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

Upper Gastrointestinal Endoscopic Screening in Bariatric Surgery Candidates: Correlating the Findings with GERD symptoms

INTRODUCTION

The role of routine preoperative esophagogastroduodenoscopy (EGD) in bariatric surgery candidates is controversial. This study compares preoperative EGD outcomes with patient-reported gastroesophageal reflux disease (GERD) symptoms to determine if a case-based EGD is appropriate.

PATIENTS AND METHODS

A prospective cohort study was conducted from April 2022 through September 2023 in Mashhad, Iran. All patients underwent EGD. To assess GERD symptoms, we used the GERD-Health Related Quality of Life questionnaire. Patients were categorized into two groups: the asymptomatic group (GERD-HRQL = 0) and the symptomatic group (GERD-HRQL > 0).

RESULTS

A total of 165 patients were included, out of which 133 (80.6%) were in the symptomatic group and 32 (19.4%) were in the asymptomatic group. Esophagitis was present in 41 (24.8%) patients. There was no significant difference in the frequency of esophagitis (18.8% vs. 26.3%, p-value = 0.37), hiatal hernia (18.8% vs. 18.8%, p-value = 1.00), gastritis (56.3% vs. 63.9%, p-value = 0.42), and H. pylori infection (9.4% vs. 12.0%, p-value = 1.00) between the asymptomatic and symptomatic groups, respectively. None of the demographic factors or comorbidities of asymptomatic patients were associated with esophagitis, except for hiatal hernia (OR = 7.67, 95% CI 3.01-19.53, p-value < 0.001). Receiver operating characteristic (ROC) analysis showed that the GERD-HRQL total scores, as well as the heartburn and regurgitation subscales, were poor predictors of esophagitis (AUC 0.57, 0.51, and 0.56, respectively).

CONCLUSION

EGD findings were not associated with GERD symptoms in candidates for bariatric surgery.

Surgeon variability in repair of hiatal hernia at the time of bariatric surgery

BACKGROUND

Hiatal hernia (HH) is estimated to affect between 20 and 50% of patients undergoing bariatric surgery. However, there is no consensus regarding the preoperative assessment and intraoperative repair of HH. The aim of this study was to evaluate the variation in surgeon assessment and repair of HH during bariatric surgery across a multi-hospital healthcare system.

METHODS

A retrospective cohort analysis was conducted using data obtained from the metabolic and bariatric accreditation quality improvement program (MBSAQIP) and institutional medical records. All adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Preoperative assessment of HH was defined as either EGD or upper GI/Esophagram (UGI) within one year of surgery. Surgeons were evaluated individually and by hospital. Chi-square analysis and ANOVA were performed.

RESULTS

From January 2018 to February 2023, 3,487 bariatric surgeries were performed across 4 hospitals and 11 surgeons (2481 SG and 1006 RYGB). HH were concurrently repaired during 24% of operations. The rate of HH repair in SG was 25 and 22% in RYGB (p = 0.06). Preoperatively, 41% of patients underwent EGD and 23% had an UGI. HH was diagnosed in 22% of EGDs. Patients who underwent preoperative EGD had higher rates of HH repair than those without a preop EGD (33% vs. 17%; p < 0.001). The rate of preoperative EGD utilization by surgeon varied significantly from 3 to 92% (p < 0.001) as did HH repair rates between surgeons (range 8-57%; p < 0.001). Even among patients with a preoperatively diagnosed HH, the repair rate ranged 20-91% between individual surgeons (p < 0.001).

CONCLUSION

Within a healthcare system there was significant heterogeneity in approach to assessment and repair of HH during bariatric surgery. This appears to be mediated by multiple factors, including utilization of preoperative studies, individual surgeon differences, and differences between hospitals.

Frequency of Clinically Significant Findings in the Surgical Pathology Specimen Following Laparoscopic Sleeve Gastrectomy and Concordance with Preoperative Endoscopy: Insights from a Large Single-Center Experience

INTRODUCTION

Endoscopy prior to bariatric surgery is not always performed, and in sleeve gastrectomy (SG), the surgical specimen is not always sent for pathological examination. There is limited data on the frequency of clinically significant findings in SG specimens or correlation with preoperative endoscopy.

METHODS

We reviewed 426 consecutive SG patients to determine the concordance of preoperative endoscopy findings in patients with clinically significant postoperative pathology.

RESULTS

Preoperative endoscopy was performed on 397 patients (93.2%). Three hundred seventy-three patients had preoperative endoscopy and surgical pathology results available. Then, 20/373 (5.4%) patients had potentially significant postoperative pathology, including intestinal metaplasia, autoimmune metaplastic atrophic gastritis (AMAG), gastrointestinal stromal tumors, and/or gastric cancer. The overall incidence of AMAG in the entire cohort was 2.3%. Preoperative gastric biopsies (to include gastric body) identified AMAG in nearly 1/2 of patients. Patients with clinically significant postoperative pathology results had a median [interquartile range] of 3 [3-5] tissue blocks examined as compared to 3 [1-3] for the remainder of the cohort (p < 0.001).

CONCLUSION

This is one of the largest studies describing clinically significant postoperative pathology after SG. AMAG, in particular, is of particular importance as it is associated with a 3-fivefold increase in risk for gastric cancer. The incidence of significant postoperative pathology in this population is small but potentially clinically significant and requires validation in larger studies. We recommend wider sampling in preoperative endoscopy (body and antrum), especially in patients being planned for gastric bypass, consideration for routine pathological examination of SG surgical specimens, with careful gross examination and targeted sampling.

Gastro-esophageal diagnostic workup before bariatric surgery or endoscopic treatment for obesity: position statement of the International Society of Diseases of the Esophagus

Obesity is a chronic and multifactorial condition characterized by abnormal weight gain due to excessive adipose tissue accumulation that represents a growing worldwide challenge for public health. In addition, obese patients have an increased risk of hiatal hernia, esophageal, and gastric dysfunction, as well as gastroesophageal reflux disease, which has a prevalence over 40% in those seeking endoscopic or surgical intervention. Surgery has been demonstrated to be the most effective treatment for severe obesity in terms of long-term weight loss, comorbidities, and quality of life improvements and overall mortality decrease. The recent emergence of bariatric endoscopic techniques promises less invasive, more cost-effective, and reproducible approaches to the treatment of obesity. With the endorsement of the International Society for Diseases of the Esophagus, we started a Delphi process to develop consensus statements on the most appropriate diagnostic workup to preoperatively assess gastroesophageal function before bariatric surgical or endoscopic interventions. The Consensus Working Group comprised 11 international experts from five countries. The group consisted of gastroenterologists and surgeons with a large expertise with regard to gastroesophageal reflux disease, bariatric surgery and endoscopy, and physiology. Ten statements were selected, on the basis of the agreement level and clinical relevance, which represent an evidence and experience-based consensus of the International Society for Diseases of the Esophagus.

Single Anastomosis Duodenal Switch versus Classic Duodenal Switch: Long-term Outcomes from a Prospective Comparative Cohort Study

PURPOSE

The literature on long-term outcomes of duodenal switch (DS) compared to single anastomosis duodenal switch (SADI-S) procedures is lacking. We evaluated the long-term outcomes of SADI-S compared to those after the classic DS procedure.

METHODS

This is a follow-up report from a single-institution prospective cohort study comparing long-term outcomes of SADI-S versus DS both as one- and two-stage procedures (ClinicalTrials.gov: NCT02792166). Data is depicted as count (percentage) or median (interquartile range).

RESULTS

Forty-two patients underwent SADI-S, of whom 11 had it as a second-stage procedure (26%). Of 20 patients who underwent DS, twelve had it as a second-stage procedure (60%). Both groups were similar at baseline. Median follow-up times for one-stage SADI-S and DS were 57 (24) and 57 (9) months, respectively (p = 0.93). Similar BMI reductions were observed after one-stage SADI-S (16.5 kg/m2 [8.5]) and DS (18.9 kg/m2 [7.2]; p = 0.42). At median follow-up of 51 (21) and 60 (15) months after second-stage SADI-S and DS, respectively (p = 0.60), surgical procedures yielded reductions in BMI of 20.5 kg/m2 (14.0) and 24.0 kg/m2 (13.9), respectively (p = 0.52). Follow-up rates were similar for one-stage (≥ 88%; p = 0.29) and second-stage procedures (≥ 83%; p = 0.16). Similar diabetes and hypertension remissions were found (p = 0.77; P = 0.54, respectively). Despite fat-soluble vitamin deficiencies at baseline, after supplementation, they were either eliminated or less prevalent long-term after SADI-S. Daily bowel movements were also less frequent.

CONCLUSIONS

Long-term weight and comorbidity outcomes after SADI-S are similar to those of DS both as one- and two-stage surgeries. SADI-S procedure may allow for similar beneficial outcomes with less burden from gastrointestinal symptoms and fat-soluble vitamin deficiencies.

GERD-screening before bariatric surgery: the predictive value of the GERD-HRQL questionnaire score compared with preoperative EGD findings

BACKGROUND

There is an ongoing debate on how to best identify patients with gastroesophageal reflux disease (GERD) before bariatric surgery. The value of routine preoperative esophagogastroduodenoscopy (EGD) is questioned, and patient reported symptoms are commonly used for screening. The goal of this study is to determine if patient reported symptoms using a validated questionnaire correlate with preoperative EGD findings.

METHODOLOGY

A prospective cohort study at a single institution was performed. Patients undergoing bariatric surgery between December 2020 and March 2023 were required to report symptoms of reflux by completing a preoperative GERD. Health-Related Quality of Life (GERD-HRQL) questionnaire and undergo a mandatory preoperative screening EGD. Patients were stratified into two cohorts: (group A) asymptomatic (score = 0) and (group B) symptomatic (score > 0). Statistical analysis was conducted using Pearson's chi-squared test and Wilcoxon rank-sum test in RStudio version 4.2.2. The predictive value of the GERD-HRQL score was analyzed using Areas Under the Curve (AUC; AUC = 0.5 not predictive, 0.5 < AUC ≥ 6 poor prediction & AUC > 0.9 excellent prediction) calculated from Receiver Operating Characteristic (ROC) curves.

RESULTS

200 patients were included; median age was 42.0 years (IQR 36.0 to 49.2). There were 79 patients (39.5%) in Group A and 121 patients (60.5%) in Group B. There was no difference in the frequency esophagitis (27.8% vs 32.2%, p = 0.61) or hiatal hernias (49.4% vs 47.1%, p = 0. 867) between group A and group B, respectively. ROC analysis revealed that the total GERD HRQL scores, heartburn only scores and regurgitation only scores, were poor predictors of esophagitis found on EGD (AUC 0.52, 0.53, 0.52), respectively. In asymptomatic patients, higher BMI was significantly associated with esophagitis (OR 1.15, 95% CI 1.06-1.27, p = 0.002).

CONCLUSION

Symptoms, identified through the GERD-HRQL questionnaire, are a poor indicator of esophagitis or its severity in patients undergoing workup for bariatric surgery. Therefore, liberal screening upper endoscopy is recommended for pre-bariatric surgery patients to guide appropriate procedure selection.

The Role of Endoscopy in the Management of Adolescent Bariatric Patients: A Primer For Pediatric Gastroenterologists

PURPOSE OF REVIEW

The prevalence of childhood and adolescent obesity in the United States has reached alarming levels, necessitating effective interventions such as bariatric surgery. This article reviews the current state of bariatric surgery in the adolescent population, highlighting the common complications encountered in post-bariatric patients. Furthermore, it outlines the pivotal role of endoscopy in both the prevention and management of these bariatric complications.

RECENT FINDINGS

Though only a minority of eligible adolescent patients undergo bariatric surgery the number of cases continues to increase. Sleeve gastrectomy has emerged as the preferred type of surgery, with the best balance of safety and efficacy. However, only a small number of pediatric surgeons have additional bariatric training and a number of technical aspects of the surgery itself impact the risk for post-surgical complications. Gastric sleeve stenosis, anastomotic leaks and gastroesophageal reflux are the most common of these complications. Ability to perform dilation of sleeve stenosis, closure of anastomotic leaks and evaluation of reflux are critical tools in the endoscopic toolbox necessary for the management of these complicated patients. Bariatric surgery remains the most effective treatment available for management of morbid obesity in adolescents but has significant associated complications. Pediatric gastroenterologists must be familiar in the endoscopic management of these complications and are crucial in creating a high functioning adolescent bariatric program.

Reflux and Barrett's esophagus after sleeve gastrectomy: analysis of a statewide database

BACKGROUND

Recent studies have suggested that sleeve gastrectomy (SG) is associated with the development of Barrett esophagus (BE) even in the absence of gastroesophageal reflux disease (GERD) symptoms.

OBJECTIVE

The aim of this study was to assess the rates of upper endoscopy and incidence of new BE diagnoses in patients undergoing SG.

SETTING

This was a claims-data study of patients who underwent SG between 2012 and 2017 while enrolled in a U.S. statewide database.

METHODS

Diagnostic claims data were used to identify pre- and postoperative rates of upper endoscopy, GERD, reflux esophagitis, and BE. Time-to-event analysis using a Kaplan-Meier approach was performed to estimate the cumulative postoperative incidence of these conditions.

RESULTS

We identified 5562 patients who underwent SG between 2012 and 2017. Of these, 1972 patients (35.5%) had at least 1 diagnostic record of upper endoscopy. The preoperative incidences of a diagnosis of GERD, esophagitis, and BE were 54.9%, 14.6%, and .9%, respectively. The predicted postoperative incidences of GERD, esophagitis, and BE, respectively, were 18%, 25.4%, and 1.6% at 2 years and 32.1%, 85.0%, and 6.4% at 5 years.

CONCLUSIONS

In this large statewide database, rates of esophagogastroduodenoscopy remained low after SG, but the incidence of a new postoperative esophagitis or BE diagnosis in patients who underwent esophagogastroduodenoscopy was higher than in the general population. Patients undergoing SG may have a disproportionately high risk of developing reflux complications including BE after surgery.

Preoperative Oesophagogastroduodenoscopy and the Effect on Bariatric Surgery: a Systematic Review and Meta-Analysis

Preoperative oesophagogastroduodenoscopy (OGD) in bariatric surgery remains a controversial topic, with a large variety in practice globally. An electronic database search of Medline, Embase and PubMed was performed in an aim to categorise the findings of preoperative endoscopies in bariatric patients. A total of 47 studies were included in this meta-analysis resulting in 23,368 patients being assessed. Of patients assessed, 40.8% were found to have no novel findings, 39.7% had novel findings which did not affect surgical planning, 19.8% had findings that affected their surgery and 0.3% were ruled to not be suitable for bariatric surgery. Preoperative OGD is altering surgical planning in one-fifth of patients; however, further comparative studies are required to determine if each patient should undergo this procedure especially if asymptomatic.

Preoperative endoscopy and pathology report of the specimen to be recommended in sleeve gastrectomy?

Objective

Preoperative upper gastrointestinal endoscopy (UGIE) and postoperative histopathological examination (HPE) of resected specimens are still controversial issues in bariatric surgery.

Methods

A retrospective review of prospectively collected laparoscopic sleeve gastrectomies (SG) performed at our institution for morbid obesity was carried out. All patients underwent pre-operative UGIE with biopsy, post-operative HPE and conventional post-operative follow-up.

Results

From January 2019 through January 2021 we performed a total of 501 laparoscopic SG. A total of 12 (2.4%) neoplasms were found, 2 evident at preoperative UGIE, 4 detected during operation, and 6 at HPE. Eight of these 12 cases had some malignant potential and 5 would not have been detected without HPE of the specimen. The most significant unexpected case was a fundic gland type adenocarcinoma in a 64-year-old female with severe obesity.

Conclusion

On the basis of our clinical experience, we recommend both preoperative endoscopic assessment and postoperative HPE of the specimen to provide the best available treatment to these patients.

Evaluation and Treatment of Obesity and Its Comorbidities: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity

The goal of the 8th edition of the Clinical Practice Guidelines for Obesity is to help primary care physician provide safe, effective care to patients with obesity by offering evidence-based recommendations to improve the quality of treatment. The Committee for Clinical Practice Guidelines comprised individuals with multidisciplinary expertise in obesity management. A steering board of seven experts oversaw the entire project. Recommendations were developed as the answers to key questions formulated in patient/problem, intervention, comparison, outcomes (PICO) format. Guidelines underwent multi-level review and cross-checking and received endorsement from relevant scientific societies. This edition of the guidelines includes criteria for diagnosing obesity, abdominal obesity, and metabolic syndrome; evaluation of obesity and its complications; weight loss goals; and treatment options such as diet, exercise, behavioral therapy, pharmacotherapy, and bariatric and metabolic surgery for Korean people with obesity. Compared to the previous edition of the guidelines, the current edition includes five new topics to keep up with the constantly evolving field of obesity: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of information and communication technology-based interventions for obesity treatment. This edition of the guidelines features has improved organization, more clearly linking key questions in PICO format to recommendations and key references. We are confident that these new Clinical Practice Guidelines for Obesity will be a valuable resource for all healthcare professionals as they describe the most current and evidence-based treatment options for obesity in a well-organized format.

Menetrier's disease in a morbid obese patient undergoing bariatric surgery: A case report

Introduction and importance

Menetrier's disease is a rare type of hypertrophic gastropathy characterized by the atrophy of the gastric parietal cells and dilatation of mucus releasing glands. Hereby, we present a morbid obese patient who has undergone laparoscopic sleeve gastrectomy (LSG) and he has also diagnosed with Menetrier's disease.

Case presentation

A 67-year-old male patient whose body mass index (BMI) was 39 kg/m². Preoperative endoscopy was done. There were no pathologies except increased gastric mucosal folds. LSG was done. During the surgery it was noticed that gastric tissue was abnormally thick. After LSG completed, it was observed that there was an abnormal bleeding from the staple line. The staple line was oversewed with 3.0 V-Loc™ and bleeding was stopped. Pathology report was compatible with menetrier's disease.

Clinical discussion

Hypoalbuminemia and H. pylori take an important place in diagnosis of Menetrier's disease, but H. pylori was not detected and albumin level was normal in our patient. For certain diagnosis full-thickness gastric biopsy is needed. The routine use of preoperative endoscopy in patients scheduled for bariatric surgery was still controversial until recently.

Conclusion

This is the first case with menetrier's disease that has undergone LSG. Preoperative endoscopic evaluation before bariatric surgery is crucial. As in this case, it will be effective in terms performing additional intraoperative precautions when necessary and preventing possible complications.

The utility of endoscopy prior to bariatric surgery: an 11-year retrospective analysis of 885 patients

INTRODUCTION

Our aim was to evaluate the diagnostic yield of routine preoperative esophagogastroduodenoscopy (p-EGD) in patients undergoing bariatric surgery. Many medical problems that are common in patients with obesity, including gastroesophageal reflux disease (GERD) and hiatal hernias, have important implications for patients undergoing bariatric surgery. While p-EGD is considered standard of care prior to antireflux surgery, the role of p-EGD in bariatric surgery patients remains controversial.

METHODS AND PROCEDURES

We performed a retrospective chart review of 885 patients who underwent primary bariatric surgery at a university hospital-based bariatric surgery program between March 2011 and February 2022. Clinical history, demographics, and preoperative EGD reports were reviewed for abnormal findings.

RESULTS

Of the 885 patients evaluated in this study, one or more abnormal EGD findings were observed in 83.2% of patients. More than half of our patients (54.7%) presented with history of heartburn, reflux, or GERD. EGD findings demonstrated a hernia in 43.1% of patients [(Type I: 40.6%; Type II: 0.5%; Type III: 2.1%)]. 68.0% of patients were biopsied. Among patients who were biopsied, other findings included gastritis (32.4%), esophagitis (8.0%), eosinophilic esophagitis (4.7%), or duodenitis (2.7%). We found ulcers in 6.7% of patients. Pathology was consistent with H. pylori in 9.8% of biopsies taken and consistent with BE in 2.7%. Following routine p-EGD, 11.2% of patients were placed on PPI and 8.3% were recommended to stop NSAIDs.

CONCLUSION

Gastroesophageal reflux disease and associated pathology are common in the bariatric population. Preoperative EGD in patients undergoing bariatric surgery frequently identifies clinically significant UGI pathology. This may have important implications for medical and surgical management. Given the rate of abnormal preoperative endoscopic findings in obese patients, the work-up for bariatric surgery should align with the current recommendations for foregut surgery.

Predictive Factors for Developing GERD After Sleeve Gastrectomy: Is Preoperative Endoscopy Necessary?

INTRODUCTION

Sleeve gastrectomy (SG) is the most common bariatric procedure performed in the USA. There is a concern for new gastroesophageal reflux disease (GERD) and Barrett's esophagus after SG. Endoscopic screening before bariatric surgery is controversial. We sought to identify preoperative endoscopic factors that may predict the development of GERD after SG.

METHODS

We prospectively evaluated 217 patients undergoing primary robotic-assisted SG. All patients underwent endoscopy before SG and for-cause postoperatively. Patients were followed for the development of GERD, diagnosed by either biopsy-proven reflux esophagitis or a positive esophageal pH test. Patients were separated into 2 groups: Those who developed GERD after surgery (GERD group) and those who did not (No GERD group). Patients with a positive preoperative pH test, LA Grade B or greater esophagitis, or hiatal hernia > 5 cm on preoperative endoscopy were counseled to undergo gastric bypass and excluded.

RESULTS

There were more males in the No GERD group (25.6% vs. 8.1%; p = 0.02). More patients had preoperative heartburn symptoms in the GERD group (40.5% vs. 23.9%; p = 0.04). Endoscopically identified esophagitis was more common in the GERD group (29.7% vs. 13.3%; p = 0.01), as was biopsy-proven esophagitis (24.3% vs. 11.1%; p = 0.03). There was no significant difference in the incidence or size of hiatal hernia or in the rate of H. pylori infection between the groups. On multivariate analysis, the strongest predictors of GERD after SG were endoscopically identified esophagitis (odds ratio [OR] 2.79; 95% confidence interval [CI]1.17-6.69; p = 0.02) and biopsy-proven esophagitis (OR 2.80; 95% CI 1.06-7.37; p = 0.04). Male patients were less likely to develop GERD after SG (OR 0.23; 95% CI 0.06-0.85; p = 0.03).

CONCLUSION

Our findings strengthen the rationale for routine preoperative endoscopy and highlight critical clinical and endoscopic criteria that should prompt consideration of alternatives to SG for weight loss.

Is gastroscopy necessary before bariatric surgery?

Obesity is the abnormal accumulation of fat or adipose tissue in the body. It has become a serious health problem in the world in the last 50 years and is considered a pandemic. Body mass index is a widely used classification. Thus, obese individuals can be easily classified and standardized. Obesity is the second cause of preventable deaths after smoking. Obesity significantly increases mortality and morbidity. We thought of preparing a publication about routine procedures for the preoperative evaluation of obesity. The question that we asked as bariatric and metabolic surgeons but which was not exactly answered in the literature was "Is esophagogastroduodenoscopy (EGD) necessary before bariatric surgery?" We found different answers in our literature review. The European Association of Endoscopic Surgery guidelines recommend EGD for all bariatric procedures. They strongly recommend it for Roux-en-Y gastric bypass (RYGB). As a result of a recent study by the members of the British Obesity & Metabolic Surgery Society, preoperative EGD is routinely recommended for patients undergoing sleeve gastrectomy, even if they are asymptomatic, but not recommended for RYGB. It is recommended for symptomatic patients scheduled for RYGB. According to the International Sleeve Gastrectomy Expert Panel Consensus Statement, preoperative EGD is definitely recommended for patients scheduled for sleeve gastrectomy, but its routine use for RYGB is controversial. However, a different view is that the American Society for Gastrointestinal Endoscopy recommends endoscopy only for symptomatic patients scheduled for bariatric surgery. In the literature, the primary goal of EGD recommended for sleeve gastrectomy has been interpreted as determining esophagitis caused by gastroesophageal reflux. In the light of the literature, it is stated that this procedure is not necessary in America, while it is routinely recommended in the European continent. Considering medicolegal cases that may occur in the future, we are in favor of performing EGD before bariatric surgery. In conclusion, EGD before bariatric surgery is insurance for both patients and physicians. There is a need for larger and prospective studies to reach more precise conclusions on the subject.

Routine Use of Esophago-gastro-duodenoscopy (EGD) in Bariatric Surgery-an International Survey of Our Current Practice

INTRODUCTION

The role of esophago-gastro-duodenoscopy (EGD) in bariatric surgery has been widely discussed. In 2020, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued recommendations on the routine use of EGD before and after bariatric surgery. However, little is known of our current practice and the guidance uptake.

METHODS

We conducted an international survey assessing bariatric surgeons' practice on the use of EGD. The survey aimed to identify whether surgeons offer EGD in the following settings: pre-operative, post-operative at 1 year, every 2-3 years following longitudinal sleeve gastrectomy (LSG) or one-anastomosis gastric bypass (OAGB). Data was analyzed using descriptive statistics.

RESULTS

Among 121 respondents, 72% are aware of the IFSO recommendations. The commonly performed bariatric procedures were LSG, Roux-en-Y gastric bypass (RYGB), and OAGB. 53.7% surgeons routinely offer pre-operative EGD and 14.3% routinely offer post-operative EGD for bariatric patients at 1 year after surgery. Majority do not routinely offer EGD after LSG (74.8%) or OAGB (79.7%) every 2-3 years as proposed by IFSO.

CONCLUSION

The uptake of IFSO recommendation is variable according to each recommendation with better compliance among surgeons with regard to pre-operative EGD. Further research is necessary to develop robust evidence-base for the role of endoscopy after bariatric surgery with the inclusion of patient and public involvement.

Expert opinion on the preoperative medical optimization of adults with diabetes undergoing metabolic surgery

Diabetes mellitus (DM) and obesity are interrelated in a complex manner, and their coexistence predisposes patients to a plethora of medical problems. Metabolic surgery has evolved as a promising therapeutic option for both conditions. It is recommended that patients, particularly those of Asian origin, maintain a lower body mass index threshold in the presence of uncontrolled DM. However, several comorbidities often accompany these chronic diseases and need to be addressed for successful surgical outcome. Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures worldwide. The bariatric benefits of RYGB and LSG are similar, but emerging evidence indicates that RYGB is more effective than LSG in improving glycemic control and induces higher rates of long-term DM remission. Several scoring systems have been formulated that are utilized to predict the chances of remission. A glycemic target of glycated hemoglobin < 7% is a reasonable goal before surgery. Cardiovascular, pulmonary, gastrointestinal, hepatic, renal, endocrine, nutritional, and psychological optimization of surgical candidates improves perioperative and long-term outcomes. Various guidelines for preoperative care of individuals with obesity have been formulated, but very few specifically focus on the concerns arising from the presence of concomitant DM. It is hoped that this statement will lead to the standardization of presurgical management of individuals with DM undergoing metabolic surgery.

GERD and Barrett's esophagus as indications for revisional surgery after sleeve gastrectomy: experience of a bariatric center of excellence IFSO-EC and narrative review

INTRODUCTION

Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure worldwide; due to its extensive impact and analysis, multiple procedure-related early and late complications have been described. Gastroesophageal reflux and Barrett's esophagus are highly debated issues related to sleeve gastrectomy in long-term follow-up. This review aims to explore the association between sleeve gastrectomy and gastroesophageal reflux in terms of their occurrence, and to analyze the protective or affecting factors.

AREAS COVERED

Gastroesophageal reflux and Barrett's esophagus after laparoscopic sleeve gastrectomy.

EXPERT OPINION

Gastroesophageal reflux is the Achilles' heel of sleeve gastrectomy and is affected by multiple procedure-related functional or mechanical factors (intrathoracic migration, stenosis, lower esophageal sphincter incompetence). Its postoperative incidence is about 30% with significant variability among groups, especially in terms of preoperative workup (lack of routine upper gastro-intestinal endoscopy and symptom assessment). Strict patient selection and mandatory pre-operative endoscopy are the primary steps taken to prevent and reduce the incidence of post-operative severe gastroesophageal reflux. However, patients should also be informed of the possibility of the 'de novo gastroesophageal reflux disease' (incidence - 22-50%) and the need for surgical revision in selected cases (0.5-7%).

Preoperative management of obese patients undergoing bariatric surgery: Role of endoscopy and Helicobacter eradication

BACKGROUND

Obesity is a pandemic disease associated to severe health problems. Management is usually multimodal, but many patients eventually need surgery to reduce weight. Many guidelines recommend endoscopy prior to surgery. This study reviews a series of patients undergoing sleeve gastrectomy to see whether endoscopy performance and histopathological findings influence surgery outcome.

MATERIAL AND METHODS

Retrospective series of patients undergoing sleeve gastrectomy as bariatric procedure at a single institution. We have reviewed the demographic data, the associated pathologies, endoscopic findings prior to surgery, histopathological findings in the surgical resection specimen and postoperative complication rate.

RESULTS

259 patients fulfilled criteria for the study. Over 70% were women and the mean age was 46.9 (SD 9.8). Preoperative endoscopy was performed in 28.9% of the patients and biopsy only in 19.3%. Helicobacter pylori was detected in 28% of the patients undergoing endoscopy (either in the biopsy or the urease test) and eradicated before surgery in all the patients. Helicobacter pylori was present in 9.7% of the surgical resection specimens and its presence was significantly associated with the development of postoperative complications, mostly staple line leaks (p = 0.01).

CONCLUSION

Our study confirms that Helicobacter infection is significantly associated with postoperative complications after sleeve gastrectomy. It is therefore important to detect its presence and eradicate it before surgery.

Impact of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease and Risk Factors Associated with Its Occurrence Based Upon Quality of Life

BACKGROUND

To assess the impact of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) symptoms and to determine factors associated with the occurrence of post-LSG GERD symptoms.

MATERIAL AND METHODS

This is a retrospective study that included all obese patients who underwent LSG in Aseer Central Hospital, during the period from August 2017 to August 2019. GERD-Health-Related Quality of Life questionnaire was used to assess the patients' pre- and postoperative GERD symptoms and their satisfaction toward their general health.

RESULTS

The study included 326 patients (195 males and 131 females) with a mean age of 39.43 ± 11.17 years. Postoperatively, GERD symptoms newly developed in 105 patients (32.2%), while 25 patients out of 127 with preoperative GERD symptoms (19.69%) showed resolution of symptoms. There were significant associations (p < 0.001) between the old age, smoking and existence of comorbidities, and the occurrence of postoperative heartburn and regurgitation symptoms. Postoperatively, excess weight loss (EWL) was significantly associated with postoperative regurgitation (p = 0.045) and patients showed significant improvement in their satisfaction toward their health condition even those who developed GERD symptoms.

CONCLUSIONS

After LSG, GERD symptoms developed in about one-third of the patients while symptoms improved in only one-fifth of patients. Older patients, smokers, patients with comorbidities, and patients with more EWL had significantly worse GERD symptoms postoperatively. Weight loss rather than GERD symptoms significantly influenced patients' satisfaction toward their general health. Further prospective studies are needed to determine the relationship between weight loss and other factors associated with post-LSG reflux and overall quality of life.

ASMBS position statement on the rationale for performance of upper gastrointestinal endoscopy before and after metabolic and bariatric surgery

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the need and possible strategies for screening endoscopic examination before metabolic and bariatric surgery (MBS), as well as the rationale, indications, and strategies for postoperative surveillance for mucosal abnormalities, including gastroesophageal reflux disease and associated esophageal mucosal injuries (erosive esophagitis and Barrett's esophagus) that may develop in the long term after MBS, specifically for patients undergoing sleeve gastrectomy or Roux-en-Y gastric bypass. The general principles described here may also apply to procedures such as biliopancreatic diversion (BPD) and BPD with duodenal switch (DS); however, the paucity of procedure-specific literature for BPD and DS limits the value of this statement to those procedures. In addition, children with obesity undergoing MBS may have unique considerations and are not specifically addressed in this position statement. This recommendation is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to be and should not be construed as stating or establishing a local, regional, or national standard of care. The statement will be revised in the future as additional evidence becomes available.

Outcomes of Bariatric Surgery in Patients with Liver Cirrhosis: a Systematic Review

Obesity is commonly associated with non-alcoholic fatty liver disease and is a significant cause of chronic liver disease and cirrhosis. Some patients undergoing bariatric surgery suffer from cirrhosis of the liver. Currently, there is a lack of consensus on the management of these patients and the safety and efficacy of bariatric surgery in this group. This review aims to update our previously published systematic review on the same topic. A total of 21 studies reporting experience on patients with cirrhosis undergoing bariatric surgery were included. Sleeve gastrectomy was the most common surgery performed, followed by Roux-en-Y gastric bypass. The results show that bariatric surgery may be feasible in carefully selected patients with obesity and cirrhosis although they have slightly higher morbidity and mortality rates.

Barrett's Oesophagus and Bariatric/Metabolic Surgery-IFSO 2020 Position Statement

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has been playing an integral role in educating both the metabolic surgical and the medical community at large about the importance of surgical and/or endoscopic interventions in treating adiposity-based chronic diseases. The occurrence of chronic conditions following bariatric/metabolic surgery (BMS), such as gastro-oesophageal reflux disease (GERD) and columnar (intestinal) epithelial metaplasia of the distal oesophagus (also known as Barrett's oesophagus (BE)), has long been discussed in the metabolic surgical and medical community. Equally, the risk of neoplastic progression of Barrett's oesophagus to oesophageal adenocarcinoma (EAC) and the resulting requirement for surgery are the source of some concern for many involved in the care of these patients, as the surgical alteration of the gastrointestinal tract may lead to impaired reconstructive options. As such, there is a requirement for guidance of the community.The IFSO commissioned a task force to elucidate three aspects of the presenting problem: First, to determine what the estimated incidence of Barrett's oesophagus is in patients presenting for BMS; second, to determine the frequency at which Barrett's oesophagus may develop following BMS (with a particular focus on the laparoscopic sleeve gastrectomy (LSG)); and third, to determine if regression of Barrett's oesophagus may occur following BMS given the close relationship of obesity and the development of BE/EAC. Based on these findings, a position statement regarding the management of this pathology in the context of BMS was developed. The following position statement is issued by the IFSO Barrett's Oesophagus task force andapproved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion and published peer-reviewed scientific evidence. It will be reviewed regularly.

Upper gastrointestinal tract involvement in the management of bariatric patients in the Kingdom of Saudi Arabia

Background

Preoperative esophagogastroduodenoscopy (EGD) may affect the management of bariatric patients although this is not consistent universally. The present prospective study evaluated the effect of preoperative EGD findings in obese Saudi patients, including upper digestive symptoms (UDS) and comorbidities, on their planned surgery.

Methods

From January 2018 to May 2019, we conducted a 4-center retrospective observational study to evaluate the endoscopic findings among Saudi patients aged 18-65 years with a body mass index (BMI) >40 kg/m². Preoperative data included UDS, comorbidities, Helicobacter pylori (H. pylori) infection assessed during a histopathological examination, and EGD findings.

Results

717 patients underwent EGDs, and 432 underwent bariatric surgery. The mean BMI was 44.3±6.3 kg/m², and the mean age was 27.8±11.8 years. The overall UDS prevalence was 49%, with the most frequent being gastroesophageal reflux disease 54% (387/717), followed by dyspepsia 44% (315/717). H. pylori infection was detected in 287/672 (42.4%) patients. The total percentage of patients with normal EGD was 36% (258/717). A delayed bariatric procedure was performed in 15% of the patients for the following reasons: 2.3% had large polyps of >1 cm (either hyperplastic or cystic polyps); 1.62% had esophagitis grade C and D based on the Los Angeles classification; 0.7% had Barrett’s esophagus; and 5.7% had peptic ulcer disease.

Conclusions

Our findings confirmed that obesity carries a profound health burden with a significant impact on health expenditures. Routine preoperative EGD in the obese Saudi population appears to be mandatory to identify factors that may change, delay, or postpone the bariatric procedure.

Correlation between pre-operative endoscopic findings with reflux symptom score for gastro-oesophageal reflux disease in bariatric patients

Introduction:

There is a strong association between gastro-oesophageal reflux disease and morbid obesity.

Methods:

Two hundred and eleven morbidly obese patients operated between September 2007 and June 2017 were retrospectively reviewed. All patients underwent pre-operative upper gastrointestinal endoscopy and assessment by reflux symptomatic score questionnaire.

Results:

Of the total 211 patients, 156 (73.94%) were females; mean body mass index of the cohort was 46.23 ± 3.1 kg/m². There was no evidence of Barrett's oesophagus or malignancy on pre-operative endoscopy. 63.04% of the patients (n = 133) in the study cohort had normal endoscopy. Pre-operative evaluation by reflux symptom score (RSS) questionnaire revealed no evidence of gastro-oesophageal reflux disease in 61.13% of patients (n = 129). The total number of patients with symptoms was 82 (38.86%). They were further divided into two categories based on severity of symptoms, namely, mild + moderate 60 (73.17%) and severe + very severe 22 (26.83%). From the cohort of symptomatic patients, the sub-cohort of 60 mild + moderate symptomatic patients had equal number of patients with normal 30 (50%) and abnormal endoscopy 30 (50%). In the sub-cohort of patients with severe + very severe symptoms (n = 22; 26.83%), endoscopy was abnormal in 6 (27.7%) patients. Whereas, out of 129 (61.13%) asymptomatic patients, one-third (n = 42) had abnormal endoscopy. The weighted kappa score was used between pre-operative endoscopic findings and RSS was statistically not significant (k - 0.0986).

Conclusion:

Pre-operative endoscopy is a must in all bariatric patients as significant percentage of asymptomatic patients can have abnormal endoscopy and vice versa.

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.

Hiatal Hernia Evaluation Before Bariatric Surgery: Should It Be Routinely Done?

PURPOSE

The necessity of routine preoperative esophagogastroduodenoscopy (EGD) and upper gastrointestinal series (UGIS) in the evaluation of hiatal hernia (HH) among bariatric surgery candidates is controversial since most are detected during surgery, regardless of the preoperative work-up. The aim is to determine the accuracy of preoperative EGD and UGIS for HH diagnosis among bariatric surgery candidates.

MATERIAL AND METHODS

The records of bariatric surgery patients between 2011 and 2015 were reviewed. Patients underwent routine UGIS and/or EGD before the surgery. The positive and negative predictive values (PPV, NPV) for each study were calculated based on operative findings.

RESULTS

A total of 463 patients were included in the study. Mean age was 44.34 ± 12.99 years. Mean preoperative body mass index (BMI) was 42.7 ± 5.15 kg/m². A total of 450 patients (97.2%) had a UGIS, 263 patients underwent EGD (56.8%), and 258 (55.7%) patients had both tests. HH was diagnosed in 26 (5.8%), 60 (13%), and 72 (27.8%) patients, respectively. HH was found intra-operatively in 53 patients (11.4%). It was associated with heartburn (P = 0.005) and previous bariatric surgery (P = 0.008). EGD had a greater sensitivity than UGIS (47.4% vs. 30.2%) and a lower specificity (81.4% vs. 97.5%). PPV and NPV for UGIS and EGD were 61.5% and 91.3% vs. 30% and 90.2%, respectively. The sensitivity of both tests when combined together reached 60.5%.

CONCLUSIONS

Both EGD and UGIS, whether solely performed or combined, have low sensitivity for diagnosis of HH and can probably be omitted from the preoperative evaluation, except for high-risk patients.

Screening Esophagogastroduodenoscopy Before Laparoscopic Sleeve Gastrectomy: Results in 819 Patients

Aim: The routine use of esophagogastroduodenoscopy (EGD) during the preoperative evaluation of surgical weight loss candidates is controversial. The aim of this study is to evaluate the findings of preoperative EGD in patients who are scheduled for a primary laparoscopic sleeve gastrectomy (LSG). The probable effect of these findings on the medical and surgical strategy that was followed is assessed. Methods: Findings of EGD obtained from consecutive LSG candidates and all data were prospectively recorded and retrieved from the database. Results: A total of 819 patients underwent EGD successfully. Mean age and body mass index were 38 ± 11.3 and 43.17 ± 7.2 kg/m², respectively. Fifty-eight percent were female. EGD of 263 (32.1%) patients was normal and 687 (84%) patients were asymptomatic. At least one abnormal finding was detected in 65% of the asymptomatic patients. Abnormal findings that did not change the surgical strategy were found in 550 patients (67.2%). Findings such as gastritis or duodenitis that changed the medical management before surgery were found in 309 patients (38.2%). Helicobacter pylori was positive in 218 (26.6%) patients but eradication treatment was not applied in the preoperative period. No pathology was detected that would create absolute contraindication or change the type of surgery in any patient. Only technical modifications were required in 13% due to hiatal hernia. The timing of the planned surgery has changed in only 6 patients (0.74%) (early stage neuroendocrine tumor, leiomyoma, severe ulcer). Conclusions: Routine EGD performed before LSG did not change the planned bariatric option in any patient, but led to 13% rate of technical modifications due to the presence of hiatal hernia. At least one abnormal finding was detected in 65% of asymptomatic patients. Due to endoscopic findings, the rate of patients who started medical acid-suppression treatment in the preoperative period was 38%.

Perioperative screening, management, and surveillance of Barrett's esophagus in bariatric surgical patients

Obesity is a strong risk factor for Barrett's esophagus (BE), the only proven precursor lesion to esophageal adenocarcinoma (EAC). Bariatric surgery is currently the only reliable treatment that achieves long-term sustained weight loss; however, it can markedly affect the development of de novo BE, and the progression or regression of existing BE. Bariatric procedures may also have implications on future surgical management of any consequent EAC. In this review, we examine the current evidence and published guidelines for BE in bariatric surgery. Current screening practices before bariatric surgery vary substantially, with conflicting recommendations from bariatric societies. If diagnosed, the presence of BE may alter the type of bariatric procedure. A selective screening approach prevents unnecessary endoscopy; however, there is poor symptom correlation with disease. Studies suggest that sleeve gastrectomy predisposes patients to gastroesophageal reflux and de novo BE. Conversely, Roux-en-Y gastric bypass is associated with decreased reflux and potential improvement or resolution of BE. There are currently no guidelines addressing the surveillance for BE following bariatric surgery. BE is an important consideration in the management of bariatric surgical patients. Evidence-based recommendations are required to guide procedure selection and postoperative surveillance.

Pre-screening for bariatric surgery patients: comparative effectiveness of transnasal endoscopy versus esophagogastroduodenoscopy

BACKGROUND

Endoscopic evaluation is frequently performed before bariatric surgery to identify foregut pathology that may alter procedure selection. Transnasal endoscopy (TNE) is an alternative to esophagogastroduodenoscopy (EGD). The objective of this study was to compare TNE to EGD.

METHODS

Patients who underwent TNE or EGD before bariatric surgery from January 2012 through April 2019 were reviewed. Statistical analyses included Chi-square, Wilcoxon two-sample, and Fisher's exact tests. A p value < 0.05 was considered significant.

RESULTS

Three hundred and forty-five patients underwent preoperative screening (63% EGD, 37% TNE) before bariatric surgery. Mean age and preoperative body mass index in the TNE and EGD groups were 46.2 ± 12.4 vs 45.5 ± 11.6 years (p = 0.58) and 46.5 ± 7.1 vs. 45.5 ± 6.1 kg/m² (p = 0.25), respectively. Three TNEs were aborted, resulting in a success rate of 98%. Of patients who underwent EGD, 1 (0.5%) visited the emergency department (ED), and 7 (3%) called the nurse with post-procedure concerns. There were no ED visits or nurse calls from patients who underwent TNE. The median total time in the procedure room was 77 (57-97) min for EGD vs. 26 (8-33) min for TNE (p < 0.001). One patient who underwent TNE required subsequent EGD. Mean charge per patient for EGD and TNE was $5034.70 and $1464.00, respectively.

CONCLUSIONS

TNE was associated with less post-procedure care, shorter procedure time and fewer charges compared to EGD. TNE could be considered an initial screening tool for patients undergoing bariatric surgery, while EGD could be used selectively in patients with abnormal TNE findings.

Unsedated Transnasal Endoscopy for Preoperative Examination of Bariatric Patients: a Prospective Study

BACKGROUND

Esophagogastroduodenoscopy is a preoperative examination commonly required for candidates to bariatric surgery (BS). Overweight individuals have a greater risk of cardiorespiratory complications during endoscopy under sedation. This study aimed to investigate the feasibility, tolerance, and cardiovascular stress of transnasal endoscopy (TNE) without sedation in obese patients eligible for BS.

METHODS

This prospective study enrolled obese adult patients with indication for BS that consented to undergo unsedated preoperative TNE. All examinations were carried out in an outpatient center. The outcomes assessed were endoscopic findings, procedural success, patients' tolerance according to a visual analogic scale, cardiovascular stress estimated by double product (i.e., systolic blood pressure × heart rate) and adverse events. Statistical analyses were used to compare each patient's double product among different examination periods.

RESULTS

Ninety-four patients (77.6% female) completed the study, with an average body mass index (BMI) of 53 kg/m² (range, 35-73.4 kg/m²). There were 63 super-obese individuals (67%), with BMI > 50 kg/m². In 93 patients (98.9%), unsedated TNE was successfully completed up to the second part of the duodenum. TNE failed in one patient. Tolerance was rated as excellent or good in 95.7%. Minimal cardiovascular stress was noted in obese individuals, whereas the double product remained stable throughout the procedure in super-obese patients. Three patients (3.2%) had self-limited epistaxis.

CONCLUSIONS

Unsedated TNE for preoperative endoscopic evaluation of obese patients is feasible, safe, and well tolerated and should be preferentially considered when examining super-obese patients.

Prevalence of Endoscopic Findings Before Bariatric Surgery and Their Influence on the Selection of the Surgical Technique

PURPOSE

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most popular procedures performed. The decision of which technique is most appropriate depends on the surgeon's preferences and experience. However, several factors strongly influence the decision of the procedure performed, including gastrointestinal disorders or asymptomatic upper gastrointestinal endoscopy (UGE) findings. This study aimed to describe the pathological endoscopic findings in morbidly obese patients undergoing preoperative routine UGE.

MATERIALS AND METHODS

A retrospective review of a prospectively collected database of all UGEs performed before bariatric surgery was performed. UGE was routinely performed to all the patients as part of the preoperative evaluation protocol.

RESULTS

A total of 790 patients were included. Surgical technique included 610 (77.2%) RYGB and 180 (22.8%) SG. Twenty-one asymptomatic patients presented esophagitis at UGE. In only seven patients (0.89%), the endoscopic findings of esophagitis had changed the initial surgical decision. The presence of ulcers or adenomatous or incompletely resected polyps was an indication for SG, to assure future endoscopic access in case it is needed. In 25 patients (3.17%), the initial operation would have been changed based on UGE findings.

CONCLUSION

Preoperative UGE allows the diagnosis of asymptomatic esophagitis related to gastroesophageal reflux disease and the identification of asymptomatic polyps and ulcers, with the potential ability for malignant transformation. In up to 3.17% of the cases, the endoscopic findings changed the operative strategy. As the complication rate associated with the procedure is low, we recommend the routine performance of preoperative UGE before bariatric surgery.

The role of preoperative upper endoscopy in adolescents undergoing laparoscopic vertical sleeve gastrectomy

BACKGROUND

Vertical sleeve gastrectomy (VSG) has been associated with gastroesophageal reflux symptoms and, in adults, with a development of Barrett's esophagus. Adults with Barrett's esophagus identified at baseline before bariatric operation are generally advised against VSG operations. The role of preoperative esophagogastroduodenoscopy (EGD) in adolescents preparing for bariatric surgery is not clearly defined.

OBJECTIVE

The goal of this study was to report the frequency of abnormalities identified on EGD performed at baseline in adolescents undergoing VSG for severe obesity.

SETTING

Free-standing academic children's hospital. United States.

METHODS

A retrospective chart review was conducted to describe findings of EGD performed just before VSG in a cohort of 40 adolescents and young adults (age range 14-25 yr) immediately before VSG. Review of findings from gross and histopathological evaluation of the esophagus, resected stomach, and duodenum was performed.

RESULTS

Five individuals reported preoperative symptoms of gastroesophageal reflux. Anatomic findings at EGD were normal in 98% of individuals. Histopathology of the esophagus, stomach, and duodenum was normal in 88%, 70%, and 95%, respectively. Abnormal findings of gastritis (18%), esophagitis (13%), and/or Helicobacter pylori (10%) infection were most common. Those with evidence of H. pylori in gastric resection specimens were treated appropriately with eradication therapy postoperatively. With the exception of 2 patients with incidentally detected esophageal mucosal eosinophilia, EGD findings did not lead to additional changes in medical or surgical management. There were no complications of the EGD procedure.

CONCLUSIONS

Routine EGD at the time of VSG was safe but resulted in low yield of abnormal findings requiring a change in clinical management.

Gastroesophageal Reflux and Laparoscopic Sleeve Gastrectomy: Results of the First International Consensus Conference

BACKGROUND

Gastroesophageal reflux disease (GERD) is probably the main drawback of laparoscopic sleeve gastrectomy (LSG). Herein, we critically discuss the issue and report the results of the first international consensus conference held in Montpellier, France, during June 2019.

METHODS

Fifty international bariatric experts from 25 countries convened for 2 days for interactive discussions, and to formulate the most relevant questions by electronically submitting 55 preliminary questions to panelists. Following the meeting, a final drafted questionnaire comprised of 41 questions was sent to all experts via e-mail.

RESULTS

Forty-six experts responded (92%). Esophago-gastro-duodenoscopy was considered mandatory before (92%) and after (78%) surgery. No consensus was achieved as to time intervals after surgery and the role of specialized tests for GERD. Higher degrees of erosive esophagitis (94%) and Barrett's esophagus (96%) were viewed as contra-indications for LSG. Roux-en-Y gastric bypass was recommended in postoperative patients with uncontrolled GERD and insufficient (84%) or sufficient (76%) weight loss and Barrett's esophagus (78%). Hiatal hernia (HH) repair was deemed necessary even in asymptomatic patients without GERD (80% for large and 67% for small HH). LSG with fundoplication in patients with GERD was considered by 77.3% of panelists.

CONCLUSIONS

The importance of pre- and postoperative endoscopy has been emphasized. The role of specialized tests for GERD and the exact surveillance programs need to be further defined. LSG is viewed as contra-indicated in higher degrees of endoscopic and clinical GERD. LSG with anti-reflux fundoplication emerges as a new valid option in patients with GERD.

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP

BACKGROUND

Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery.

METHODS

A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards.

RESULTS

Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure.

CONCLUSION

This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.

High Cost for Low Yield: A Systematic Review and Meta-Analysis to Assess Cost of Routine Preoperative Esophagogastroduodenoscopy Before Bariatric Surgery

Routine esophagogastroduodenoscopy (EGD) is an area of continued controversy in the preoperative evaluation for bariatric surgery; more information is needed regarding its impact on surgical management and associated costs. This systematic review and meta-analysis reports rates of abnormalities detected on preoperative EGD that changed operative management or delayed bariatric surgery. Sensitivity analysis examined the impact of controversial findings of hiatal hernia, Helicobacter pylori, gastritis, peptic ulcer disease. Data were used to calculate the cost per surgical alteration made due to abnormalities detected by routine EGD, compactly termed "cost-of-routine-EGD." Thirty-one retrospective observational studies were included. Meta-analysis found 3.9% of EGDs resulted in a change in operative management; this proportion decreased to 0.3% after sensitivity analysis, as detection of hiatal hernia comprised 85.7% of findings that changed operative management. Half of the 7.5% of cases that resulted in surgical delay involved endoscopic detection of H. pylori. Gastric pathology was detected in a significantly greater proportion of symptomatic patients (65.0%) than in asymptomatic patients (34.1%; P<0.001). Cost-of-routine-EGD to identify an abnormality that changed operative management was $601,060, after excluding controversial findings. The cost-of-routine-EGD to identify any abnormality that led to a change in type of bariatric operation was $281,230 and $766,352 when controversial findings were included versus excluded, respectively. Cost-of-routine-EGD to identify a malignancy was $2,554,506. Cost-of-routine-EGD is high relative to the low proportion of abnormalities that alter bariatric surgery. Our results highlight the need to develop alternative strategies to preoperative screening, in order to improve access and decrease cost associated with bariatric surgery.

Preoperative Endoscopic and Radiologic Evaluation of Bariatric Patients: What Do They Add?

BACKGROUND

Preoperative esophagogastroduodenoscopy (EGD) and barium swallow (BS) are commonly performed for evaluation in bariatric surgery patients. The routine use of these modalities has been controversial.

METHODS

A retrospective review of a prospectively maintained database was performed to include primary bariatric surgery patients between March 2013 and August 2016.

RESULTS

Two hundred nine patients were included. All the patients underwent preoperative EGD and BS. The mean age was 43.12 years and BMI 46.4 kg/m². Reflux symptoms were present in 58.5% of patients. Preoperative EGD revealed abnormalities in 87.5% of patients: esophagitis (54.5%), Barrett's esophagus (5.3%), dysplasia (1%), and gastritis (51%). Endoscopic evidence of HH was documented in 52.2% of patients while only 34% of patients had evidence of HH in their BS. Of the asymptomatic patients, 80.2% had abnormal EGD. Helicobacter pylori on biopsy was found in 17.2% patients, out of which 47.2% were asymptomatic. Based on EGD findings, the choice of surgical procedure was changed in 3.34% of patients. Repair of HH was performed in 107 patients, with 68.2% (n = 73) symptomatic patients and 31.8% (n = 34) asymptomatic patients. On ROC analysis, EGD was better predictive of the presence of HH (AUC = 0.802, OR 5.20, p  =   < 0.0001) and symptoms were a poor indicator for GERD.

CONCLUSIONS

Preoperative EGD is abnormal in the majority of patients regardless of their symptoms. EGD is the only modality that can provide tissue sample, which can potentially determine the type of bariatric surgery. Given the low diagnostic accuracy of BS, its routine use can be eliminated.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Upper endoscopy after Roux-en-Y gastric bypass: diagnostic yield and factors associated with relevant findings

BACKGROUND

After laparoscopic Roux-en-Y gastric bypass many patients present with complaints for which an upper endoscopy is performed. However, often no abnormalities are found.

OBJECTIVES

To investigate the incidence of relevant findings at upper endoscopy and identify patient characteristics associated with a relevant finding.

SETTING

A high-volume bariatric center.

METHODS

A retrospective cohort study was performed. All patients presenting with complaints after laparoscopic Roux-en-Y gastric bypass who consequently underwent a diagnostic upper endoscopy were identified from a prospective endoscopic database. Primary outcomes were the number and type of relevant findings at upper endoscopy and its association with patient characteristics. Relevant findings were defined as abnormalities requiring treatment.

RESULTS

Ninety-eight (39.2%) of 250 patients had a relevant finding at upper endoscopy, mostly marginal ulcer and stomal stenosis. Male sex (odds ratio [OR] 3.47 [1.12-10.76]), alcohol consumption (OR 7.27 [1.58-33.36]), dysphagia or suspicion of bleeding as referral reason (OR 3.62 [1.54-8.52] and 39.93 [4.96-321.47], respectively, compared with abdominal pain), an abnormal upper gastrointestinal series (OR 6.81 [2.06-22.48]), and no abdominal ultrasound (OR 7.41 [1.48-37.08] compared with a normal ultrasound) were significantly associated with a relevant finding at upper endoscopy.

CONCLUSIONS

In this study sex, alcohol consumption, referral reason, and prior imaging studies were associated with a relevant finding at upper endoscopy after laparoscopic Roux-en-Y gastric bypass.

Hiatal hernia diagnosis prospectively assessed in obese patients before bariatric surgery: accuracy of high-resolution manometry taking intraoperative diagnosis as reference standard

BACKGROUND

Hiatal hernia (HH) is common in obese patients undergoing bariatric surgery. Preoperative traditional techniques such as upper gastrointestinal endoscopy (UGIE) or barium swallow/esophagram do not always correlate with intraoperative findings. High-resolution manometry (HRM) has shown a higher sensitivity and specificity than traditional techniques in non-obese patients in the HH diagnosis, whereas there is a lack of data in the morbidly obese population. We aimed to prospectively assess the diagnostic accuracy of HRM in HH detection, in comparison with barium swallow and UGIE, assuming intraoperative diagnosis as a standard of reference.

METHODS

Forty-one consecutive morbidly obese patients prospectively recruited from a tertiary-care referral hospital devoted to bariatric and metabolic surgery underwent a preoperative evaluation including standardized GERD questionnaires, barium swallow, UGIE, and HRM. The surgical procedures were performed by a single surgeon who was blinded to the results of other investigations.

RESULTS

HH was intraoperatively diagnosed in 11/41 patients (26.8%). In 10/11 patients, the preoperative HRM showed an esophagogastric junction suggestive of HH. When compared to intraoperative evaluation, the sensitivity of the HRM was 90.9% and the specificity 63.3%, with a positive predictive value of 47.6% and a negative predictive value of 95.0%. HRM showed a higher sensitivity and specificity compared to barium swallow and UGIE.

CONCLUSIONS

HRM has a high accuracy of HH detection in morbidly obese patients assuming an intraoperative diagnosis as reference standard. It could therefore be a very useful tool in the preoperative work-up of obese patients undergoing bariatric surgery.

Cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy: a case report and review of the literature

BACKGROUND

Obesity is considered a chronic disease with an increasing prevalence worldwide during the last decades. Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure, due to its relative safety and long-term efficacy. The use of bougie to ensure correct size of the gastric tube is part of the standard operation, usually placed by the anesthesiologist and with a very low rate of complications. We report the first case, to our knowledge, of a cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy.

CASE PRESENTATION

The complication occurred in a previously healthy 42-year old female patient who underwent laparoscopic sleeve gastrectomy for class 1 obesity (BMI 31 kg/m²) and was diagnosed the first post-operative day. She was subsequently treated with an emergency thoracoscopy and evacuation of a mediastinal fluid collection, with additional neck incision for primary closure of the esophageal defect which was reinforced with a sternocleidomastoid muscle flap. The post-operative course was uneventful.

CONCLUSIONS

We made a literature review to better understand the options considering the diagnosis and treatment in case of very proximal iatrogenic esophageal perforations. The risks related to the use of bougie during surgery should not be underestimated, and its insertion must be done with extreme caution. Esophageal perforation is still a challenging, life threatening complication where prompt diagnosis and adequate treatment are essential.

Training in bariatric and metabolic endoscopy

The limited penetration of bariatric surgery and the scarce outcome of pharmacological therapies created a favorable space for primary bariatric endoscopic techniques. Furthermore, bariatric endoscopy is largely used to diagnose and treat surgical complications and weight regain after bariatric surgery. The increasingly essential role of endoscopy in the management of obese patients results in the need for trained professionals. Training methods are evolving, and the apprenticeship method is giving way to the simulation-based method. Existing simulation platforms include mechanical simulators, ex vivo and in vivo models, and virtual reality simulators. This review analyzes current training methods for bariatric endoscopy and available training programs with dedicated bariatric core curricula, giving a glimpse of future perspectives.