] was used to calculate both Phi and Point Biserial coefficients.

  Results Top

The study population is composed of 60 patients. Consecutive patients who underwent SG were included from 8 January 2017 to 6 December 2017. The average age was 48±12 years, with an average preoperative BMI of 43±6 kg/m2; 42 were women with comorbidities including diabetes mellitus, hypertension, and obstructive sleep apnea. Gastroesophageal reflux disease (GERD) was identified in 23 patients and history of H. pylori infection was noted in 43 patients. Coronary artery disease was noted in 13 patients. All demographics are based on the date of surgery. H. pylori infection was based on preoperative immune status serology of at least 0.90. Of those patients (43) with positive H. pylori serology, eight were found to have H. pylori bacteria within the gastric remnant. Of the specimens found to have ‘other’ pathologies one was with scattered benign lymphoid aggregates and one with portions of the stomach showing autolytic changes. Pathologic findings that were categorized as ‘other’ also included focal lymphoid aggregates, a lymph node with reactive changes, well-formed lymphoid follicles, submucosal fat in two specimens, and one specimen with features suggestive of reactive gastropathy. Complete gross and microscopic pathologic evaluation was performed by pathologists.. Forty-five were noted to have abnormal pathology. Gastritis or inflammation was the most common abnormality, noted in 99% specimens. Of these, two had areas of acute and chronic inflammation and one specimen had isolated active gastritis. Additional abnormalities were noted in other specimens. These included: benign polyps and active H. pylori. Intestinal hyperplasia/metaplasia was identified in two specimens and no dysplasia or malignancy was observed. For this study, significant pathology was defined as any pathology that might require follow-up or treatment beyond that for normal postbariatric intervention follow-up. This may include identification of H. pylori or metaplasia in the gastric remnant specimen. Urgently abnormal pathology was defined as abnormal pathology requiring treatment or intervention in the 30-day postoperative period. [Table 1] shows both the incidence and 95% two-sided confidence interval for abnormal, significantly abnormal, and urgently abnormal pathology.
Table 1 Incidence of urgent pathology

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[Table 2] shows the incidence of each abnormal pathologic finding in the study as well as the 95% two-sided confidence interval of expected incidence. Statistical analysis was performed for each level of pathology (abnormal, significantly abnormal, and urgently abnormal) and the correlation with preexisting medical conditions. This analysis was also performed on patient sex. Analysis revealed a statistically significant association between preoperative presence of H. pylori and abnormal pathology. There was also a trend toward association between female sex and abnormal pathology, although this did not meet statistical significance (P=0.052).
Table 2 Shows the incidence of abnormal pathologic finding in the study

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  Discussion Top

Bariatric surgery remains the gold standard for the treatment of obesity, its comorbidities, or patients who have failed medical management. SG has increased in popularity [2],[3]. Our data suggest that this practice is not necessary. In this study, none of the specimens showed pathological findings of malignancy or conditions that required treatment or immediate follow-up beyond that of the standard postsurgical bariatric follow-up. In an era of increasing health-care costs, these results suggest that full pathologic evaluation of the gastric remnant following SG is unnecessary, particularly when abnormal gross pathology is not noted at the time of the initial operation. In high-risk or symptomatic patients, such as those with active or long-term GERD symptoms, preoperative esophagogastroduodenoscopy (EGD) may be warranted. EGD is also indicated in patients with symptoms of early satiety or abdominal pain or those individuals in whom gastric pathology is suspected. These data indicate that a good screening test for patients that would require pathologic review of the gastric remnant is an H. pylori serology at the preoperative clinical visit. This, however, may also be unnecessary. With a two-sided confidence interval range of 4.2–9.7% for significantly abnormal pathology in patients with a positive preoperative serology for H. pylori, not performing serology prior to surgery (and not sending the remnant for pathology) would result in missing significant pathology in less than 10% of SG patients. If that incidence is deemed an acceptable level of missed pathology, then preoperative serology is also not indicated. In average risk patients or those patients with negative H. pylori serology at the preoperative visit, back-table examination of the remnant at the time of surgery, including both palpation of the remnant for submucosal lesions and visual inspection for abnormalities of the mucosa, may be all that is required. Full pathologic analysis can be requested following surgery if an abnormality is noted at the time of back-table evaluation. The most common pathology in our data was gastritis or inflammation. Nine specimens contained active H. pylori infection of the study samples. With [7] specimens showing intestinal metaplasia predictors of abnormalities that would influence postsurgical management, it differs from previously published data addressing incidental findings within gastric remnants that include gastrointestinal stromal tumors and mucosa-associated lymphoid tissue lymphomas [8],[9],[10],[11]. Although H. pylori was identified in 2.6% of our specimens, it is unclear if these patients would require further follow-up based upon the incidental finding of bacterial infection. Current data suggest that H. pylori infection does not affect the outcomes of SG [12],[13]. The data also suggests that although H. pylori infection has been shown to increase the rate of marginal ulcer formation following Roux-en-Y gastric bypass surgery, there is no increase in morbidity rates following SG in patients found to have active infection [14]. The question remains as to whether patients with active H. pylori infection warrant further treatment [1],[15]. During SG, ∼85% of the greater curvature of the stomach is removed. This includes the majority of tissue that is potentially colonized or infected with the bacteria. In addition, most acid-producing cells are resected, minimizing the risk of peptic ulcer disease. For these reasons, some groups have stopped treating patients found to be infected with H. pylori if they have undergone SG [16]. There will always be evidence to suggest that full pathological evaluation be performed on all patients. In the period after data collection was completed and writing of this manuscript, the remnant of one patient was found to contain an incidental gastrointestinal stromal tumor on review of pathology. However, our surgeons continue to follow institutional policy, sending all remnants for pathology. This small tumor would very likely have been identified by palpation on back-table examination of the specimen. Despite the large variation of cost figure estimates, time approach to pathologic evaluation of the gastric remnant, it would be unwise to suggest that every pathologic review be completely abandoned for all patients undergoing elective SG. However, a more selective approach can be used safely by both institutions and individual surgeons corroborated by the findings of this review. In patients with preoperative symptoms of reflux, existing diagnosis of GERD, or those deemed high risk based on clinical suspicion a preoperative EGD may be used. This is in line with agreement of American Society for gastrointestinal endoscopy guideline recommendation for obese patient which states: ‘An upper endoscopy should be performed in all patients with upper gastrointestinal-tract symptoms who are to undergo bariatric surgery. (level 2C)’ and ‘In patients without symptoms and who are not undergoing an endoscopy, noninvasive H. pylori testing followed by treatment, if positive, is recommended. (level 3)’ 7, 9, 17. In those with positive serology, sending the gastric remnant for full pathologic review would be a high consideration. It would also be our recommendation that all specimens removed undergo back-table evaluation at the time of surgery performed by the operating surgeon. If, at the time of inspection, there is gross abnormality by visual inspection or by palpation, the specimen then be sent for full pathologic review.

  Conclusion Top

From this study, in all patients undergoing SG, it is not necessary to send part of the stomach removed for histopathological evaluation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Burguera B, Agusti A, Arner P, Baltasar A, Barbe F, Barcelo A et al. Critical assessment of the current guidelines for the management and treatment of morbidly obese patients. J Endocrinol Invest 2007; 30:844–852.  Back to cited text no. 1
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Basso N, Capoccia D, Rizzello M, Abbatini F, Mariani P, Maglio C et al. First-phase insulin secretion, insulin sensitivity, ghrelin, GLP-1, and PYY changes 72 h after sleeve gastrectomy in obese diabetic patients: the gastric hypothesis. Surg Endosc 2011; 25:3540–3550.  Back to cited text no. 6
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Viscido G, Signorini F, Navarro L, Campazzo M, Saleg P, Gorodner V et al. Incidental finding of gastrointestinal stromal tumors during laparoscopic sleeve gastrectomy in obese patients. Obes Surg 2017; 27:2022–2025.  Back to cited text no. 8
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Beltran MA, Pujado B, Méndez PE, Gonzáles FJ, Margulis DI, Contreras MA et al. Gastric gastrointestinal stromal tumor (GIST) incidentally found and resected during laparoscopic sleeve gastrectomy. Obes Surg 2010; 20:393–396.  Back to cited text no. 11
Shanti H, Almajali N, Al-Shamaileh T, Samarah W, Mismar A, Obeidat F. Helicobacter pylori does not affect postoperative outcomes after sleeve gastrectomy. Obes Surg 2017; 27:1298–1301.  Back to cited text no. 12
Gonzalez-Heredia R, Tirado V, Patel N, Masrur M, Murphey M, Elli E et al. The impact of Helicobacter pylori on the complications of laparoscopic sleeve gastrectomy. Obes Surg 2014; 24:412–415.  Back to cited text no. 13
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ASGE STANDARDS OF PRACTICE COMMITTEE, Anderson MA, Gan SI, Fanelli RD, Baron TH, Banerjee S, Cash BD et al. Role of endoscopy in the bariatric surgery patient. Gastrointest Endosc 2008; 68:1–10.  Back to cited text no. 16


  [Table 1], [Table 2]

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