WHAT TO EXPECT IN THE EXCLUDED STOMACH MUCOSA AFTER VERTICAL BANDED GASTROPLASTYROUXENY GASTRIC BYPASS FOR MORBID OBESITY

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WHAT TO EXPECT IN THE EXCLUDED STOMACH MUCOSA AFTER VERTICAL BANDED GASTROPLASTY-ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITYAdriana Vaz Safatle-Ribeiro, Rogério Kuga, Kiyoshi Iriya, Ulysses Ribeiro, Jr, Joel Faintuch, Robson K. Ishida, Carlos Eduardo P. Corbett, Arthur Belarmino Garrido Júnior, Shinichi Ishioka, Paulo SakaiDepartments of Gastroenterology and PathologyUniversity of São Paulo School of Medicine, São Paulo, BrazilJ. Gastrointest. Surg. 2007 Feb;11(2):133-7

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Mucosal alterations after vertical banded Roux-en-Y gastric bypass for morbid obesity has not been clearly evaluated, since the excluded stomach is not easily reached by conventional endoscopy. Few cases of gastric adenocarcinoma in the bypassed stomach have been described (Raijman et al., 1991; Lord et al., 1997; Khitin et al., 2003; Escalona et al., 2005). The new technique of enteroscopy, a double-balloon method (Fujinon), enables endoscopic evaluation of the excluded stomach (Sakai et al., 2005). BACKGROUND

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AIM To analyze the histological findings and the presence of Helicobacter pylori in the excluded stomach.

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METHODS Double-balloon enteroscopy was performed in 40 consecutive patients who underwent Roux-en-Y gastric bypass longer than 36 months. The excluded stomach was reached in 35/40 patients (87.5%). All H. pylori positive patients were treated before surgery. Morphological alterations were analyzed through hematoxilin and eosin method. The presence of H. pylori was confirmed with Giemsa staining.

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Figure 1: Schematic representation of Roux-en-Y gastric bypass.

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Figure 2: Endoscopic image of excluded stomach. Bile refluxate can be seen.

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Figure 3: Chronic inflammatory infiltrate in the epithelium of excluded stomach (H&E, X20).

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Figure 4: Atrophy of the epithelial glands can be detected (H&E, X20).

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Figure 5: Foci of intestinal metaplasia can be noted (H&E, X20).

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Figure 6: Helicobacter pylori colonization in the gastric pits of the excluded stomach (Modified Giemsa, X100).

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RESULTS Gender: 30/35 patients (85.7%) were female Mean age: 43.4 years-old (22 - 61 years-old) Mean post-operative time: 77.6 months (range 36 - 110 months) Endoscopy: 8/35 (22.8%) cases endoscopically normal bypassed stomach 2/35 (5.7%) patients had suspicious areas of intestinal metaplasia

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RESULTS All patients had chronic gastritis in the bypassed stomach, with pangastritis in 33/35 (94.3%) Mild gastritis: 23/35 (65.7%) Moderate gastritis: 12/35 (34.3%) Severe gastritis: none Atrophy: 5/35 (14.3%) cases (4 with intestinal metaplasia) H. pylori in the excluded stomach: 7/35 (20%) Positive in the antrum in all of them, and also positive in the body in 4 patients

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RESULTS Severity of gastritis (inflammation) of the excluded stomach was associated to the presence of H. pylori, p=0.02 H. pylori in the gastric stump (functional pouch): 12/35 (34.3%) All positive H. pylori patients in the excluded stomach were also positive in the gastric stump, p=0.0005

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Table 1. Distribution of Helicobacter pylori in the excluded stomach of 35 patients who underwent Roux-en-Y gastric bypass for morbid obesity*

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CONCLUSIONS H. pylori is still present in the excluded stomach after Roux-en-Y gastric bypass and might be considered for treatment; Histological findings indicated high prevalence of atrophy and intestinal metaplasia in this selected population; Long-term endoscopic follow-up with biopsies is advised.

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