Impact of tumor size on the outcomes of hepatic resection for hepatocellular carcinoma: a retrospective study.

BACKGROUND: To evaluate the impact of tumor size on the perioperative and long-term outcomes of liver resection for hepatocellular carcinoma (HCC). METHODS: We reviewed the patients' data who underwent liver resection for HCC between November 2009 and 2019. Patients were divided into 3 groups according to the tumor size. Group I: HCC < 5 cm, Group II: HCC between 5 to 10 cm, and Group III: HCC ≥ 10 cm in size. RESULTS: Three hundred fifteen patients were included in the current study. Lower platelets count was noted Groups I and II. Higher serum alpha-feto protein was noted in Group III. Higher incidence of multiple tumors, macroscopic portal vein invasion, nearby organ invasion and presence of porta-hepatis lymph nodes were found in Group III. More major liver resections were performed in Group III. Longer operation time, more blood loss and more transfusion requirements were found in Group III. Longer hospital stay and more postoperative morbidities were noted in Group III, especially posthepatectomy liver failure, and respiratory complications. The median follow-up duration was 17 months (7-110 months). Mortality occurred in 100 patients (31.7%) and recurrence occurred in 147 patients (46.7%). There were no significant differences between the groups regarding recurrence free survival (Log Rank, p = 0.089) but not for overall survival (Log Rank, p = 0.001). CONCLUSION: HCC size is not a contraindication for liver resection. With proper selection, safe techniques and standardized care, adequate outcomes could be achieved.

Feasibility and outcomes of living-donor liver transplantation utilizing the right hemi-liver graft with portal vein anatomical variations.

PURPOSE: Portal vein (PV) reconstruction is a key factor for successful living-donor liver transplantation (LDLT). Anatomical variations of right PV (RPV) are encountered among potential donors. METHODS: To evaluate a single center experience of reconstruction techniques for the right hemi-liver grafts with PV variations during the period between May 2004 and 2022. RESULTS: A total of 915 recipients underwent LDLT, among them 52 (5.8%) had RPV anatomical variations. Type II PV was found in 7 cases (13.5%), which were reconstructed by direct venoplasty. Type III PV was found in 27 cases (51.9%). They were reconstructed by direct venoplasty in 2 cases (3.8%), Y graft interposition in 2 cases (3.8%), and in situ double PV anastomoses in 23 cases (44.2%). Type IV PV was found in 18 cases (34.6%) and was reconstructed by Y graft interposition in 9 cases (17.3%), and in situ double PV anastomoses in 9 cases (17.3%). Early right posterior PV stenosis occurred in 2 recipients (3.8%). Early PV thrombosis occurred in 3 recipients (5.8%). The median follow-up duration was 54.5 months (4 - 185). The 1-, 3-, and 5-years survival rates were 91.9%, 86%, and 81.2%, respectively. Late PV stenosis occurred in 2 recipients (3.8%) and was managed conservatively. CONCLUSION: Utilization of potential living donors with RPV anatomic variations may help to expand the donor pool. We found that direct venoplasty and in situ dual PV anastomoses techniques were safe, feasible, and associated with successful outcomes.

Long-term follow-up of living liver donors: A single-center experience.

Living donors are healthy individuals who are exposed to a major surgical procedure during which a major part of their liver is resected. Data on the long-term consequences of living liver donation are scarce. This study examined clinical, laboratory, and long-term health-related quality of life (HRQoL) in 237 living liver donors and 239 matched controls during 48-168 months of postdonation follow-up. We used the 36-item short-form health survey (SF-36), version 1. The scores for the four following subscales were higher in nondonors than in donors: physical functioning (p = 0.009), role limitations due to physical health (p = 0.002), energy/fatigue (p < 0.001), and bodily pain (p < 0.001). The scores on the eight subscales of the SF-36 were higher in donors with living recipients than in donors whose recipients died (p < 0.001). Our results suggest that living donor right hepatectomy is safe and results in a postdonation HRQoL similar to that of nondonors in those donors whose recipients are healthy, whereas donors whose recipients die have a lower HRQoL that is significantly negatively correlated with the time since recipient death and improves over time.

Outcomes of Hepatic Resection for Hepatocellular Carcinoma Associated with Portal Vein Invasion.

BACKGROUND: To evaluate our experience of liver resection for hepatocellular carcinoma (HCC) patients associated with macroscopic portal vein invasion (PVI). METHODS: Consecutive HCC patients who underwent liver resection for HCC between November 2009 & June 2019 were included. To overcome selection bias between patients with and without macroscopic PVI, we performed 1:1 match using propensity score matching (PSM). RESULTS: Macroscopic PVI was detected in 37 patients (12.8%). We divided our patients into two groups according to the presence of macroscopic PVI. After PSM, 36 patients of PVI group were matched with 36 patients from Non-PVI group. After PSM, both groups were well balanced regarding tumor site, number, liver resection extent and type. Longer operation time and more blood loss were noted in PVI group. Higher incidence of post-operative morbidities occurred in PVI group especially, post-hepatectomy liver dysfunction. The 1-, 2-, and 3-y overall survival rates for Non-PVI group were 85.3%, 64.6%, and 64.6% & 69.8%, 42%, and 0% for PVI group, respectively (P = 0.009). There were no significant differences regarding the recurrence rate, site, and its management. The 1-, 2-, and 3-y disease-free survival (DFS) rates for Non-PVI group were 81.7%, 72.3%, and 21.7% & 67.7%, 42.3%, and 0% for PVI group, respectively (P = 0.172). CONCLUSION: Surgical management of advanced HCCs with macroscopic PVI is feasible, and associated with comparable DFS but poorer overall survival, compared to patients without PVI.

Donor wound satisfaction after living-donor liver transplantation in the era of pure laparoscopic donor hepatectomy.

BACKGROUND: Donor safety and cosmetic outcome are the main concerns raised by most living-donors. Pure laparoscopic living-donor hepatectomy (PLLDH) can provide the balance between those concerns. No studies evaluated the donors' satisfaction after PLLDH. The aim of this study is to evaluate the donors' satisfaction after PLLDH compared with donors who underwent open approach. METHODS: We randomly assigned a questionnaire (Donor satisfaction questionnaire) to the donors, operated between 2011 and 2017, during their follow-up visits in the outpatient clinic. Donors who responded to the questionnaire were included in our study. Donors were divided into 3 groups: L group (conventional inverted L incision), M group (midline incision), and PL group (laparoscopic approach). RESULTS: 149 donors were included in our study. L group included 60 donors (40.3%), M group included 39 patients (26.2%), and PL group included 50 patients (33.5%). There were no significant differences between the groups regarding preoperative and perioperative outcomes apart from shorter operation time in PL group and higher wound infection in M group. Body image scale was significantly better in PL group (p = 0.001). Cosmetic scale was significantly higher in PL group (p = 0.001). Regarding self-confidence scale, it was significantly higher in PL group (p = 0.001). There was no significant difference between the groups regarding the sense of dullness or numbness on the scar (p = 0.113). CONCLUSION: PLLDH is safe and feasible for living-donor hepatectomy. Donors operated by pure laparoscopic approach have better satisfaction scores compared to conventional open approach.

Impact of Acute Inflammation on the Survival Outcomes of Patients with Resected Pancreatic Ductal Adenocarcinoma.

INTRODUCTION: The impact of acute inflammation on cancer progression is still not well elucidated. Pancreatic head cancer is occasionally associated with acute cholangitis. C-reactive protein (CRP) is a biomarker that indicates presence of acute inflammation. METHODS: We reviewed the patients' data with pancreatic ductal adenocarcinoma (PDAC) who underwent pancreaticoduodenectomy between 2004 and 2018. RESULTS: Two hundred ninety-one patients were included. Median preoperative CRP was 0.45 mg/dL (0-18.9). Median follow-up duration was 22 months (4-152). The 1-, 3-, and 5-year overall survival (OS) rates were 76.4%, 32.2%, and 22.9%, respectively. Recurrence occurred in 168 cases (57.7%). The 1-, 3-, and 5-year disease-free survival (DFS) rates were 53.9%, 27.1%, and 21.9%, respectively. The median OS was higher in normal CRP patients (27 months) than those with elevated CRP (18 months) (log-rank 0.038). The median DFS was higher in normal CRP patients (17 months) than those with elevated CRP (9 months) (log-rank < 0.001). Predictive factors for OS included BMI, CRP, adjuvant therapy, positive lymph nodes, and microvascular invasion. Predictive factors for DFS included CRP, positive lymph nodes, and microvascular invasion. CONCLUSION: Preoperative CRP was an independent poor prognostic factor for OS and DFS of patients with resected PDAC.

Post-hepatectomy liver failure after hepatic resection for hepatocellular carcinoma: a single center experience.

PURPOSE: Post-hepatectomy liver failure (PHLF) is one of the most feared morbidities after liver resection (LR) for hepatocellular carcinoma (HCC). We aimed to investigate the incidence and predictors of PHLF after LR for HCC and its impact on survival outcomes. METHODS: We reviewed the patients who underwent LR for HCC during the period between January 2010 and 2019. RESULTS: Two hundred sixty-eight patients were included. Patients were divided into two groups according to the occurrence of PHLF, defined according to ISGLS. The non-PHLF group included 138 patients (51.5%), while the PHLF group included 130 patients (48.5%). Two hundred forty-six patients (91.8%) had hepatitis C virus. Major liver resections were more performed in the PHLF group (40 patients (30.8%) vs. 18 patients (13%), p = 0.001). Longer operation time (3 vs. 2.5 h, p = 0.001), more blood loss (1000 vs. 500 cc, p = 0.001), and transfusions (81 patients (62.3%) vs. 52 patients (37.7%), p = 0.001) occurred in PHLF group. The 1-, 3-, and 5-year Kaplan-Meier overall survival rates for the non-PHLF group were 93.9%, 79.5%, and 53.9% and 73.2%, 58.7%, and 52.4% for the PHLF group, respectively (log rank, p = 0.003). The 1-, 3-, and 5-year Kaplan-Meier disease-free survival rates for the non-PHLF group were 77.7%, 42.5%, and 29.4%, and 73.3%, 42.9%, and 25.3% for the PHLF group, respectively (log rank, p = 0.925). Preoperative albumin, bilirubin, INR, and liver cirrhosis were significant predictors of PHLF in the logistic regression analysis. CONCLUSION: Egyptian patients with HCC experienced higher PHLF incidence after LR for HCC. PHLF significantly affected the long-term survival of those patients.

Surgical Loupe at 4.0× Magnification in Pancreaticoduodenectomy-Does It Affect the Surgical Outcomes? A Propensity Score-Matched Study.

BACKGROUND: There is paucity of data about the impact of using magnification on rate of pancreatic leak after pancreaticoduodenectomy (PD). The aim of this study was to show the impact of using magnifying surgical loupes 4.0× EF (electro-focus) on technical performance and surgical outcomes of PD. PATIENTS AND METHOD: This is a propensity score-matched study. Thirty patients underwent PD using surgical loupes at 4.0× magnification (Group A), and 60 patients underwent PD using the conventional method (Group B). The primary outcome was postoperative pancreatic fistula. Secondary outcomes included operative time, intraoperative blood loss, postoperative complications, mortality, and hospital stay. RESULTS: The total operative time was significantly longer in the loupe group ( P = .0001). The operative time for pancreatic reconstruction was significantly longer in the loupe group ( P = .0001). There were no significant differences between both groups regarding hospital stay, time to oral intake, total amount of drainage, and time of nasogastric tube removal. Univariate and multivariate analyses demonstrated 3 independent factors of development of postoperative pancreatic fistula: pancreatic duct <3 mm, body mass index >25, and soft pancreas. CONCLUSION: Surgical loupes 4.0× added no advantage in surgical outcomes of PD with regard to improvement of postoperative complications rate or mortality rate.

Efficacy of octreotide in the prevention of complications after pancreaticoduodenectomy in patients with soft pancreas and non-dilated pancreatic duct: A prospective randomized trial.

BACKGROUND: The efficacy of octreotide to prevent postoperative pancreatic fistula (POPF) of pancreaticoduodenectomy (PD) is still controversial. This study aimed to evaluate the effect of postoperative use of octreotide on the outcomes after PD. METHODS: This is a prospective randomized controlled trial for postoperative use of octreotide in patients undergoing PD. Patients with soft pancreas and pancreatic duct < 3 mm were randomized to 2 groups. Group I did not receive postoperative octreotide. Group II received postoperative octreotide. The primary end of the study is to compare the rate of POPF. RESULTS: A total of 104 patients were included in the study and were divided into two randomized groups. There were no significant difference in overall complications and its severity. POPF occurred in 11 patients (21.2%) in group I and 10 (19.2%) in group II, without statistical significance (P = 0.807). Also, there was no significant differences between both groups regarding the incidence of biliary leakage (P = 0.083), delayed gastric emptying (P = 0.472), and early postoperative mortality (P = 0.727). CONCLUSIONS: Octreotide did not reduce postoperative morbidities, reoperation and mortality rate. Also, it did not affect the incidence of POPF and its clinically relevant variants.

Impact of donor-recipient genetic relationship on outcome of living donor liver transplantation.

Living donor liver transplantation (LDLT) is a valuable option for expanding the donor pool, especially in localities where deceased organ harvesting is not allowed. In addition, rejection rates were found to be lower in LDLT, which is attributed to the fact that LDLT is usually performed between relatives. However, the impact of genetic relation on the outcome of LDLT has not been studied. In this study, we examined the difference in rejection rates between LDLT from genetically related (GR) donors and genetically unrelated (GUR) donors. All cases that underwent LDLT during the period from May 2004 until May 2014 were included in the study. The study group was divided into 2 groups: LDLT from GR donors and LDLT from GUR donors. A total of 308 patients were included in the study: 212 from GR donors and 96 from GUR donors. Human leukocyte antigen (HLA) typing was not included in the workup for matching donors and recipients. GUR donors were wives (36; 11.7%), sons-in-law (7; 2.3%), brothers-in-law (12; 3.9%), sisters-in-law (1; 0.3%), and unrelated (38; 12.3%). The incidence of acute rejection in the GR group was 17.4% and 26.3% in the GUR group (P value = 0.07). However, there was a significant difference in the incidence of chronic rejection (CR) between the 2 groups: 7% in GR group and 14.7% in the GUR group (P value = 0.03). In terms of overall survival, there was no significant difference between both groups. LDLT from the GUR donors is not associated with a higher incidence of acute cellular rejection. However, CR was significantly lower when grafts were procured from GR donors. HLA matching may be recommended before LDLT from GUR donors. Liver Transplantation 23:43-49 2017 AASLD.

Laparoscopic liver resection for hepatocellular carcinoma in cirrhotic patients: 10-year single-center experience.

BACKGROUND: Liver resection in cirrhotic patients reported to have higher morbidity and mortality rates compared to non-cirrhotic patients. Recently, there is increased acceptance of laparoscopic approach in liver surgery. However, few reports evaluated laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) in cirrhotic patients. The aim of this study is to evaluate our experience of LLR for HCC and to compare perioperative and long-term outcomes between patients with and without liver cirrhosis (LC). METHODS: A retrospective analysis of 232 patients who underwent LLR for HCC between 2004 and 2013 was carried out. Patients were divided into two groups according to the pathological status of their liver parenchyma, in terms of presence or absence of LC. RESULTS: LC group had 141 patients, and non-LC group had 91 patients. There were no statistically significant differences between both groups regarding operation time, blood loss, transfusion requirements, intraoperative complications, hospital stay, and postoperative complications. Long-term oncologic outcomes were comparable between both groups regarding the recurrence rates (p = 0.067), overall survival (OS) rates (p = 0.908), and disease-free survival (DFS) rates (p = 0.197). The 1-, 3-, 5-, and 7-year OS were 91.7, 85.5, 79.4, and 70.1% in LC group, and 93.9, 86, 79.5, and 72.3% in non-LC group. The 1-, 3-,5-, and 7-year DFS were 75.3, 52.4, 42.6, and 32.7% in LC group, and 74.1, 57.6, 55.3, 50.2% in non-LC group. CONCLUSIONS: LLR for HCC is feasible in patients with LC. Cirrhotic patients showed comparable perioperative and long-term outcomes to non-cirrhotic patients.

Outcomes of pancreaticoduodenectomy in elderly patients.

BACKGROUND: Although the mortality and morbidity of pancreaticoduodenectomy (PD) have improved significantly over the past years, the concerns for elderly patients undergoing PD are still present. Furthermore, the frequency of PD is increasing because of the increasing proportion of elderly patients and the increasing incidence of periampullary tumors. This study aimed to analyze the outcomes of PD in elderly patients. METHODS: We studied all patients who had undergone PD in our center between January 1995 and February 2015. The patients were divided into three groups based on age: group I (patients aged <60 years), group II (those aged 60 to 69 years) and group III (those aged ≥70 years). The primary outcome was the rate of total postoperative complications. Secondary endpoint included total operative time, hospital mortality, length of postoperative hospital stay, delayed gastric emptying, re-exploration, and survival rate. RESULTS: A total of 828 patients who had undergone PD for resection of periampullary tumor were included in this study. There were 579 (69.9%) patients in group I, 201 (24.3%) in group II, and 48 (5.8%) in group III. The overall incidence of complications was higher in elderly patients (25.9% in group I, 36.8% in group II, and 37.5% in group III; P=0.006). There were more patients complicated with delayed gastric emptying in group II compared with the other two groups. There was no significant difference in the incidence of postoperative pancreatic fistula, biliary leakage, pancreatitis, pulmonary complications and hospital mortality. CONCLUSIONS: PD can be performed safely in selected elderly patients. Advanced age alone should not be a contraindication for PD. The outcome of elderly patients who have undergone PD is similar to that of younger patients, and the increased rate of complications is due to the presence of associated comorbidities.

Laparoscopic versus open liver resection for hepatocellular carcinoma: Case-matched study with propensity score matching.

BACKGROUND & AIMS: Laparoscopic liver resection has gained wide acceptance and is established as a safe alternative to open liver resection. Until now, there is no prospective randomized comparative study between laparoscopic and open liver resection. Previous comparative studies reported minor resections for peripheral tumors, and enrolled small numbers of patients. Moreover, few reported the long term outcomes. The aim of this study is to compare perioperative and long term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma between two matched groups. METHODS: 389 patients underwent liver resection for hepatocellular carcinoma during the period between 2004 and 2013. To overcome selection bias, we performed 1:1 match using propensity score matching between laparoscopic and open liver resection. RESULTS: After propensity score matching, 88 patients were included in each group. Laparoscopic group had shorter hospital stay (8 vs. 10 days, p⩽0.001), and lower postoperative morbidity (12.5% vs. 20.4%, p=0.042). The 1-, 3- and 5-year overall survivals were 91.6%, 87.5%, and 76.4%, for laparoscopic group, and were 93.1%, 87.8%, and 73.2%, for open group (p=0.944). The 1-, 3- and 5-year disease free survivals were 69.7%, 52%, and 44.2%, for laparoscopic group, and 74.7%, 49.5%, 41.2%, for open group (p=0.944). CONCLUSIONS: Our study showed comparative perioperative and long term outcomes between both groups, providing evidence regarding the safety and efficacy of laparoscopic liver resection for hepatocellular carcinoma.

Outcomes of liver resection for huge hepatocellular carcinoma exceeding 10 cm in size: A single center experience.

BACKGROUND: To evaluate our experience of resection for huge hepatocellular carcinoma (HCC) (exceeding 10 cm in diameter). METHODS: We reviewed the patients' data who underwent liver resection for huge HCC between 2010 and 2019. We divided them into two groups according to liver resection extent (minor/major). RESULTS: 40 patients were included. Minor Group included 19 patients (47.5%), and Major Group included 21 patients (52.5%). Longer operation time, hospital stay, and more severe complications were found in Major Group. The 1-, 3-, and 5-years OS rates were 76.6%, 39.5%, and 39.5%, respectively. The 1-, 3-, and 5-year DFS rates were 65.6%, 40%, and 0%, respectively. There were no significant differences between the two groups regarding OS (p = 0.598) and DFS (p = 0.564). CONCLUSION: Liver resection for huge HCC is associated with average morbidities and mortality. Proper selection, adequate techniques and standardized care can provide favorable patients' survival.

Predictive factors of postendoscopic retrograde cholangiopancreatography pancreatitis for biliary complications in living-donor liver transplantation recipients.

OBJECTIVES: Endoscopic retrograde cholangiopancreatography (ERCP) has shown great safety and efficacy in the management of post-living-donor liver transplantation (LDLT) biliary complications. Pancreatitis is the most commonest and the most feared complication after ERCP. METHODS: We reviewed the data of liver transplant recipients who underwent ERCP for biliary complications after LDLT between 2011 and 2022. RESULTS: In total 63 patients underwent ERCP after LDLT. They were targeted to 134 set of ERCP. Pancreatitis occurred in 52 sets (38.8%). We subclassified the patients into two groups, without pancreatitis: 31 patients (49.2%) and with pancreatitis 32 patients (50.8%). A higher incidence of pancreatitis was noticed with the first ERCP set (P = 0.04). Biliary strictures were more noted in the pancreatitis group (P = 0.025). Difficult cannulation requiring precut was more observed in the pancreatitis group (P = 0.007). Also, more frequent sphincterotomy was observed in the pancreatitis group (P = 0.003). Longer hospital stay, more fever, abdominal pain and vomiting were noted in the pancreatitis group (P = 0.001). Higher post-ERCP serum amylase (P = 0.001) and creatinine (P = 0.021), while lower serum calcium (P = 0.21) were noticed in the pancreatitis group. On multivariate analysis, preoperative diabetes, number of biliary anastomoses (single/multiple) and difficult cannulation requiring precut were significant predictors of post-ERCP pancreatitis. CONCLUSION: Patient-related risk factors and bedside procedure-related risk factors play an essential role in the development of pancreatitis after ERCP for LDLT recipients. Endoscopists should be mindful by those high-risk patients during ERCP to apply appropriate techniques to prevent the development of this serious complication.

Clinical, hematological and some biochemical alterations during diarrhea in Friesian calves naturally infected with E. coli and Salmonella.

Background: This study aimed to assess the clinical and hemato-biochemical changes associated with diarrhea in E. coli and Salmonella pathogens in Friesian bovine calves less than one month old as well as to examine the relationship between Vit D3 and cardiac biomarkers. Results: The study was carried out on 43 Friesian calves from a private farm in Ash Sharqia Governorate, 33 diarrheic calves aged 1-14 days with an average body weight 43.7 ± 1.2 kg, and 10 apparently healthy calves were kept as a control group to investigate the clinical and hemato-biochemical profiles. E. coli and Salmonella pathogens were isolated from the diarrheic calves where 76% were E. coli and 24% were Salmonella. Diarrheic calves showed signs of anorexia, weakness, dullness, staggering gait, pale mucous membranes with sunken eyes and dehydration. Analysis of clinical and hemato-biochemical profile of the diarrheic calves revealed significant increase in body temperature, respiratory rate, heart rate, white blood cells, neutrophils, serum potassium, urea, creatinine, ALT, AST, cardiac NT-proBNP and cardiac troponin I with significant decrease in hemoglobin, packed cell volume, erythrocytes, serum Vit D3, sodium, glucose, total protein and albumin concentrations. Conclusions: It could be concluded that bacterial diarrhea has a severe negative impact on the clinical and hemato-biochemical profile of the neonatal calves with diarrhea. Serum cardiac biomarkers such as cardiac troponin I (cTn-I) and NT-proBNP were significantly higher in neonatal calves with diarrhea, and there is an important relationship between cardiac biomarkers and vitamin D levels.

The Relation Between Host TLR9 -1486T/C, rs187084 Gene Polymorphisms and Helicobacter pylori cagA, sodB, hsp60, and vacA Virulence Genes among Gastric Cancer Patients.

To identify the associations between different genotypes of TLR9 -1486T/C (rs187084) with gastric cancer patients and reveal their relation to Helicobacter pylori virulence genes (cagA, sodB, hsp60 and vacA). Patients with gastric cancer were recruited to our study, diagnosed both endoscopically and histopathologically. H. pylori were isolated from gastric samples by culture and PCR amplification of the glmM gene. Virulence genes cagA, sodB, hsp60, and vacA were detected by multiplex PCR. Blood samples were used for genotyping of TLR9 -1486T/C (rs187084) by PCR-RFLP. Out of 132 patients with gastric cancer, 106 (80.3%) were positive for H. pylori. A similar number of healthy participants was recruited as controls. The prevalence of cagA, sodB, hsp60, and vacA genes among H. pylori was 90.6%, 70.8%, 83.0%, and 95.3%, respectively. The vacA gene alleles had a prevalence of 95.3% for vacAs1/s2, 52.8% for vacAm1, and 42.5% for vacAm2. The CC genotype of TLR9 -1486T/C had a significantly higher frequency in gastric cancer patients when compared to healthy participants (p = 0.045). Furthermore, the CC genotype demonstrated a significant association with H. pylori strains carrying sodB, hsp60, and vacAm1 virulence genes (p = 0.021, p = 0.049, and p = 0.048 respectively). Patients with CC genotype of TLR9 -1486T/C (rs187084) might be at higher risk for the development of gastric cancer, and its co-existence with H. pylori strains carrying sodB, hsp60, or vacAm1 virulence genes might have a synergistic effect in the development of gastric cancer. Further studies on a wider scale are recommended.