Gastrectomy patients may not need preoperative H. pylori eradication

Last Updated: 2015-04-16

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - Preoperative Helicobacter pylori eradication therapy may not be necessary before gastrectomy in gastric cancer patients, regardless of the planned procedure, new research from Japan suggests.

Dr. Michitaka Honda of the Japanese Foundation for Cancer Research in Tokyo, and colleagues assigned 70 patients about to undergo gastrectomy to a preoperative eradication group and 72 patients to a postoperative eradication group, at one medical center. They reported their results online April 8 in the Journal of the American College of Surgeons.

The participants were older than 20 and had gastric adenocarcinoma. Those in the preoperative group received oral lansoprazole 30 mg, amoxicillin 1 mg, and clarithromycin 500 mg every 12 hours for 7 days before their operation, and those in the postoperative group received same medications after postoperative day 8.

Gastrectomy for 18 patients involved Billroth I; for 70 patients Roux-en-Y; and for 57 patients pylorus-preserving gastrectomy.

In the preoperative group, 68.6% of patients successfully eradicated H. pylori, and the result was similar in the post-op group at 69.4%. Subgroup analysis showed no significant difference among the reconstruction methods used.

"If there is intent to eradicate H. pylori infection, whether this is pursued pre- or post-gastrectomy does not appear to differ based on this trial and a previous randomized controlled trial in patients who are able to tolerate oral intake relatively soon after surgery," Dr. Joseph Chao of the City of Hope Comprehensive Cancer Center in Duarte, California, who was not involved in the study, told Reuters Health email.

"These findings are somewhat surprising as the stomach remnant environment may change post-gastrectomy through factors that the authors also highlight, such as gastric pH, bacterial load, and bile reflux, which may lower the success of H. pylori eradication post-surgery," Dr. Chao said.

"The results are as one would expect, but the success rates for both groups were very poor, suggesting that the therapy chosen was one where increasing resistance has made it ineffective," Dr. David Y. Graham, of Baylor College of Medicine in Houston, Texas, told Reuters Health by email.

"The infection was acquired in childhood and there should be little reason to expect a difference in response or eventual outcome. The therapy used for these patients should be reconsidered and a more effective one used," advised Dr. Graham, also not involved in the study.

Dr. Chao said that it was important to do this study to have prospective data to address whether preoperative medication is better than postoperative medication.

"Clinicians should be encouraged by this study that if H. pylori eradication is not done prior to gastric cancer surgery, it can still be pursued post-surgery with fairly equivalent outcomes."

"However," Dr. Chao added, "eradication pre-surgery should still be the primary consideration as it may not be possible to extrapolate these results to patients who have difficulty eating after surgery. The study excluded such patients, but delayed oral intake can be a potential complication postoperatively that may negatively impact attempts at H. pylori eradication."

"Whether the equivalent rates of H. pylori eradication pre- and post-surgery will translate into equivalent rates of reducing the development of new primary gastric carcinomas within the gastric remnant remains unanswered. This will likely be difficult to answer without much longer patient follow-up and potentially larger patient numbers," he said.

The corresponding author did not respond to requests for comments.

The authors reported no external funding or disclosures; Drs. Chao and Graham had no disclosures.

SOURCE: http://bit.ly/1J8fdUc

J Am Coll Surg 2015.