The role of endoscopy in bariatric surgery

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

Bariatric surgery and the endoscopist

Bariatric surgery is an effective treatment for obesity and its metabolic related disorders. With the numbers of bariatric procedures being performed rising annually endoscopists are now more likely than ever to encounter this patient cohort on routine diagnostic lists. Endoscopy plays a vital role in both the pre and postoperative periods to diagnose and treat certain complications associated with bariatric surgery. Preoperative endoscopy may be useful in identifying pathologies that then influence the type of bariatric surgery being proposed. Postoperative endoscopy has an established role in identifying and managing complications such as anastomotic leaks and gastrointestinal bleeding. As endoscopic techniques develop, these complications may be managed without the need for surgical intervention or revision. Increased knowledge and awareness of the indications for endoscopy, together with the altered anatomy and common complications of bariatric surgery, is paramount in managing these patients effectively.

Preoperative esophagogastroduodenoscopy in patients without reflux symptoms undergoing laparoscopic sleeve gastrectomy: utility or futility?

Aim

To evaluate the value of esophagogastroduodenoscopy (EGD) as a preoperative investigation in individuals without symptoms of Gastro-Esophageal Reflux Disease (GERD) who will undergo laparoscopic sleeve gastrectomy (LSG).

Materials and methods

After Institutional Review Board approval was obtained, patients scheduled for LSG were prospectively enrolled in the study between January 2016 and March 2018. Patients with symptoms of GERD were excluded from the study. Participants were randomly allocated to two groups: individuals who underwent EGD before the surgery as a usual routine investigation (Group A), and individuals who were scheduled without preoperative EGD (Group B). Patient demographics, endoscopic findings, endoscopic biopsy results, and histopathological findings of the resected parts of the stomach after LSG were analyzed and recorded. Additionally, operative characteristics and outcomes, and follow up findings were recorded and analyzed with appropriate statistical methods.

Results

A total of 219 individuals without symptoms of GERD underwent LSG were enrolled. Group A included 111 individuals (25 males and 86 females). Group B comprised 108 individuals (20 males and 88 females). The mean age and mean Body Mass Index (BMI) were similar in both groups. From Group A, 86 out of 111 individuals (77.5%) had no pathology identified on EGD, while 21 individuals (18.9%) were found to have areas of gastric erythema and biopsies showed active gastritis. All LSG operations were performed without any major complication. After one year, all individuals were assessed for the presence of symptomatic GERD and no significant difference was found between the two groups.

Conclusion

Preoperative EGD may not be mandatory for asymptomatic GERD individuals undergoing LSG as post-operative complications and early follow up for GERD symptoms are not significantly different. Further prospective studies with longer follow up are needed to evaluate the role of EGD in individuals undergoing LSG.

The role of routine preoperative upper endoscopy in bariatric surgery: a systematic review and meta-analysis

BACKGROUND

The necessity of routine preoperative esophagogastroduodenoscopy (EGD) before bariatric surgery is controversial. European guidelines recommend routine EGD while North American guidelines recommend a selective approach.

OBJECTIVE

Perform a systematic review and meta-analysis to determine the proportion and scope of clinical findings discovered at preoperative EGD.

SETTING

Academic hospital, Canada.

METHODS

A search of MEDLINE, Embase, and Cochrane databases included MeSH terms "bariatric surgery," "endoscopy," and "preoperative." Inclusion criteria were any case series, cohort study, or clinical trial describing results of preoperative EGD for any bariatric surgery. Exclusion criteria were studies with<10 patients, patients<18 years of age, or revisional operations. Changes in surgical and medical management and proportions of pathologic findings were extracted and combined in a meta-analysis using the random effects model.

RESULTS

Initial search identified 532 citations. Forty-eight were included after full text review. Included studies comprised 12,261 patients with a mean (SD) age of 40.5 (1.3) years and body mass index of 46.3 (1.5) kg/m(2). The majority of patients (77.1%) were female. The proportion of EGDs resulting in a change in surgical management was 7.8%. After removing benign findings with controversial impact on management (hiatal hernia, gastritis, peptic ulcer), this was found to be .4%. Changes in medical management were seen in 27.5%, but after eliminating Helicobacter pylori eradication, this was found to be 2.5%.

CONCLUSION

Preoperative EGD in average-risk, asymptomatic bariatric surgery patients should be considered optional, as the proportion of EGDs that resulted in important changes in management was low.

Endoscopic management of bariatric surgery complications: what the gastroenterologist should know

Obesity is a serious disorder in almost the entire world. It is an important risk factor for a series of conditions that affect and threaten health. Currently, bariatric surgery is the most effective treatment for morbid obesity, and in addition to the resulting weight loss, it reduces morbidity in this population. There has been a significant increase in the number of obese patients operated on. Despite the success of bariatric surgery, an important group of patients still present with major postoperative complications. In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. The present article is a review of the resulting anatomic aspects of the main surgical techniques employed, the most common postoperative symptoms, the potential complications, and the possibilities that endoscopic diagnosis and treatment offer. Endoscopy is a growing and continuously evolving method in the treatment of bariatric surgery complications. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population.

The cooperation between endoscopists and surgeons in treating complications of bariatric surgery

The results of lifestyle interventions and pharmacotherapy are disappointing in severe obesity which is characterised by premature death and many obesity-associated co-morbidities. Only surgery may achieve significant and durable weight losses associated with increased life expectancy and improvement of co-morbidities. Bariatric surgery involves the gastrointestinal tract and may therefore increase gastrointestinal complaints. Bariatric surgery may also result in complications which in many cases can be solved by endoscopic interventions. This requires a close cooperation between surgeons and endoscopists. This chapter will concentrate on the most commonly performed operations such as the Roux-en-Y gastric bypass, the adjustable gastric banding and the sleeve gastrectomy, in the majority of cases performed by laparoscopy. Operations such as the vertical banded gastroplasty and the biliopancreatic diversion with or without duodenal switch will not be discussed at length as patients with these operations will not be encountered frequently and their management can be found under the headings of the other operations.

Endoscopic findings of asymptomatic patients one year after Roux-en-Y gastric bypass for treatment of obesity

BACKGROUND

In the late post-operative period, the necessity of performing an upper gastrointestinal endoscopy (GIE) to check for complications is controversial. Some authors suggest it should be routine for all patients, others selectively, but not all patients with endoscopic abnormalities are symptomatic and some abnormalities are potentially severe. The study was conducted to evaluate the endoscopic findings from asymptomatic obese patients after Roux-en-Y gastric bypass (RYGB) and correlate them with the demographic data and the presence of Helicobacter pylori (Hp).

METHODS

A total of 715 asymptomatic patients were prospectively submitted to an upper GIE at the end of their first post-operative year. These examinations were evaluated for the presence of abnormalities, their prevalence and their potential severity.

RESULTS

Abnormalities were found in 189 patients (26.5 %). Eighty-four (11.7 %) presented esophageal abnormalities, with 72 (10.1 %) characterized as esophagitis and 12 (1.7 %) as hiatal hernia. Forty-five patients (6.3 %) presented abnormalities of the stomach and the anastomosis, with 26 (3.6 %) characterized as anastomotic ulcers, nine (1.3 %) as stenosis of the gastrojejunal anastomosis, ten (1.4 %) as band erosion and 72 (10.1 %) as jejunitis. There was a statistically significant correlation between super obesity and band erosion.

CONCLUSIONS

An upper GIE at the end of the first year of RYGB plays an important role, even for asymptomatic patients. One fourth of these asymptomatic patients had their treatment modified after the upper GIE was performed.

Obesity and the elderly

The prevalence of obesity is rising progressively, even among older age groups. By the year 2030 to 2035 over 20% of the adult US population and over 25% of the Europeans will be aged 65 years or older. The predicted prevalence of obesity in Americans, 60 years and older was 37% in 2010. The predicted prevalence of obesity in Europe in 2015 varies between 20% and 30% dependent on the model used. This means 20.9 million obese 60 years or older people in the United States in 2010 and 32 million obese elders in 2015 in EU. Although cutoff values of body mass index, waist circumference, and percentages of fat mass have not been defined for the elderly, it is clear from several meta-analyses that mortality and morbidity associated with overweight and obesity only increases at a body mass index >30 kg/m(2). Thus, treatment should only be offered to patients who are obese rather than overweight and who have functional impairments, metabolic complications, or obesity-related diseases, that can benefit from weight loss. The weight loss therapy should minimize muscle and bone loss and vigilance as regards the development of sarcopenic obesity--a combination of an unhealthy excess of body fat with a detrimental loss of muscle and fat-free mass including bone--is important. Lifestyle intervention should be the first step and consists of a diet with a 500 kcal energy deficit and an adequate intake of protein of high biological quality, together with calcium and vitamin D, behavioral therapy, and multicomponent exercise. Multicomponent exercise includes flexibility training, balance training, aerobic exercise, and resistance training. The adherence rate in most studies is around 75%. Knowledge of constraints and modulators of physical inactivity should be of help to engage the elderly in physical activity. The role of pharmacotherapy and bariatric surgery in the elderly is largely unknown as in most studies people aged 65 years and older were excluded.