LAUSR

Dear Editor, We thank Prof. Kountouras et al. of this letter to the editor for their insights and comments to our recent findings concerning the impact of Helicobacter pylori (HP) and eradication on early complications after sleeve gastrectomy (SG) [1]. The results of our study suggest that the presence of HP does not affect early outcomes following SG, when compared with HP negative patients. We also found that preoperative HP eradication was not associated with improved outcomes. We guardedly concluded that the role of routine preoperative HP screening and eradication may be limited in SG patients. This is in line with other studies [2–7] that showed similar results concerning early morbidity and mortality after SG. We agree with Prof. Kountouras et al. that this represents one side of the coin, as indeed was emphasized throughout our manuscript. HP induces systemic immunomodulation and inflammatory response, which might lead to severe gastric pathologies, such as intestinal metaplasia, adenocarcinoma, and B-cell lymphoma, and HP screening and eradication are highly important as preventive measures [8, 9]. We therefore mentioned in our manuscript that this argument is pro-routine screening and eradication, especially in high-risk populations. Nonetheless, SG preserves endoscopic access to the stomach; therefore, it does not preclude further surveillance and treatment, even in the event of HP recurrence. The possible association of HP with metabolic syndromerelated parameters, as stated by Prof. Kountouras et al. [10–12] is intriguing; however, no causative association was found. Furthermore, there is conflicting evidence in the literature. For example, we found a decreased incidence of non-alcoholic fatty liver disease (NAFLD) in HP positive SG patients. In contrast, in several studies, HP was found to be associated with an increased risk of NAFLD [13, 14], whereas a large cross-sectional study adjusted confounding factors, and no association was found [15]. We also encourage further research of the interaction between HP and metabolic syndrome-related parameters, specifically in the morbidly obese, as results may differ from the general population. In our manuscript, we found that HP positivity was associated with a higher risk of postoperative respiratory complications and VTE; however, numbers were too low to deduce clinical significance. We stated that the possible association between HP and systemic rather than gastricrelated complication could serve as an argument in favor of preoperative eradication, especially in populations with high endemic incidence of HP. In conclusion, we still believe that in non-endemic populations, routine pre-SG screening and eradication may be of limited value; however, all SG specimens should be evaluated for HP, and eradication can be completed post-SG, accordingly. Should an association between HP and systemic complications rather than gastric-related complications be demonstrated, it may warrant preoperative eradication, especially in populations with high endemic incidence of HP. A large-scale, long-term, prospective randomized controlled study is indeed warranted to settle this controversy.