Retrospective review of the preoperative biliary and gastrointestinal evaluation for gastric bypass 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.

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.

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.

Gastro-Intestinal Tract Cancers Following Bariatric Surgery: a Narrative Review

The association between obesity and malignancies has been identified epidemiologically. Meanwhile, the increasing global number of bariatric surgeries is reported annually; bariatric surgery's effect on different types of cancers is not well understood. Unfortunately, nonspecific presentations and difficulties regarding investigations make diagnosis challenging. The aim of this study is to compile available data about gastro-intestinal (GI) cancers, occurring after different bariatric surgeries. Although GI cancers are considered a rare complication of obesity surgery, they do exist, and diagnosis needs a high index of suspicion.

Body Mass Index and Helicobacter pylori among Obese and Non-Obese Patients in Najran, Saudi Arabia: A Case-Control Study

Objective: We examine obese and non-obese patients with respect to Helicobacter pylori (H. pylori) positive-infection (HPPI) and associated factors, specifically body mass index (BMI). Methods: This study took place in the Department of Endoscopy of a central hospital in the Najran region of Saudi Arabia (SA). A total of 340 obese Saudi patients (BMI ≥ 30 kg/m²) who had undergone diagnostic upper endoscopy before sleeve gastrectomy, were compared with 340 age and gender-matched control patients (BMI < 30 kg/m²) who had undergone diagnostic upper endoscopy for other reasons. Data collected included diagnosis of HPPI. Descriptive and multivariable binary logistic regression was conducted. Results: Mean patient age was 31.22 ± 8.10 years, and 65% were males. The total prevalence of HPPI was 58% (95% CI = 54–61%) with obese patients presenting significantly more HPPI than non-obese patients (66% vs. 50%, OR = 1.98, 95% CI = 1.45–2.70, p < 0.0005). Age and gender did not associate significantly with HPPI (p = 0.659, 0.200, respectively) and increases in BMI associated significantly with increases in HPPI (p < 0.0005). BMI remained a significant factor in HPPI when modelled with both age and gender (OR = 1.022, 95% CI = 1.01–1.03, p < 0.0005). Conclusions: Within the limitations of this study, the significance of HPPI in obese Saudi patients residing in the Najran region in SA was demonstrated alongside the significance role of BMI in HPPI.

The Prevalence of Helicobacter pylori in Estonian Bariatric Surgery Patients

Helicobacter pylori (Hp) is one of the most important human pathogens that can cause duodenal and gastric ulcers, gastritis and stomach cancer. Hp infection is considered to be a cause of limiting access to bariatric surgery. The aim of this study was to determine the prevalence of Hp in patients with obesity going into bariatric surgery and to reveal the relationship between Hp and clinical data. The study group was formed of 68 preoperative bariatric surgery patients (body mass index (BMI) 44.7 ± 4.8). Gastric biopsies (antrum and corpus) were used for histological and molecular (caqA and glmM genes) examinations. The PCR method revealed Hp infection in 64.7% of obese patients that is higher in comparison with histological analysis (55.9%). The prevalence of cagA and glmM genes in antrum mucosa was 45.6% and 47.0% while in the corpus it was 41.2% and 38.3%, respectively. The coincidence of both cagA and glmM virulence genes in the antrum and corpus mucosa was 33.8% and 22.1%, respectively. Either of the genes was found in 58.8% of antrum and 57.3% of corpus mucosa. Presence of caqA and glmM genes was in association with active and atrophic chronic gastritis. In conclusion, our study demonstrated that two thirds of morbidly obese patients undergoing bariatric surgery are infected with Hp and have a high prevalence of cagA and glmM virulence genes that points out the necessity for diagnostics and treatment of this infection before surgery.

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

BACKGROUND

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

OBJECTIVE

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

SETTING

Academic hospital, Canada.

METHODS

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

RESULTS

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

CONCLUSION

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

The value of routine gastroscopy before laparoscopic Roux-en-Y gastric bypass surgery in Chinese patients

BACKGROUND

Obesity is closely related to upper gastrointestinal diseases. China has a high incidence of gastropathy. Postoperative examination of the distal stomach becomes extremely difficult after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). Whether preoperative routine gastroscopy should be performed at all remains controversial. The objective of this study was to explore the value of routine gastroscopy before performing LRYGB in Chinese patients.

METHODS

The preoperative gastroscopy reports of 180 patients who had undergone LRYGB for morbid obesity and/or metabolic syndrome in the Department of Gastrointestinal Surgery of our hospital from January 2009 to August 2013 were retrospectively analyzed.

RESULTS

Gastroscopy showed chronic superficial gastritis (n = 159, 88.3%), reflux esophagitis (n = 19, 10.6%), erosion (n = 69, 38.3%), hiatal hernia (n = 5, 2.8%), gastric ulcer (n = 3, 1.7%), duodenal ulcer (n = 32, 17.8%), and gastric polyps (n = 10, 5.6%).

CONCLUSION

It is useful to perform gastroscopy before LRYGB. The findings of this investigation can help physicians to develop tailored therapies and procedures and thus improve the prognosis considerably. Gastroscopy should be routinely performed in Chinese patients who are planning to undergo bariatric surgery.

The presence of Helicobacter pylori is not associated with long-term anastomotic complications in gastric bypass patients

BACKGROUND

Eradication of Helicobacter pylori prior to Roux-en-Y gastric bypass (RYGB) has been advocated as a measure to reduce the complications of anastomotic ulceration. However, evidence to support a causal relationship between preoperative H. pylori status and postoperative anastomotic ulceration is weak.

METHODS

Intraoperative gastric biopsies were obtained on consecutive patients who underwent laparoscopic RYGB at our institution from December 2007 to June 2010. These samples were analyzed by Warthin-Starry stain for H. Pylori organisms. Retrospective chart review was conducted to determine the preoperative presence of acid dyspepsia and acid suppression therapy and to determine postoperative ulcer symptoms, smoking, NSAID or steroid use, and compliance with ulcer prophylaxis. The incidence of ulcer visualization, perforation, and stricture were obtained from a prospectively collected database. Fisher's exact test was used for analyzing associations between discrete groups. Multiple logistic regression was used to assess associations between anastomotic ulcer complications and potential predictors.

RESULTS

Histologic evaluation for H. pylori was available in 708 of the 728 patients who underwent RYGB. Fourteen patients were lost to follow up leaving 694 patients available for review. H. pylori was positive in 66 (9.5 %) patients who did not go on to receive definitive treatment for eradication. Marginal ulcers or related late complications were seen in a total of 113 (16.3 %) patients. In the H. pylori positive group, five patients (7.6 %) developed ulcer complications compared to 108 (17.1 %) in the H. pylori negative group (p = 0.05). Groups were not different in terms of preoperative demographics, postoperative ulcer prophylaxis compliance, steroid, NSAIDs, and cigarette use.

CONCLUSION

The presence of H. pylori infection at the time of RYGB was found to be associated with a significantly lower incidence of anastomotic ulcer complications postoperatively. This study brings into question efforts and expense allocated to identify and eradicate H. pylori prior to RYGB.

Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory?

BACKGROUND

Roux-Y Gastric Bypass is a frequently used technique in bariatric surgery. Postoperative anatomy is altered by exclusion of the stomach, which makes this organ inaccessible for future esophagogastroduodenoscopy (EGD). The value of preoperative assessment of the stomach is unclear. Some institutions choose to investigate the future remnant stomach by EGD, others do not. Aim of the present study is to quantify the yield of preoperative EGD in our institution.

METHODS

Patients, planned for primary laparoscopic Roux-Y Gastric Bypass (LRYGB) or laparoscopic sleeve gastrectomy from December 2007 until August 2012, were screened by EGD in advance. Results of EGD and patient characteristics were retrospectively analyzed and categorized according to a classification system based on intervention needed.

RESULTS

523 patients (122 male, 401 female, mean age 44.3 years, average BMI 46.6) underwent preoperative EGD. In 257 patients (48.9%) no abnormality was found (group A), 117 patients (17.2%) had abnormalities without treatment consequences (B1), 84 patients (of the 326 tested [comment #1, reviewer #1, 26.8%] were H. Pylori positive (B2), in 75 (14.3%) treatment with proton pump inhibitors was required (B3), 6 (1.1%) required follow up EGD before surgery (C). For1 patient (0.2%) the operation was canceled because preoperative EGD presented with Barrett's esophagus with carcinoma (D). When all abnormalities were taken into account, baselines did show a significant difference for age, gender and reflux symptoms.

CONCLUSION

Standard preoperative assessment by EGD in patients who are planned for bariatric surgery is not indicated. The number needed to screen to find clinically significant abnormalities is high.

Is routine preoperative upper GI endoscopy needed prior to gastric bypass?

BACKGROUND

In Finland, upper GI endoscopy (UGI) prior to bariatric surgery is routine in all but one hospital performing bariatric surgery. However, UGI is an unpleasant investigation for the patient and requires resources. Helicobacter pylori (HP) can be tested from blood and cannot be considered as an indication for UGI. We wanted to identify the most common findings in UGI and see if the findings influenced the decision to operate or if they even canceled the operation.

METHODS

We evaluated retrospectively the data of 412 patients undergoing preoperative UGI in Vaasa Central Hospital in the years 2006-2010.

RESULTS

UGI was considered normal in 191 (55.8 %) patients. The most common findings were hiatal hernia in 25.4 % (n = 87); gastritis, 13.7 % (n = 47); and esophagitis, 13.2 % (n = 45). Also benign polyps, 6.7 % (n = 23), and ulcers, 2.9 % (n = 10), were detected. One 0.5-cm esophageal leiomyoma was found, but no malignant lesions. Histology was found normal in 185 (54.1 %) patients. HP was found in 12.0 % (n = 41) of patients.

CONCLUSIONS

In this study, all the findings were benign and mild. The findings did not influence the operative plan. The most common findings were hiatal hernia and esophagitis which may be considered contraindications for sleeve gastrectomy, but not for gastric bypass. Our results do not support the performance of routine preoperative UGI prior to gastric bypass.

Helicobacter pylori infection in obesity and its clinical outcome after bariatric surgery

The present review summarizes the prevalence and active clinical problems in obese patients with Helicobacter pylori (H. pylori) infection, as well as the outcomes after bariatric surgery in this patient population. The involvement of H. pylori in the pathophysiology of obesity is still debated. It may be that the infection is protective against obesity, because of the gastritis-induced decrease in production and secretion of the orexigenic hormone ghrelin. However, recent epidemiological studies have failed to show an association between H. pylori infection and reduced body mass index. H. pylori infection might represent a limiting factor in the access to bariatric bypass surgery, even if high-quality evidence indicating the advantages of preoperative H. pylori screening and eradication is lacking. The clinical management of infection is complicated by the lower eradication rates with standard therapeutic regimens reported in obese patients than in the normal-weight population. Prospective clinical studies to ameliorate both H. pylori eradication rates and control the clinical outcomes of H. pylori infection after different bariatric procedures are warranted.

Prevalence of Helicobacter pylori infection in bariatric patients: a histologic assessment

BACKGROUND

Studies on rates of Helicobacter pylori (HP) infection in morbidly obese patients awaiting bariatric surgery are conflicting because of small sample size and variability in diagnostic testing. The objective of this study was to determine the rate of biopsy-proven active HP infection in morbidly obese patients undergoing bariatric surgery.

METHODS

Retrospective analysis was done on all morbidly obese patients who underwent bariatric surgery between 2001 and 2009. All patients underwent preoperative upper endoscopy with biopsy to evaluate HP status. All endoscopies and surgeries were performed by a single endoscopist and surgeon, respectively. Data were analyzed with Student t test, Pearson χ(2) test, and logistic regression for multivariate analysis.

RESULTS

The 611 patients included 79 males (12.9%) and 532 females (87.1%). Mean age was 39.9 ± 10.7 years, and mean body mass index (BMI) was 47.8 ± 6.4 kg/m(2). The overall HP infection rate was 23.7%. Rate of infection did not differ between gender (22.8% in males, 23.9% in females; P = .479) or BMI (48.6 ± 6.5 kg/m(2) in HP-positive patients, 47.5 ± 6.4 kg/m(2) in HP-negative patients; P = .087). Patients with HP were older compared with those without infection (41.2 versus 38.7 years; P =.016). Hispanics had a higher prevalence of HP (OR 2.35; P = .023).

CONCLUSION

Increasing BMI is not an independent risk factor for active HP infection within the morbidly obese patient population. Need for invasive testing to detect HP infection in these patients should be re-evaluated. Other methods of detecting active HP infection should be considered as an alternative to invasive or serologic testing.

Prevalence of upper digestive endoscopy and gastric histopathology findings in morbidly obese patients

CONTEXT: The prevalence of obesity has been increasing in modern society. Roux-en-y gastric bypass is a bariatric surgery that involves the exclusion of significant part of the stomach. Atrophy, intestinal metaplasia and gastric cancer have been associated with infection by Helicobacter pylori. OBJECTIVES: To evaluate the presence of endoscopy findings and histological changes in morbid obese patients for the presence of inflammatory cells, inflammatory activity, lymphoid hyperplasia, H. pylori infection, atrophy and intestinal metaplasia in the gastric mucosa. METHODS: Upper digestive endoscopy and gastric histopathological were studied in 126 obese patients in the preoperative evaluation for bariatric surgery. RESULTS: Upper digestive endoscopy abnormalities were diagnosed in 73/126 (57.9%) patients. In three patients (2.4%) the upper gastrointestinal endoscopy diagnosed gastric ulcer and one patient (0.8%) had duodenal ulcer. The histopathological from gastric biopsies of these obese patients showed 65.1% of mucosa inflammation, inflammatory activity in 50.0%, infection by H. pylori in 53.2%, lymphoid hyperplasia in 50.0% and atrophy and/or intestinal metaplasia in 16.7%. CONCLUSIONS: In present study, with routine preoperative upper gastrointestinal endoscopy and histopathological examination, were detected 57.9% patients with endoscopy abnormalities, high prevalence of infection by H. pylori (53%) and 16.7% of gastric atrophy and/or intestinal metaplasia.

[Recommendations for the peri-operative management of bariatric surgery patients: results of a national survey]

To standardise possible peri-operative bariatric surgery protocols, a survey was prepared to be filled in by members of the Spanish Society for Obesity (Sociedad Española de Cirugía de la Obesidad) (SECO), and to approve it at the XII National Congress. A total of 47 members of SECO from 14 autonomous communities responded, and it unanimously approved by the Congress. As highly recommended peri-operative procedures, were proposed: full laboratory analysis (98%) with an endocrine study (90%), ECG (96%), chest x-ray (98%), an oesophageal-gastric imaging test (endoscopy or gastro-duodenal transit study (98%), antibiotic prophylaxis (92%) and use of low molecular weight heparins pre-operatively (96%), and for 2 weeks (83%). Pre-surgical, abdominal ultrasound (86%), spirometry (80%), diet (88%) and psychological study (76%), and during surgery, use of elastic stockings (76%), leak tests (92%) and drainages (90%), were established as advisable procedures.

Prevalence of Helicobacter pylori infection in a group of morbidly obese Saudi patients undergoing bariatric surgery: a preliminary report

BACKGROUND/AIM

Earlier reports from Saudi Arabia have shown high prevalence of Helicobacter pylori infection. However, recent studies have documented a reduction in the infection prevalence. No prior study has assessed the prevalence in morbidly obese Saudi patients. We aimed to study the prevalence of H. pylori infection in a group morbidly obese Saudi patients referred for endoscopy prior to bariatric surgery.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of all patients who were referred for upper endoscopy prior to bariatric surgery from June 2006 to September 2008. All data were recorded including patient's demographics, comorbid conditions, endoscopic and histological findings.

RESULTS

There were 62 patients included, 20 males and 42 females. The mean age was 34 years (range 18-51) with a mean BMI of 55 Kg/m 2 (range 35-92). H. pylori were present in 53 patients (85.5%) with chronic active gastritis. All patients with positive H. pylori had chronic gastritis of variable severity. Intestinal metaplasia was present in 5%. The prevalence of H. pylori infection was similar in patients with and without co-morbid conditions. Main endoscopic findings were gastritis in 67.7%, hiatus hernia in 13%, and gastric erosions in 13%. No patient had duodenal or gastric ulcer.

CONCLUSIONS

There is a high prevalence of H. pylori infection in morbidly obese Saudi patients undergoing bariatric surgery being referred for upper GI endoscopy. Further prospective studies are needed to evaluate the clinical implication and benefit of eradication treatment of infection in these patients.

Perioperative Management of Cholelithiasis in Patients Presenting for Laparoscopic Roux-en-Y Gastric Bypass: Have we Reached a Consensus?

Obesity and rapid weight loss after bariatric surgery is associated with the development of cholelithiasis and related complications. Several algorithms have been suggested in the management of the asymptomatic gallstones in patients presenting for weight loss surgery (WLS). Charts of patients presenting for laparoscopic Roux-en-Y (LRYGB) were retrospectively reviewed. Concomitant or delayed cholecystectomies were performed for symptomatic disease at the time of or after LRYGB, respectively. A total of 1376 patients underwent LRYGB and 21.0 per cent had a history of a cholecystectomy. An additional 2.7 per cent underwent cholecystectomy. The remaining 1050 “at-risk” patients were followed for a mean of 32.3 months and 4.9 per cent underwent delayed cholecystectomy for symptomatic disease. Of these patients, 88.5 per cent presented within 2 years of LRYGB. No significant morbidities were experienced by the “at-risk” cohort. Currently, there is no consensus in the treatment of asymptomatic cholelithiasis in patients presenting for WLS. A conservative regimen of reserving cholecystectomy for symptomatic disease is safe in patients undergoing LRYGB. Subsequent cholecystectomy was required in 4.9% with the majority of these patients presenting within 2 years of LRYGB. Further investigations in the form of randomized, prospective studies are necessary to clearly define the indications for cholecystectomy at the time of WLS.

Preoperative bariatric screening and treatment of Helicobacter pylori

BACKGROUND

A preoperative screening and treatment program for pre-existing H. pylori infections was hypothesized to reduce postoperative bariatric complications and associated morbidity as the role of H. pylori in gastrointestinal symptomatology and peptic ulcer disease is well established.

METHODS

A single-institution, single-surgeon, IRB-approved, retrospective chart review was performed. It included 183 consecutive patients who underwent an initial laparoscopic gastric bypass over a 40-month period from December 2003 to April 2006. The patients were divided into a H. pylori untested group (125 patients) and a tested and treated if indicated group (58 patients). Patient demographics and incidence of hospital re-admissions, GI ulceration and bleeding, perforated viscus, esophagogastroduodenoscopy (EGD), and foregut symptoms were documented at routine follow-up and emergency room visits. Results were subjected to analysis with Fisher's exact test.

RESULTS

Seven patients (12%) in the tested group were positive for H. pylori and treated. The number of GI ulcers and bleeding, EGDs, ER visits, and hospital re-admissions were not statistically different between groups; however, in the untested group, six patients (5%) presented with viscus perforation compared with none in the tested and treated group (p = 0.09). Demographics for both groups were similar and both had a large number of nonspecific foregut symptoms.

CONCLUSION

Preoperative H. pylori screening should continue, especially in geographically high-prevalence areas, as data suggest that the incidence of viscus perforation may be reduced with preoperative treatment if indicated.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Increased colorectal epithelial cell proliferation and crypt fission associated with obesity and roux-en-Y gastric bypass

BACKGROUND AND AIMS

The relationship between obesity, weight reduction, and future risk of colorectal cancer is not well understood. Therefore, we compared mucosal biomarkers in normal weight individuals [body mass index (BMI), 18.5-24.9 kg/m(2)] with those in morbidly obese patients (BMI >40 kg/m(2)) before and 6 months after Roux-en-Y gastric bypass (RYGB).

METHODS

Rectal epithelial cell mitosis, crypt area, and crypt branching were measured following whole crypt microdissection. Apoptosis was measured by immunohistochemistry for neo-cytokeratin 18 on fixed tissue sections. Serum levels of C-reactive protein and cytokines were assayed in combination with quantification of mucosal proinflammatory gene expression by real-time RT-PCR.

RESULTS

Twenty-six morbidly obese patients (mean BMI, 54.4 kg/m(2)) had significantly increased mitosis, crypt area, and crypt branching (all P < 0.01) compared with 21 age- and sex-matched normal weight individuals (mean BMI, 22.5 kg/m(2)). Morbidly obese patients underwent a mean excess weight loss of 41.7% at a mean of 26 weeks after RYGB. Surprisingly, this was associated with a further increase in mitosis and decreased apoptosis of epithelial cells. At the same time, lower levels of serum C-reactive protein and interleukin-6 following RYGB were accompanied by a reduction in mucosal IL-6 protein content but elevated mucosal expression of other proinflammatory genes such as cyclooxygenase-1 and cyclooxygenase-2.

CONCLUSIONS

Mucosal biomarkers, accepted as indicators of future colorectal cancer risk, are increased in morbidly obese patients compared with normal weight controls. The hyperproliferative state that exists 6 months after RYGB may have important implications for long-term colorectal cancer risk in bariatric surgery patients.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

[Precancerous lesions of the gallbladder]

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

Prevalence of Helicobacter pylori infection and value of preoperative testing and treatment in patients undergoing laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Previous studies have reported a high prevalence of Helicobacter pylori infection in patients undergoing Roux-en-Y gastric bypass (RYGB) and a greater incidence of anastomotic ulcer in patients positive for H. pylori, leading to recommendations for routine preoperative screening. Our hypotheses were that the prevalence of H. pylori in patients undergoing RYGB is similar to that of the general population and that preoperative H. pylori testing and treatment does not decrease the incidence of anastomotic ulcer or pouch gastritis.

METHODS

A retrospective analysis of H. pylori serology, preoperative and postoperative endoscopy findings, and the development of anastomotic ulcer or erosive pouch gastritis was performed. All patients positive for H. pylori received treatment. Univariate parametric and nonparametric statistical tests, as well as multiple logistic regression analyses, were performed.

RESULTS

A total of 422 LRYGB patients were included in the study. Of these patients, 259 (61.4%) were tested for H. pylori and 163 (38.6%) were not. Of the 259 patients, 58 (22.4%) tested positive for H. pylori, 197 (76.1%) tested negative, and 4 (1.5%) had an equivocal result. Postoperatively, 53 patients (12.6%) underwent upper endoscopy. Of these 53 patients, 19 (4.5%) had positive endoscopy findings for anastomotic ulcer (n = 16) or erosive pouch gastritis (n = 3). Five patients underwent biopsy at endoscopy; all biopsies were negative for H. pylori. No difference was found in the rate of positive endoscopy between patients tested preoperatively for H. pylori (5%) and patients not tested (3.7%).

CONCLUSION

The results of our study have shown that the prevalence of H. pylori infection in patients undergoing RYGB is similar to that of the general population. Our study has shown that H. pylori testing does not lower the risk of anastomotic ulcer or pouch gastritis.

Management of gastrointestinal disorders in the bariatric patient

Morbid obesity continues to grow at an alarming rate. As of 2004, 35% of Americans were considered to have a body mass index (BMI) over 30. As the number of patients undergoing weight loss surgery increases, the patient population presenting to primary care physicians with previous gastric bypass will also increase. Accordingly, it will become imperative for primary care physicians to be familiar and comfortable with the care of these patients. This review focuses on the management of gastrointestinal disorders in postoperative gastric bypass patients.