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Owen CK, Felinski MM, Bajwa KS, Walker PA, Mehta SS, Wilson EB, Boodoo S, Kudav V, Akhtar SJ, Shah SK, Kling ME. 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. Obes Surg 2024; 34:1442-1448. [PMID: 38472705 DOI: 10.1007/s11695-024-07155-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
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.
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Affiliation(s)
- Christopher K Owen
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Melissa M Felinski
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kulvinder S Bajwa
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Peter A Walker
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Erik B Wilson
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Vishal Kudav
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shaan J Akhtar
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Shinil K Shah
- Division of Minimally Invasive and Elective General Surgery, Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
- Michael E DeBakey Institute of Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX, USA.
| | - M Elaine Kling
- Brown and Associates Medical Laboratories, Sugar Land, TX, USA
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de la Cruz Cuadrado C, López-Tomassetti Fernández E, García Plaza G, Hernández Hernández JR. Polypoid Sleeve. Obes Surg 2023; 33:1281-1283. [PMID: 36781594 DOI: 10.1007/s11695-023-06493-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 01/28/2023] [Accepted: 02/01/2023] [Indexed: 02/15/2023]
Affiliation(s)
- Cristina de la Cruz Cuadrado
- Complejo Hospitalario Universitario Insular-Materno Infantil, Avenida Marítima del Sur, s/n, 35016, Las Palmas de Gran Canaria, Spain.
| | | | - Gabriel García Plaza
- Complejo Hospitalario Universitario Insular-Materno Infantil, Avenida Marítima del Sur, s/n, 35016, Las Palmas de Gran Canaria, Spain
| | - Juan Ramón Hernández Hernández
- Complejo Hospitalario Universitario Insular-Materno Infantil, Avenida Marítima del Sur, s/n, 35016, Las Palmas de Gran Canaria, Spain
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Kanat BH, Doğan S. Is gastroscopy necessary before bariatric surgery? World J Gastrointest Endosc 2022; 14:29-34. [PMID: 35116097 PMCID: PMC8788171 DOI: 10.4253/wjge.v14.i1.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/26/2021] [Accepted: 12/22/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Burhan Hakan Kanat
- Department of General Surgery, Malatya Turgut Özal University, School of Medicine, Malatya 44100, Turkey
| | - Serhat Doğan
- Department of General Surgery, Malatya Turgut Özal University, School of Medicine, Malatya 44100, Turkey
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Controversies in the Preoperative Workup and Management for Patients Undergoing Bariatric Surgery: A Review of the Literature. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2020.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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IFSO Position Statement on the Role of Esophago-Gastro-Duodenal Endoscopy Prior to and after Bariatric and Metabolic Surgery Procedures. Obes Surg 2021; 30:3135-3153. [PMID: 32472360 DOI: 10.1007/s11695-020-04720-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
One of the roles of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) is to provide guidance on the management of patients seeking surgery for adiposity-based chronic diseases. The role of endoscopy around the time of endoscopy is an area of clinical controversy. In 2018, IFSO commissioned a task force to determine the role of endoscopy before and after surgery for the management of adiposity and adiposity-based chronic diseases. The following position statement is issued by the IFSO Endoscopy in Bariatric/Metabolic Surgery Taskforce. It has been approved 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.
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Assaf D, Rayman S, Segev L, Neuman Y, Zippel D, Goitein D. Improving pre-bariatric surgery diagnosis of hiatal hernia using machine learning models. MINIM INVASIV THER 2021; 31:760-767. [PMID: 33779469 DOI: 10.1080/13645706.2021.1901120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Bariatric patients have a high prevalence of hiatal hernia (HH). HH imposes various difficulties in performing laparoscopic bariatric surgery. Preoperative evaluation is generally inaccurate, establishing the need for better preoperative assessment. OBJECTIVE To utilize machine learning ability to improve preoperative diagnosis of HH. METHODS Machine learning (ML) prediction models were utilized to predict preoperative HH diagnosis using data from a prospectively maintained database of bariatric procedures performed in a high-volume bariatric surgical center between 2012 and 2015. We utilized three optional ML models to improve preoperative contrast swallow study (SS) prediction, automatic feature selection was performed using patients' features. The prediction efficacy of the models was compared to SS. RESULTS During the study period, 2482 patients underwent bariatric surgery. All underwent preoperative SS, considered the baseline diagnostic modality, which identified 236 (9.5%) patients with presumed HH. Achieving 38.5% sensitivity and 92.9% specificity. ML models increased sensitivity up to 60.2%, creating three optional models utilizing data and patient selection process for this purpose. CONCLUSION Implementing machine learning derived prediction models enabled an increase of up to 1.5 times of the baseline diagnostic sensitivity. By harnessing this ability, we can improve traditional medical diagnosis, increasing the sensitivity of preoperative diagnostic workout.
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Affiliation(s)
- Dan Assaf
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Shlomi Rayman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Lior Segev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Yair Neuman
- The Department of Cognitive and Brain Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Douglas Zippel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Goitein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Hiatal Hernia Evaluation Before Bariatric Surgery: Should It Be Routinely Done? Obes Surg 2020; 31:1013-1020. [PMID: 33130945 DOI: 10.1007/s11695-020-05092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
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.
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El Ansari W, El-Menyar A, Sathian B, Al-Thani H, Al-Kuwari M, Al-Ansari A. Is Routine Preoperative Esophagogastroduodenoscopy Prior to Bariatric Surgery Mandatory? Systematic Review and Meta-analysis of 10,685 Patients. Obes Surg 2020; 30:3073-3083. [PMID: 32468339 PMCID: PMC7305097 DOI: 10.1007/s11695-020-04672-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This systematic review and meta-analysis searched, retrieved and synthesized the evidence as to whether preoperative esophagogastroduodenoscopy (p-EGD) should be routine before bariatric surgery (BS). METHODS Databases searched for retrospective, prospective, and randomized (RCT) or quasi-RCT studies (01 January 2000-30 April 2019) of outcomes of routine p-EGD before BS. STROBE checklist assessed the quality of the studies. P-EGD findings were categorized: Group 0 (no abnormal findings); Group 1 (abnormal findings that do not necessitate changing the surgical approach or postponing surgery); Group 2 (abnormal findings that change the surgical approach or postpone surgery); and Group 3 (findings that signify absolute contraindications to surgery). We assessed data heterogeneity and publication bias. Random effect model was used. RESULTS Twenty-five eligible studies were included (10,685 patients). Studies were heterogeneous, and there was publication bias. Group 0 comprised 5424 patients (56%, 95% CI: 45-67%); Group 1, 2064 patients (26%, 95% CI: 23-50%); Group 2, 1351 patients (16%, 95% CI: 11-21%); and Group 3 included 31 patients (0.4%, 95% CI: 0-1%). CONCLUSION For 82% of patients, routine p-EGD did not change surgical plan/ postpone surgery. For 16% of patients, p-EGD findings necessitated changing the surgical approach/ postponing surgery, but the proportion of postponements due to medical treatment of H Pylori as opposed to "necessary" substantial change in surgical approach is unclear. For 0.4% patients, p-EGD findings signified absolute contraindication to surgery. These findings invite a revisit to whether p-EGD should be routine before BS, and whether it is judicious to expose many obese patients to an invasive procedure that has potential risk and insufficient evidence of effectiveness. Further justification is required.
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Affiliation(s)
- Walid El Ansari
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
- Schools of Health and Education, University of Skovde, Skövde, Sweden
| | - Ayman El-Menyar
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Brijesh Sathian
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery Section, Hamad Medical Corporation, Doha, Qatar
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High Cost for Low Yield: A Systematic Review and Meta-Analysis to Assess Cost of Routine Preoperative Esophagogastroduodenoscopy Before Bariatric Surgery. J Clin Gastroenterol 2020; 54:398-404. [PMID: 32168132 DOI: 10.1097/mcg.0000000000001334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Preoperative Endoscopic and Radiologic Evaluation of Bariatric Patients: What Do They Add? J Gastrointest Surg 2020; 24:764-771. [PMID: 31073799 DOI: 10.1007/s11605-019-04219-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 03/27/2019] [Indexed: 01/31/2023]
Abstract
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.
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Upper Gastrointestinal Endoscopy in Adolescents With Severe Obesity Before Vertical Sleeve Gastrectomy. J Pediatr Gastroenterol Nutr 2019; 69:287-291. [PMID: 31436669 DOI: 10.1097/mpg.0000000000002371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Esophagogastroduodenoscopy (EGD) is often performed to evaluate for mucosal and anatomical abnormalities before vertical sleeve gastrectomy (SG). Little is known, however, about how prebariatric EGD in adolescents influences clinical management or outcome. Our aim was to assess if an abnormal prebariatric EGD resulted in interventions or modification of bariatric surgery. METHODS We performed a retrospective cohort study of adolescents undergoing evaluation for bariatric surgery. We obtained demographic and anthropometric data in addition to EGD findings, biopsy pathology, gastrointestinal symptoms, and surgical outcomes. An EGD was considered abnormal if either abnormal gross findings or abnormal pathology was reported. Patients were followed until a 6-week postop visit. RESULTS Of 134 patients presenting for evaluation, 94 (70%) underwent preoperative EGD. Fifty-one (54%) had a normal EGD and 43 (46%) had EGD abnormalities including 7 with an anatomical abnormality and 36 with mild mucosal abnormalities. Among patients with EGD abnormalities, 22% received medical intervention including proton pump inhibitor (PPI) administration (n = 10) and Helicobacter pylori eradication (n = 11). GI symptoms were the only predictor of EGD abnormalities (odds ratio [OR] 4.9: 95% confidence interval [CI] 1.6-15.0; P < 0.001). No factors predicted likelihood of a post-EGD intervention. An abnormal EGD did not correlate with any postoperative complications. CONCLUSIONS In this cohort of adolescents undergoing evaluation for SG, 46% had an abnormal EGD, of which 22% received a medical intervention. Symptoms were the only predictor of EGD abnormalities. Abnormal EGD findings were not associated with modification of the surgery or any adverse outcome.
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Mazahreh TS, Aleshawi AJ, Al-Zoubi NA, Allouh MZ, Jadallah KA, Elayyan R, Novotny NM. Preoperative esophagogastroduodenoscopy in patients without reflux symptoms undergoing laparoscopic sleeve gastrectomy: utility or futility? Clin Exp Gastroenterol 2019; 12:295-301. [PMID: 31456645 PMCID: PMC6620317 DOI: 10.2147/ceg.s216188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 06/12/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Tagleb S Mazahreh
- Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Abdelwahab J Aleshawi
- Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Nabil A Al-Zoubi
- Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Mohammed Z Allouh
- Department of Anatomy, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan.,Department of Anatomy, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain 17666, UAE
| | - Khaled A Jadallah
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Rasheed Elayyan
- Department of General Surgery and Urology, Faculty of Medicine, Jordan University of Science & Technology, Irbid 22110, Jordan
| | - Nathan M Novotny
- Department of Pediatric Surgery, Beaumont Children's, Oakland University William Beaumont School of Medicine, Michigan 48073, USA
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Fernández JA, Frutos MD, Ruiz-Manzanera JJ, Navarro A, Torres G, Soria T. Gastrointestinal Stromal Tumors After Laparoscopic Gastric Bypass for Morbid Obesity: a Diagnostic and Therapeutic Challenge. Obes Surg 2019; 29:2618-2621. [DOI: 10.1007/s11695-019-03944-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Raj PP, Bhattacharya S, Misra S, Kumar SS, Khan MJ, Gunasekaran SC, Palanivelu C. Gastroesophageal reflux-related physiologic changes after sleeve gastrectomy and Roux-en-Y gastric bypass: a prospective comparative study. Surg Obes Relat Dis 2019; 15:1261-1269. [PMID: 31279562 DOI: 10.1016/j.soard.2019.05.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The development of gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG) is a major concern as it affects the quality of life of the patients and potentially exposes them to the complications of GERD. The reported incidence of GERD after LSG is up to 35%. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the procedure of choice for patients with morbid obesity with GERD but objective evidence based on physiologic studies for the same are limited. OBJECTIVE The objectives of the study were to determine the physiologic changes related to gastroesophageal reflux based on symptoms index, 24-hour pH study, impedance, and manometry after LSG and LRYGB. SETTINGS Tertiary care teaching hospital, India. METHODS This registered study (CTRI/2017/06/008834) is a prospective, nonrandomized, open-label clinical trial comparing the incidence of GERD after LSG and LRYGB. In this study, non-GERD patients were evaluated for GERD based on clinical questionnaires, 24-hour pH study, and impedance manometry preoperatively and 6 months postoperatively. RESULTS Thirty patients underwent LSG, and 16 patients underwent LRYGB. The mean DeMeester score increased from 10.9 ± 11.8 to 40.2 ± 38.6 (P = .006) after LSG. The incidence of GERD after LSG was 66.6%. The increase in DeMeester score from 9.5 ± 4.6 to 12.2 ± 17.2 after LRYGB was not significant (P = .7). There was a significant increase in the nonacid reflux both after LSG and LRYGB. CONCLUSION The incidence of GERD after LSG is high, making it a contraindication for LSG. LRYGB remains the preferred procedure for patients with GERD. However, more studies are needed to understand the physiologic changes in patients with preexisting GERD.
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Affiliation(s)
- P Praveen Raj
- Department of Bariatric & Metabolic Surgery, GEM Hospital & Research Centre, Coimbatore, India.
| | - Siddhartha Bhattacharya
- Department of Bariatric & Metabolic Surgery, GEM Hospital & Research Centre, Coimbatore, India
| | - Shivanshu Misra
- Department of Bariatric & Metabolic Surgery, GEM Hospital & Research Centre, Coimbatore, India
| | - S Saravana Kumar
- Department of Bariatric & Metabolic Surgery, GEM Hospital & Research Centre, Coimbatore, India
| | - Mohd Juned Khan
- Department of Medical Gastroenterology, GEM Hospital & Research Centre, Coimbatore, India
| | | | - C Palanivelu
- Department of Surgical Gastroenterology, GEM Hospital & Research Centre, Coimbatore, India
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15
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Is Routine Preoperative Esophagogastroduodenoscopy Screening Necessary Prior to Laparoscopic Sleeve Gastrectomy? Review of 1555 Cases and Comparison with Current Literature. Obes Surg 2018; 28:52-60. [PMID: 28685362 DOI: 10.1007/s11695-017-2813-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Controversy exists as to whether routine preoperative esophagogastroduodenoscopy (p-OGD) in bariatric surgery should be routinely undertaken or undertaken selectively based on patients' symptoms. As very few studies have focused on the role of p-OGD prior to the increasingly common laparoscopic sleeve gastrectomy (LSG), we assessed the role/impact of p-OGD in LSG patients. METHODS Retrospective review of records of all LSG patients operated upon at Hamad General Hospital, Qatar (2011-2014, n = 1555). All patients were screened by p-OGD. Patient characteristics were analyzed, and p-OGD findings were categorized into four groups employing Sharaf et al.'s classification (Obes Surg 14:1367-1372, 23). We assessed the impact of p-OGD findings on any change in surgical management or lack thereof. RESULTS p-OGD findings indicated that 89.5% of our patients had normal or mild findings and were asymptomatic (groups 0 and 1, not necessitating any change in surgical management), and no patients had gastric cancer or varices (group 3). A total of 10.5% of our sample were categorized as group 2 patients who, according to Sharaf et al. (Obes Surg 14:1367-1372, 23), might have their surgical approach changed. All patients diagnosed preoperatively with hiatal hernia (HH) had LSG with crural repair and their symptoms resolved postoperatively. CONCLUSION Due to effectiveness and best utilization of resources, routine p-OGD screening in patients scheduled for LSG may require further justification for asymptomatic patients especially in regions with low upper GI cancers. p-OGD findings had low impact on the management of asymptomatic patients. Crural repair plus LSG was effective for hiatal hernia.
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16
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Fernandes SR, Meireles LC, Carrilho-Ribeiro L, Velosa J. The Role of Routine Upper Gastrointestinal Endoscopy Before Bariatric Surgery. Obes Surg 2018; 26:2105-2110. [PMID: 26750117 DOI: 10.1007/s11695-016-2056-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Obesity remains a major health concern for which surgery has proven to be the most effective treatment in the long term. Routine upper gastrointestinal endoscopy (UGE) is recommended before surgery, but few studies have evaluated its impact on postoperative complications. METHODS We studied a cohort of 613 patients submitted to UGE before being listed for bariatric surgery between May 2004 and May 2015. A logistic regression analysis was performed to evaluate potential predictors of postoperative complications. RESULTS Three hundred forty-five patients (56.3 %) presented abnormal endoscopic findings. Helicobacter pylori (Hp) was the strongest predictor of an abnormal endoscopy (OR 10.343, 95 % CI [3.970-26.943], p < 0.001). Of the 342 patients who underwent surgery, 43 (12.6%) developed a postsurgical complication and 2 (0.6%) patients died. In regression analysis, endoscopic ulceration was the only predictor of postoperative complications (OR 11.10, 95 % CI [1.80-68.467], p = 0.01). All patients with gastroduodenal ulcers were infected with Hp. CONCLUSIONS UGE before bariatric surgery can identify a wide range of abnormal findings. Gastric and duodenal ulcers appear to be the major findings associated with postoperative complications. Routine Hp eradication may potentially reduce the risk of postoperative complications and should be attempted in all patients before surgery.
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Affiliation(s)
- Samuel R Fernandes
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Avenida Professor Egas Moniz, Lisbon, 1649-035, Portugal.
| | - Liliane C Meireles
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Avenida Professor Egas Moniz, Lisbon, 1649-035, Portugal
| | - Luís Carrilho-Ribeiro
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Avenida Professor Egas Moniz, Lisbon, 1649-035, Portugal
| | - José Velosa
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Avenida Professor Egas Moniz, Lisbon, 1649-035, Portugal
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17
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Rare Entities of Histopathological Findings in 755 Sleeve Gastrectomy Cases: a Synopsis of Preoperative Endoscopy Findings and Histological Evaluation of the Specimen. Obes Surg 2017; 28:1289-1295. [DOI: 10.1007/s11695-017-3014-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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18
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Telem DA, Gould J, Pesta C, Powers K, Majid S, Greenberg JA, Teixeira A, Brounts L, Lin H, DeMaria E, Rosenthal R. American Society for Metabolic and Bariatric Surgery: care pathway for laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2017; 13:742-749. [DOI: 10.1016/j.soard.2017.01.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 02/06/2023]
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19
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Goitein D, Sakran N, Rayman S, Szold A, Goitein O, Raziel A. Barium swallow for hiatal hernia detection is unnecessary prior to primary sleeve gastrectomy. Surg Obes Relat Dis 2017; 13:138-142. [DOI: 10.1016/j.soard.2016.08.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/28/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
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20
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Dantas ACB, Santo MA, de Cleva R, Sallum RAA, Cecconello I. Influence of obesity and bariatric surgery on gastric cancer. Cancer Biol Med 2016; 13:269-76. [PMID: 27458534 PMCID: PMC4944545 DOI: 10.20892/j.issn.2095-3941.2016.0011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Esophageal and gastric cancer (GC) are related to obesity and bariatric surgery. Risk factors, such as gastroesophageal reflux and Helicobacter pylori, must be investigated and treated in obese population. After surgery, GC reports are anecdotal and treatment is not standardized. This review aims to discuss GC related to obesity before and after bariatric surgery.
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Affiliation(s)
| | - Marco Aurelio Santo
- Department of Digestive Surgery, University of São Paulo School of Medicine, São Paulo-SP 05403-000, Brazil
| | - Roberto de Cleva
- Department of Digestive Surgery, University of São Paulo School of Medicine, São Paulo-SP 05403-000, Brazil
| | | | - Ivan Cecconello
- Department of Digestive Surgery, University of São Paulo School of Medicine, São Paulo-SP 05403-000, Brazil
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21
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Mihmanli M, Yazici P, Isil G, Tanik C. Should We Perform Preoperative Endoscopy Routinely in Obese Patients Undergoing Bariatric Surgery? Bariatr Surg Pract Patient Care 2016. [DOI: 10.1089/bari.2015.0050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Mehmet Mihmanli
- General Surgery Clinic, Sisli Hamidiye Etfal Training and Research Hospital, Sisli, Istanbul, Turkey
| | - Pinar Yazici
- General Surgery Clinic, Sisli Hamidiye Etfal Training and Research Hospital, Sisli, Istanbul, Turkey
| | - Gurhan Isil
- General Surgery Clinic, Sisli Hamidiye Etfal Training and Research Hospital, Sisli, Istanbul, Turkey
| | - Canan Tanik
- Pathology Clinic, Sisli Hamidiye Etfal Training and Research Hospital, Sisli, Istanbul, Turkey
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22
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De novo gastric adenocarcinoma 1 year after sleeve gastrectomy in a transplant patient. Int J Surg Case Rep 2016; 20:10-3. [PMID: 26774417 PMCID: PMC4818282 DOI: 10.1016/j.ijscr.2015.12.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/28/2015] [Accepted: 12/28/2015] [Indexed: 11/20/2022] Open
Abstract
Gastric cancer after sleeve gastrectomy has been previously reported, completion gastrectomy is the recommended treatment. No direct relation has been established between sleeve gastrectomy and the development of gastric cancer. A minimally invasive approach should always be attempted to minimize the stress of surgery. The robotic system allows for complex multi-organ resections.
Introduction It has been reported in the literature that upper gastrointestinal malignancies after bariatric surgery are mostly gastro-esophageal, although it is not clear whether bariatric surgery represents a risk factor for the development of esophageal and/or gastric cancer. We report a case of a de novo gastric adenocarcinoma occurring in a transplant patient 1 year after a laparoscopic sleeve gastrectomy. Presentation of case A 44 year-old woman with a BMI of 38 kg/m2, hypertension, type 1 diabetes mellitus, multiple malignancies and a pancreas transplant underwent laparoscopic sleeve gastrectomy. The patient presented with intense dysphagias during the follow up. Studies were performed and the diagnoses of grade 2/3 adenocarcinoma were made. The patient underwent a robotic assisted total gastrectomy with a roux-en-y intracorporeal esophagojejunostomy. The procedure resulted in multiple metastasic lymph nodes, focal and transmural invasions to multiple organs with a tumor free margin resection. The patient presented with a postoperative pleural effusion, with no further complications. Discussion The diagnosis of gastroesophageal cancer after bariatric surgery is usually late since these patients have common upper gastrointestinal symptoms related to the procedure that could delay the diagnosis. De novo gastric cancer after sleeve gastrectomy has only been reported in one instance, in contrast with other bariatric surgery procedures. Conclusions No direct relation has been established between sleeve gastrectomy and the development of gastric cancer. Robotic procedures allow for complex multiorgan resections, while preserving the benefits of minimally invasive surgery.
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