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Chapter 21

The surgical management of benign gastric disorders has evolved significantly over the past 30 years. Elective surgery for ulcer disease has largely been abandoned in favor of medical management with surgery being utilized mainly for complications after failed medical treatment. Most elective (and some emergent) gastric procedures can now be performed with laparoscopy if local expertise is available, augmented by either radiologic (mainly via intra-operative ultrasound) or endoscopic guidance for more accurate localization. These techniques can help the surgeon perform a more targeted resection because wide margins are not necessary.

When Marshall and Warren elucidated the relationship between Helicobacter pylori and peptic ulcer disease, a discovery for which they were later awarded the Nobel Prize in Medicine, they rekindled the hypothesis that this common clinical malady was an infectious disease.1H. pylori is a gram-negative spiral flagellated organism that currently infects more than half of the people in the world. The prevalence of H. pylori infection varies among populations and is strongly correlated with socioeconomic conditions. In a number of developing countries, H. pylori infection affects more than 80% of middle-aged adults. Infection rates are lower in industrialized countries. Epidemiological data indicate that the prevalence of infection in the United States has been declining since the second half of the 19th century, with the decreases corresponding to improvements in sanitation. Nonetheless, H. pylori infection is predicted to remain endemic in the United States for the next century.

Human beings are the only reservoir for H. pylori. Infection is presumed to occur by oral ingestion of the bacterium. Direct transmission from person to person occurs via saliva and feces, and infection also occurs through contact with contaminated water. In developing countries, most individuals are infected during childhood. Family members are at increased risk of infection. A number of occupations also show increased rates of H. pylori infestation, notably health care workers. Infection with H. pylori is a chronic disease and does not resolve spontaneously without specific treatment.

H. pylori has evidently adapted to the hostile gastric environment and displays a number of features that permit its entry into the surface mucus layer, attachment to gastric epithelial cells, evasion of immune responses, and persistent colonization despite luminal acidity. Up to 15% of the protein in a helicobacter organism is composed of cytoplasmic urease that converts periplasmic urea into CO2 and ammonia, the latter buffering the surrounding acid.2

### Host Response to H. Pylori

H. pylori infestation is followed by continuous gastric inflammation in virtually all individuals. Because spontaneous cure is unusual for most infected individuals, this means that H. pylori gastritis is a lifelong affliction. Worldwide, H. pylori–induced gastritis accounts for 80–90% of all gastritis.

H. pylori infection is not invasive of the gastric mucosa, and the host immune response is triggered by the attachment of bacteria to surface epithelial cells. The initial inflammatory response is ...

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