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INTRODUCTION

Most benign gastric disorders are either inflammatory or neoplastic. A variety of vascular, mechanical, congenital, and traumatic disorders also affect the stomach. Some of these are covered in other chapters of this book. Surgical management of benign gastric disorders has evolved significantly over the last 40 years. Elective peptic ulcer surgery for intractability has largely been replaced by medical management, though urgent operation for perforation is not uncommon, and occasional elective ulcer operation is still necessary for obstruction or nonhealing. Most elective (and even urgent) gastric procedures can now be performed with laparoscopy (and in some cases with robotic assistance) if local expertise is available. Intraoperative endoscopic guidance with or without ultrasound allows accurate lesion localization and can help the surgeon perform a more targeted resection when wide margins are not necessary.

HELICOBACTER PYLORI INFECTION

Helicobacter pylori−induced chronic gastritis is the most important risk factor for peptic ulcer and gastric adenocarcinoma, a major cause of cancer death worldwide. Successful H pylori treatment largely eliminates recurrent peptic ulcer in infected patients, and eradication of H pylori worldwide would eliminate most cases of gastric adenocarcinoma. H pylori infection is also associated with mucosa-associated lymphoid tissue (MALT) lymphoma, dyspepsia, hyperplastic gastric polyps, and even idiopathic thrombocytopenic purpura (ITP). When Marshall and Warren elucidated the relationship between H 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. It is now clear that most gastric adenocarcinoma is also related to chronic Helicobacter gastritis.

H 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, and reinfection risk after curative treatment is high. 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 hygiene and 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. Family members of infected individuals are at increased risk of infection. In developing countries, most people become infected during childhood. A number of occupations also show increased rates of H pylori infestation, notably healthcare workers. Infection with H pylori is a chronic disease and does not resolve spontaneously without specific treatment. Worldwide, H pylori–induced gastritis accounts for 80% to 90% of all gastritis.

H pylori has evidently adapted to the hostile gastric environment and displays a number of ...

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