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]

Reflux-Related Abnormalities at Distal oesophagus, Gastric Pouch and Anastomotic Site 4 Years After OAGB: Diagnostic Accuracies of Endoscopy Compared to Biopsy and of Symptoms Compared to Both

BACKGROUND

The purpose of the current study is to appraise the diagnostic accuracy of upper endoscopy (UE) vs histopathological assessment of patients after one-anastomosis gastric bypass (OAGB), and the presence/absence of symptoms vs these two diagnostic modalities.

METHODS

Retrospective study of 50 consecutive patients who underwent OAGB during April 2019-April 2020 and consented to participate. Symptoms (symptoms score questionnaire), macroscopic and microscopic data were collected 4 years later to assess distal oesophageal, gastric pouch and anastomotic site changes. Diagnostic accuracies (sensitivity, specificity, positive/negative predictive values) of UE vs biopsy and symptoms vs both were assessed.

RESULTS

Mean age was 48.6 ± 13.3 years; 66% were females. At 4 years, 54% had symptoms (symptom score ≥ 4). There were no dysplasia or cancer among this series. UE abnormalities included non-erosive gastritis (44%) and ulcer/s or erosive gastritis (16% each); histopathology abnormalities included chronic gastritis (80%) and Barrett's oesophagus (14%). For UE compared to biopsy, highest sensitivity (76.5%) was at the level of distal oesophagus and highest specificity (100%) at anastomotic site. Pertaining to symptoms compared to investigative modality, highest sensitivity (81.5%) was in relation to symptoms vs UE, while highest specificity (82.6%) was for symptoms vs biopsy.

CONCLUSIONS

It is generally not recommended that (a) UE be used to forecast biopsy abnormalities or lack thereof, except at the anastomotic site, and (b) symptoms or lack thereof be used to forecast the findings of investigative modalities, except with caution, to forecast UE findings in identifying healthy individuals, or to forecast biopsy findings in identifying diseased individuals. Long-term routine follow-up is needed post-OAGB regardless of whether patients are symptomatic or otherwise to rule in or out possible macroscopic/microscopic pathologies. Further research on UE and biopsy findings post-OAGB and their relationships with each other and with symptoms/lack thereof are required to strengthen the thin evidence base.

How reliable is pre-sleeve endoscopy to characterize pathological features?

BACKGROUND

Vertical sleeve gastrectomy is a relatively new bariatric procedure with lower morbidity and mortality than other weight loss surgeries. The predictive values of preoperative esophagogastroduodenoscopy for detecting histopathological abnormalities prior to sleeve gastrectomy have not been clearly described. This study aimed to determine the negative predictive value of preoperative endoscopic biopsies for detecting Helicobacter pylori (H. pylori) infection and other pathological findings.

METHODS

This cross-sectional study examined 102 patients who underwent vertical sleeve gastrectomy from January 2023 to November 2023. Preoperative histopathology of esophagogastroduodenoscopy specimens was compared to postoperative ones for H. pylori infection, gastritis, atrophy, and metaplasia. Moreover, gastroesophageal reflux disease symptoms were postoperatively followed for 6 months.

RESULTS

The negative predictive value of preoperative esophagogastroduodenoscopy for detecting H. pylori infection, gastritis, metaplasia and atrophy were 95 %, 79 %, 93 %, and 98 %, respectively. In an overall view, for all pathologies, the negative predictive value was 53.4 %. Moderate gastritis and focal metaplasia were significantly underdiagnosed preoperatively (p < 0.001). H. pylori infection and focal metaplasia were significantly more prevalent in females after surgery (p < 0.001). H. pylori infection and gastritis were positively correlated with increased postoperative gastroesophageal reflux disease symptoms (p < 0.001).

CONCLUSION

Preoperative endoscopy has a high negative predictive value for detecting H. pylori infection, atrophy, and metaplasia but has suboptimal values for gastritis.

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.

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.

Endoscopic Assessment Prior to Bariatric Surgery in Saudi Arabia

BACKGROUND

There are marked local inconsistencies in the Arabian Peninsula about the role of preoperative esophagogastroduodenoscopy (EGD) in bariatric surgery. Thus, this study was conducted to determine the frequency of endoscopic and histological findings in the Saudi population presenting for pre-bariatric surgery evaluation.

MATERIAL AND METHODS

This was a retrospective study that included all the patients who were evaluated by EGD at Dammam Medical Complex, Dammam, Saudi Arabia, between 2018 and 2021 as a part of their pre-bariatric-surgery evaluation.

RESULTS

A total of 684 patients were included. They consisted of 250 male and 434 female patients (36.5% and 63.5%, respectively). The mean ± standard deviation for the patients' age and body mass index (BMI) were 36.4±10.6 years and 44.6±5.1 kg/m², respectively. Significant endoscopic or histopathological findings as defined by the presence of large (≥ 2 cm) hiatus hernia, esophagitis, gastroesophageal reflux disease (GERD), Barrett esophagus, gastric ulcer, duodenal ulcer, or intestinal metaplasia were found in 143 patients (20.9%); 364 patients (53.2%) were diagnosed to have Helicobacter pylori infection.

CONCLUSION

The high number of significant endoscopic and histopathological findings in our study supports the routine use of preoperative EGD in all bariatric surgery patients. However, omitting EGD before Roux-en-Y gastric bypass (RYGB) in asymptomatic patients is still reasonable as the most frequently found significant findings, esophagitis, and hiatus hernia, are less likely to impact the operative plans in RYGB. Similarly, active surveillance and treatment of H. pylori infections in obese patients are important but it is not clear whether H. pylori eradication should be done before bariatric surgery.

Impacts of sleeve gastrectomy on gastroesophageal reflux disease in severely obese Korean patients

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has established popularity as a bariatric and metabolic surgery. However, the incidence of gastroesophageal reflux disease (GERD) following LSG is controversial. This study aims to describe the prevalence of de novo GERD after LSG.

METHODS

A retrospective chart review was performed for 130 patients who underwent a routine endoscopic surveillance before and after LSG between January 2013 and October 2018. The diagnosis of GERD was determined by presence of symptoms, history of PPI treatment, and endoscopic findings. The esophagogastroduodenoscopy (EGD) was performed annually after LSG and/or when the patients complained of severe reflux symptoms.

RESULTS

The prevalence of GERD before surgery was 18.5%. At 1 year after LSG, GERD was present in 70 (53.8%) of the 130 patients. GERD consisted of 55 patients with newly developed GERD, and 15 with preexisting GERD. 9 (37.5%) out of pre-existing GERD patients were free of symptoms and abnormal finding at EGD following LSG. During the LSG, 66 (50.8%) patients with hiatal hernia underwent re-approximation of the diaphragmatic crura. There was no significant relationship between hiatal hernia repair and postoperative GERD (p = 0.39). Number of patients taking PPI medication before and after LSG were 34 (26.2%) and 49 (37.7%). Out of 56 (43.1%) patients with endoscopic lesions, LA grade A was 31 (23.9%), B = 15 (11.5%), C = 4 (3.1%), and D = 6 (4.6%).

CONCLUSION

In this study, 42.3% (n = 55) of total patients developed newly developed GERD, and 7.7% (n = 10) had LA grade C or D esophagitis.

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.

Preoperative Assessment of Patients Undergoing Bariatric Sleeve Gastrectomy: A Cross-Sectional Study

Introduction

Saudi Arabia (SA) is one of the top countries in the world when it comes to the number of bariatric procedures performed each year. There is still some debate on whether to do regular or selective upper endoscopy during the preoperative examination. The purpose of this study was to explore various endoscopic findings and Helicobacter pylori (HP) infection in symptomatic and asymptomatic patients having laparoscopic sleeve gastrectomy (LSG) prior to surgery.

Methods

We investigated a cohort of 132 patients referred to the endoscopy unit from the bariatric surgery outpatient clinic for prebariatric esophagogastroduodenoscopy (EGD) as a part of preoperative LSG. Data extraction from medical records included clinical data such as body mass index (BMI), gastrointestinal symptoms (that include heartburn, regurgitation, epigastric pain, and nausea), medical comorbidities, and laboratory investigations. It included data about the endoscopic findings of EGD procedure as esophageal, gastric, and duodenal findings results as well as the results of biopsy specimens that were taken.

Results

Out of 132 patients, 29 (22%) had a BMI of less than 40 kg/m2 whereas 103 (78%) had a BMI of 40 kg/m2 or above, with an average of 44.4 ± 6.4 kg/m2. The average age of participants was 33.6 ± 10.4 years. HP was detected in 36 patients (35.0%) with a slightly greater prevalence in patients with a higher BMI (33.7%) than in patients with lower BMI (35.0%). Collectively, 73 patients (55.7%) had positive endoscopic findings of various grades, sites, and combinations. Incompetent cardia (35.6%) was the most often seen esophageal finding, antral gastritis (34.1%) was the most frequently encountered gastric finding, and duodenitis 1st part was the commonest duodenal endoscopic finding (7.8%). Among asymptomatic patients, incompetent cardia was detected in 33.3%, antral gastritis was found in 30.1%, and around one-quarter of them were positive on HP testing (26.6%). Additionally, 16.1% of them had signs of reflux esophagitis, 17.2% had hiatal hernia, and 14.0% had nodular gastritis.

Conclusion

The current study revealed a high prevalence of positive endoscopic findings as well as HP infection upon routine endoscopic examination among patients undergoing bariatric surgery even those who were asymptomatic from any gastrointestinal symptoms.

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.

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%).

Bariatric surgery in the Middle East and North Africa: narrative review with focus on culture-specific considerations

There is an increasing volume of bariatric surgeries in the Middle East and North Africa (MENA), but the context of bariatric surgery in the region is not fully understood. Incorporating culture-specific considerations in the provision of care to patients who undergo bariatric surgery may help to optimize outcomes after surgery. We conducted a narrative review of published research studies on bariatric surgery in the MENA region, highlighting cultural and contextual aspects relevant to the care of bariatric surgery patients who undergo surgery in this geographic area. The authors searched the following online databases: PubMed, CINAHL, Embase, and Academic Search Elite from 2010-2020 for studies conducted in 18 countries in the MENA region. This narrative review identifies cultural-specific considerations that may affect bariatric care and outcomes in 6 domains: knowledge of bariatric surgery; mental health, body image, and quality of life; influence of family; religion and lifestyle; preoperative practices; and healthcare access. Provision of culturally congruent care may help patients to achieve the best possible outcomes after bariatric surgery. Results may inform efforts to provide safe and culture-specific care in the MENA region, as well as those who migrate or seek care in other countries. More research is warranted on this heterogeneous population to optimize postsurgery weight trajectory and psychosocial adjustment.

IFSO Position Statement on the Role of Esophago-Gastro-Duodenal Endoscopy Prior to and after Bariatric and Metabolic Surgery Procedures

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.

Non-cardia gastric adenocarcinoma more than 5 years after laparoscopic sleeve gastrectomy: A case report and literature review

Obesity is associated with an increased risk of several cancers including adenocarcinomas of the esophagus and gastric cardia but not with distal gastric cancer (GC). Laparoscopic sleeve gastrectomy (LSG) is a popular bariatric procedure. We report the fifth case in the medical literature of non-cardia gastric adenocarcinoma 63 months after LSG in a 26-year-old woman with no known recognizable risk factors. Among these five cases, the median (range) age at time of diagnosis of GC was 47 (26-64) years, the body mass index (BMI) prior to LSG was 47 (35.3-65.1) kg/m² , the BMI at time of cancer diagnosis was 32 (29.3-47.0) kg/m² , and the interval between LSG and diagnosis was 54 (9-63) months. Nonetheless, the link between LSG and the risk of GC remains skeptical and is discussed.

The Effect of Bariatric Surgery and Endoscopic Procedures on Gastroesophageal Reflux Disease

Obesity is a global epidemic posing a significant burden on patients and healthcare systems. Gastroesophageal reflux disease is associated with obesity and its prevalence is also growing worldwide. Numerous bariatric surgeries and endoscopic procedures have arisen to assist with weight loss and management of obesity-related conditions. However, the effect of these interventions on reflux is variable and the evidence is often conflicting. To date, Roux-en-Y gastric bypass remains the gold-standard for attaining both reflux and weight loss management, however novel endoscopic techniques are quickly becoming more prevalent as an alternative to surgery. This review aims to summarize currently available endoscopic and surgical weight loss procedures and their impact on reflux symptoms while emphasizing areas requiring additional investigation.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

Prevalence of Upper Gastrointestinal Pathology in Patients with Obesity on Preoperative Endoscopy

Background and Objectives:

The preoperative work up for bariatric surgery is variable and not all centers perform a preoperative upper gastrointestinal endoscopy. A study was undertaken to determine the frequency of clinically significant gross endoscopic and pathological diagnoses in a large sample of patients with obesity undergoing work-up for bariatric surgery.

Methods:

Routine endoscopy was performed on all preoperative bariatric patients. A retrospective chart review of 1000 consecutive patients was performed. Patients were divided into three groups: Group A (no endoscopic findings), Group B (clinically insignificant findings), Group C (clinically significant findings).

Results:

Patients had a mean body mass index (BMI) of 49 kg/m2 and 79% were female. In this sample one finding was found on preoperative EGD in 95.2% of patients, 33.9% had at least two diagnoses, and 29.9% had three or more diagnoses. Group A (no findings) consisted of 4.8% of patient, 52.5% in Group B (clinically insignificant findings), and 42.7% were in Group C (clinically significant findings). Clinically significant findings included hiatal hernia 23.5%, esophagitis 9.5%, H. pylori 7.1%, gastric erosions 5.7%, duodenitis 3.7%, Barrett's esophagus 3.1%, and Schatzki ring 1.2%. There was no significant correlation between preoperative BMI and any endoscopic findings (all p-value 0.05). Patients in Group C were statistically older than Groups A and B.

Conclusion:

Upper gastrointestinal pathology is highly common in patients with obesity. There is a significant rate of clinically significant endoscopy findings and all bariatric surgery patients should undergo preoperative endoscopy.

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.

A case of gastric cancer after sleeve gastrectomy

There is concern over how to survey the remnant upper gastrointestinal tract, as well as what to do if a patient subsequently develops an upper gastrointestinal cancer following bariatric surgery. We hereby report a case of gastric cancer arising 8 years after a laparoscopic sleeve gastrectomy (LSG). The patient, a 42 year-old woman, was diagnosed with a gastric cancer via esophagogastroduodenoscopy (EGD). As such, she underwent a laparoscopic total gastrectomy with lymphadenectomy. The final histopathology was that of a poorly differentiated adenocarcinoma with signet-ring cells without lymph node metastases (staging pT4aN0). The background gastric mucosa displayed no Helicobacter pylori. There have only been a few reported cases of gastric cancer after sleeve gastrectomy. Nevertheless, it may be wise to consider performing EGD at regular intervals after bariatric surgery, especially in Asia. In this regard, LSG holds an advantage over Roux-en-Y gastric bypass with respect to the feasibility of surveillance of the remnant stomach.

Is Routine Preoperative Esophagogastroduodenoscopy Prior to Bariatric Surgery Mandatory? Systematic Review and Meta-analysis of 10,685 Patients

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.

Accuracy of hiatal hernia diagnosis in bariatric patients: Preoperative endoscopy versus intraoperative reference

Background and Aim

Obesity is becoming increasingly prevalent in Asia. Bariatric surgery in the region is growing in popularity to reflect increasing demand. Hiatal hernia (HH) is common among the obese population. There is a lack of evidence comparing preoperative endoscopy against intraoperative findings as a standard of reference for HH diagnosis.

Methods

This was a retrospective analysis of a bariatric procedure database from a single tertiary teaching hospital and high‐volume endoscopy center. Electronic medical records were reviewed. Endoscopy results were compared to intraoperative findings, and subgroup analysis of >2 cm hernias was performed. Sensitivity, specificity, predictive values, likelihood ratios, and global diagnostic test accuracy were calculated.

Results

A total of 434 patients were eligible for this study, of which HH was detected in 37 patients (prevalence rate 8.55%). Mean age was 41.51 ± 11.07 years, and body mass index was 39.37 ± 5.67 kg/m². Endoscopy sensitivity was 75.68% (95% confidence interval, 58.80–88.23%) and specificity 91.44% (88.24–94.00%). Positive likelihood ratio was 8.53 (6.11–12.79) and negative likelihood ratio 0.27 (0.15–0.47). Positive predictive value was 45.16% (36.27–54.38%) and negative predictive value 97.58% (95.80–98.62%). Accuracy of endoscopy for preoperative HH diagnosis was 90.09% (86.89–92.74%).

Conclusion

Endoscopy can have a high diagnostic accuracy of preoperative HH diagnosis in obese Asian patients using intraoperative diagnosis as the reference standard.

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.

Is routine preoperative esophagogastroduodenscopy prior to bariatric surgery mandatory? protocol for a systematic review and meta-analysis

INTRODUCTION

Routine preoperative esophagogastroduodenscopy (p-EGD) prior to bariatric surgery (BS) is currently widely undertaken, and hence an important issue with many clinical and financial repercussions. Yet, the true extent of why p-EGD is routinely undertaken for all bariatric patients remains not well understood.

METHODS AND ANALYSIS

To address this, we will undertake a systematic review and meta-analysis of routine p-EGD prior to BS from around the world. This protocol describes the methodological approach to be adopted and outlines the search strategies and eligibility criteria that will be employed to identify and select studies, and the way by which data from the selected studies will be extracted for analysis. PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, Cochrane Library, MEDLINE, Scopus, clinicaltrials.gov and Google scholar will be searched from 01 January 2000 to 30 April 2019 for original studies written in English that provided prevalence estimates of the outcomes of routine p-EGD prior to BS. STROBE criteria will assess the methodological quality of the selected studies. The use of fixed or random effects model will depend on the results of statistical tests for heterogeneity. Publication bias will be visually estimated by assessing funnel plots. Pooled estimates will be calculated. This protocol conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines and has been submitted for registration at the PROSPERO International Prospective Register of systematic reviews. No ethical clearance is required for this study. This review will be published in a peer- reviewed journal and will be presented at various national and international conferences.

Preoperative Upper-GI Endoscopy Prior to Bariatric Surgery: Essential or Optional?

Introduction

The role of preoperative upper-gastrointestinal (GI) gastroscopy has been discussed with controversy in bariatric surgery. The aim of this study was to evaluate the incidence of upper-GI pathologies detected via endoscopy prior to bariatric surgery along with their clinical significance for patients’ management.

Material and Methods

In our single center prospectively established database of obese patients, who underwent bariatric surgery from January 2011 to December 2017, we retrospectively analyzed the perioperative endoscopic findings along with their influence on patients’ management.

Results

In total, 636 obese patients with median BMI (body mass index) of 49 kg/m² [range 31–92] received an upper-GI endoscopy prior to bariatric surgery. Among the surgical procedures, laparoscopic Roux-Y-gastric bypass (72.6%; n = 462) was the most frequent operation. Endoscopically detected pathological conditions were peptic ulcer 3.5% (22/636), Helicobacter pylori (Hp) gastritis 22.4% (143/636), and gastric or duodenal polyps 6.8% (43/636). Reflux esophagitis could be detected in 139/636 patients (21.9%). Barrett’s esophagus (BE) was histologically diagnosed in 95 cases (15.0%), whereas BE was suspected endoscopically in 75 cases (11.3%) only. Esophageal adenocarcinomas were detected in 3 cases (0.5%). Change of the operative strategy due to endoscopically or histologically detected pathologic findings had to be performed in 10 cases (1.6%).

Conclusion

Preoperative upper-GI endoscopy identifies a wide range of abnormal endoscopic findings in obese patients, which may have a significant impact on decision-making, particularly regarding the most suitable bariatric procedure and the appropriate follow-up. Therefore, preoperative upper-GI endoscopy should be considered in all obese patients prior to bariatric procedure.

Gastroesophageal reflux disease, obesity and laparoscopic sleeve gastrectomy: The burning questions

Obesity is a global health epidemic with considerable economic burden. Surgical solutions have become increasingly popular following technical advances leading to sustained efficacy and reduced risk. Sleeve gastrectomy accounts for almost half of all bariatric surgeries worldwide but concerns regarding its relationship with gastroesophageal reflux disease (GERD) has been a topic of debate. GERD, including erosive esophagitis, is highly prevalent in the obese population. The role of pre-operative endoscopy in bariatric surgery has been controversial. Two schools of thought exist on the matter, one that believes routine upper endoscopy before bariatric surgery is not warranted in the absence of symptoms and another that believes that symptoms are poor predictors of underlying esophageal pathology. This debate is particularly important considering the evidence for the association of laparoscopic sleeve gastrectomy (LSG) with de novo and/or worsening GERD compared to the less popular Roux-en-Y gastric bypass procedure. In this paper, we try to address 3 burning questions regarding the inter-relationship of obesity, GERD, and LSG: (1) What is the prevalence of GERD and erosive esophagitis in obese patients considered for bariatric surgery? (2) Is it necessary to perform an upper endoscopy in obese patients considered for bariatric surgery? And (3) What are the long-term effects of sleeve gastrectomy on GERD and should LSG be done in patients with pre-existing GERD?

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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