Preoperative upper gastrointestinal endoscopy in obese patients undergoing bariatric surgery: is it necessary?

Unveiling the hidden pathologies: preoperative endoscopic findings in patients with obesity undergoing bariatric surgery

BACKGROUND

Obesity is closely associated with upper gastrointestinal disorders. The recommendations for routine preoperative esophagogastroduodenoscopy (EGD) before bariatric surgery remains a topic of debate. This study aimed to describe the pathological endoscopic findings in individuals qualified for bariatric surgery.

METHODS

Retrospective analysis was conducted on preoperative gastroscopy reports of patients who underwent bariatric surgery at our hospital between October 2022 and October 2023.

RESULTS

A total of 405 patients were included in the study. The two most prevalent endoscopic findings during EGD in this patient cohort were chronic superficial gastritis (326/405, 80.5%) and reflux esophagitis (82/405, 20.2%). Some patients exhibited two or more abnormalities. Patients with reflux esophagitis were older, had a higher proportion of men, higher BMI, higher rates of smoking and drinking compared to those without it (P = 0.033, P < 0.001, P = 0.003, P = 0.001, and P = 0.003, respectively). Morbid obesity (P = 0.037), smoking habits (P = 0.012), and H. pylori infection (P = 0.023) were significant risk factors for reflux esophagitis in male patients, while age (P = 0.007) was the sole risk factor in female patients. No statistically significant differences were observed in surgical procedures between LA-A and B groups (P = 0.382), but statistically significant differences were noted between the nondiabetic and diabetic groups (P < 0.001).

CONCLUSIONS

Preoperative EGD can unveil a broad spectrum of pathologies in patients with obesity, suggesting the need for routine examination before bariatric surgery. The findings of this study can guide bariatric surgeons in developing tailored treatments and procedures, thus significantly enhancing prognosis. Gastroscopy should be performed routinely in Chinese patients planning to undergo bariatric 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.

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

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

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.

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.

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.

Management of Acute Gastric Remnant Complications After Roux-en-Y Gastric Bypass: a Single-Center Case Series

PURPOSE

Roux-en-Y gastric bypass is a common bariatric procedure. Its configuration creates an excluded gastric remnant, which is subject to potential acute complications such as bleeding, perforation, and necrosis.

MATERIAL AND METHODS

A retrospective analysis of a prospective database including all patients presenting between 2007 and 2019 to our institution with acute gastric remnant complications after RYGB was performed.

RESULTS

Seven patients were included, including 3 hemorrhages, two of which were treated with double-balloon enteroscopy, as well as 3 perforations and 1 necrosis, all of which required emergent surgery. Overall gastric remnant complication rate was 0.3% in this series.

CONCLUSION

Acute gastric remnant complications after RYGB are infrequent, but their diagnosis and management can be challenging. Double-balloon enteroscopy has diagnostic and therapeutic value for selected patients. Emergent surgery remains the standard of care for unstable patients and should not be delayed.

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

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

Gastric Histopathologic Findings in South Italian Morbidly Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: Is Histopathologic Examination of All Resected Gastric Specimens Necessary?

BACKGROUND

The value of the routine histopathologic examination of resected gastric remnants following laparoscopic sleeve gastrectomy (LSG) remains to be controversial. This study aimed to determine whether the routine histopathologic examination of gastric specimens is necessary for all patients undergoing LSG if upper gastrointestinal endoscopy (UGIE) plus multiple biopsies are performed routinely during the preoperative work-up.

MATERIALS AND METHODS

Clinicopathologic data of 474 patients who underwent LSG were analysed. Types of histopathologic findings in LSG specimens and the prevalence of these and Helicobacter pylori (HP) infection were estimated. Comparisons were conducted to assess the association of risk factors with the most frequent abnormal and premalignant histopathologic findings.

RESULTS

Chronic gastritis was the most common gastric pathology (63.5%) and premalignant lesions were present in 7.8% of the specimens. The prevalence of HP infection was 36.9%. A statistically significant association was observed between HP infection and chronic gastritis (P = .000), and premalignant lesions (P = .000). Similarly, a statistically significant association was noted between age and premalignant gastric lesions (P = .000).

CONCLUSION

Histopathologic examination of LSG specimens may not be routinely needed and can be performed on selected patients. While we recommend routine preoperative UGIE in all LSG-treated patients, we suggest that histopathologic assessment of the LSG specimens should be mandatory when UGIE biopsies demonstrate HP infection and/or premalignant lesions, in all patients older than 42 years, and in cases of intraoperative detection of incidental tumours or suspicious lesions.

Routine preoperative endoscopy in patients undergoing bariatric surgery

BACKGROUND

The role of routine preoperative endoscopy before primary weight loss surgery remains controversial.

OBJECTIVE

We reviewed our experience to determine the frequency of abnormal findings in patients undergoing routine preoperative endoscopy before bariatric surgery.

SETTING

A tertiary level, academic-affiliated bariatric surgery practice.

METHODS

A retrospective chart review was performed between July 2014 and June 2016 of patients undergoing routine preoperative endoscopy before primary bariatric surgery. Variables evaluated included preendoscopy symptoms, planned bariatric surgical procedure, abnormal findings on endoscopy, and changes in planned bariatric surgical procedure after endoscopy.

RESULTS

A total of 631 patients met inclusion criteria. Of patients, 72% (457) were female. The median age was 44 (interquartile range 36-55). The median body mass index was 46 (interquartile range 42-51). Most patients had no preendoscopy clinical symptoms (61.3%). The most frequent abnormal findings included esophagitis (26.5%), hiatal hernia (27.1%), gastric ulcer (4.9%), and biopsy-proven Barrett's esophagus (4.6%). Although patients with preoperative symptoms were more likely to have abnormal findings on endoscopy, there were no significant differences in rates of Barrett's esophagus in patients with (5.3%) or without (4.1%) symptoms. Of the total cohort, 18.4% had a change in their planned operation after endoscopy results.

CONCLUSION

The findings in our large series suggest selective screening in symptomatic patients only may lead to failure of discovery of foregut pathology that should prompt consideration for changes in the planned bariatric surgical procedure. Further study is necessary to see if our findings have broad applicability.

Esophagogastroduodenoscopy Findings in Patients on the Waiting List for Bariatric Surgery

BACKGROUND

Bariatric surgery (BS) is one of the most effective approaches to weight loss. Performing esophagogastroduodenoscopy (EGD) prior to BS is controversial but allows the detection and treatment of mucosal lesions that may affect surgical decision and type of surgery.

AIM

The aim of this study was to identify the frequency of gastric lesions and Helicobacter pylori (Hp) infection in a group of asymptomatic patients on the waiting list for BS.

METHODS

This is a retrospective descriptive study including patients undergoing EGD before BS.

RESULTS

A total of 360 patients were included with a mean age of 42.1 ± 10.8 years, 319 (88.6%) were females, with a mean body mass index of 42.8 ± 5.44 kg/m2. Regarding endoscopic findings, 25.6% presented no endoscopic lesions, 61.6% presented hyperemic gastropathy, 11.4% erosive gastropathy, 1.1% gastric polyp, and 0.3% gastric ulcer. Histologically, no changes were observed in 20.8% of the patients, 239 (66.4%) presented with superficial gastritis, 11.7% (n = 42) had chronic atrophic gastritis and intestinal metaplasia (n = 34 in the antrum, n = 1 in the body, and n = 7 in both the antrum and the body), and 1.7% (n = 6) had low-grade dysplasia. Hp was positive in 251 (69.7%) patients. We found that patients with metaplasia or dysplasia were more frequently submitted to surgical techniques that did not exclude the stomach (55.8 vs. 16.4%, p < 0.001).

CONCLUSION

EGD with histological analysis plays an important role in the pre-surgical evaluation in BS, with a high rate of pathological findings in asymptomatic patients. These findings may have an impact on the long-term management and outcomes of these patients.

Adenocarcinoma of oesophagus involving gastro-oesophageal junction following mini-gastric bypass/one anastomosis gastric bypass

Mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB) is an emerging weight loss surgical procedure. There are serious concerns not only regarding the symptomatic biliary reflux into the stomach and the oesophagus but also the increased risk of malignancy after MGB/OAGB. A 54-year-old male, with a body mass index (BMI) of 46.1 kg/m², underwent Robotic MGB at another centre on 22^nd June 2016. His pre-operative upper gastrointestinal endoscopy was not done. He lost 58 kg within 18 months after the surgery and attained a BMI of 25.1 kg/m². However, 2-year post-MGB, the patient had rapid weight loss of 19 kg with a decrease in BMI to 18.3 kg/m² within a span of 2 months. He also developed progressive dysphagia and had recurrent episodes of non-bilious vomiting. His endoscopy showed eccentric ulcerated growth in lower oesophagus extending up to the gastro-oesophageal junction and biopsy reported adenocarcinoma of oesophagus. MGB/OAGB has a potential for bile reflux with increased chances of malignancy. Surveillance by endoscopy at regular intervals for all patients who have undergone MGB/OAGB might help in early detection of Barrett's oesophagus or carcinoma of oesophagus or stomach.

The Role of Routine Upper Gastrointestinal Endoscopy Before Bariatric Surgery

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.

Spectrum of Gastric Histopathologies in Severely Obese American Patients Undergoing Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed weight loss procedure, but the pathologic findings in sleeve specimens have not been investigated in a US population.

METHODS

We performed a retrospective review of histopathologic findings in LSG specimens from 310 consecutive bariatric patients at the Hershey Medical Center between June 2008 and August 2014.

RESULTS

Patients were 19 to 75 years old (mean 45 years) with a female-to-male ratio of 3:1. The histopathologic findings included the following: no pathological alteration in 214 patients (69.0 %), chronic inactive gastritis in 41 (13.2 %), fundic gland polyp in 17 (5.5 %), proton pump inhibitor therapy effect in 12 (3.9 %), Helicobacter pylori (H. pylori)-associated chronic active gastritis in 10 (3.2 %), chronic active gastritis (H. pylori negative) in 5 (1.6 %), chronic gastritis with intestinal metaplasia in 4 (1.0 %), gastrointestinal stromal tumor (GIST) in 3 (1.0 %), and hyperplastic polyp, granulomatous inflammation, xanthogranulomatous inflammation, and mucosal ulceration in 1 patient each (0.3 %). Prior endoscopy was performed in 8 patients (2.6 %) for unrelated causes, and the results did not change the surgical management. Nine patients (2.9 %) had a concurrent liver biopsy for visual evidence of significant hepatic fibrosis.

CONCLUSION

Although most cases showed no pathologic alteration, a minority had significant findings, with the incidence of GISTs higher than that reported in other series. Despite negative preoperative H. pylori testing, 3.2 % were still histologically positive, raising questions about the accuracy of preoperative methods used for H. pylori testing and treatment. Preoperative endoscopy may not be needed in sleeve patients.

Influence of obesity and bariatric surgery on gastric cancer

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.

Place of upper endoscopy before and after bariatric surgery: A multicenter experience with 3219 patients

AIM: To study the preoperative and postoperative role of upper esophagogastroduodenoscopy (EGD) in morbidly obese patients.

METHODS: This is a multicenter retrospective study by reviewing the database of patients who underwent bariatric surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux en Y gastric bypass, or laparoscopic minigastric bypass) in the period between 2001 June and 2015 August (Jahra Hospital-Kuwait, Hafr Elbatin Hospital and King Saud Medical City-KSA, and Mansoura University Hospital - Egypt). Patients with age 18-65 years, body mass index (BMI) > 40, or > 35 with comorbidities after failure of many dietetic regimen and acceptable levels of surgical risk were included in the study after having an informed signed consent. We retrospectively reviewed the medical charts of all morbidly obese patients. The patients’ preoperative data included clinical history including upper digestive symptoms and preoperative full workup including EGD. Only patients whose charts revealed weather they were symptomatic or not were studied. We categorized patients accordingly into two groups; with (group A) or without (group B) upper digestive symptoms. The endoscopic findings were categorized into 4 groups based on predetermined criteria. The medical record of patients who developed stricture, leak or bleeding after bariatric surgery was reviewed. Logestic regression analysis was used to identify preoperative predictors that might be associated with abnormal endoscopic findings.

RESULTS: Three thousand, two hundred and nineteen patients in the study period underwent bariatric surgery (75% LSG, 10% LRYDB, and 15% MGB). Mean BMI was 43 ± 13, mean age 37 ± 9 years, 79% were female. Twenty eight percent had presented with upper digestive symptoms (group A). EGD was considered normal in 2414 (75%) patients (9% group A vs 66% group B, P = 0.001). The abnormal endoscopic findings were found high in those patients with upper digestive symptoms. Abnormal findings (one or more) were found in 805 (25%) patients (19% group A vs 6% group B, P = 0.001). Seven patients had critical events during conscious sedation due to severe hypoxemia (< 60%). Rate of stricture in our study was 2.6%. Success rate of endoscopic dilation was 100%. One point nine percent patients with gastric leak were identified with 75% success rate of endoscopic therapy. Three point seven percent patients developed acute upper bleeding. Seventy-eight point two percent patients were treated by conservative therapy and EGD was performed in 21.8% with 100% success and 0% complications.

CONCLUSION: Our results support the performance of EGD only in patients with upper gastrointestinal symptoms. Endoscopy also offers safe effective tool for anastomotic complications after bariatric surgery.

Usefulness of Upper Gastrointestinal Symptoms as a Driver to Prescribe Gastroscopy in Obese Patients Candidate to Bariatric Surgery. A Prospective Study

BACKGROUND

Before bariatric surgery, the necessity of routine upper gastrointestinal endoscopy is controversial, and guidelines recommend endoscopy in symptomatic cases. However, impaired visceral sensation occurring in obese patients may be misleading. The purpose of the study is to evaluate prospectively the prevalence of gastrointestinal symptoms, endoscopic findings, and the relation between symptoms and endoscopic findings in obese patients before surgery.

MATERIALS AND METHODS

One hundred forty-two consecutive patients candidate to primary bariatric surgery filled out the validated Rome III symptomatic questionnaire and performed endoscopy.

RESULTS

With a median age of 41 years and BMI of 44 Kg/m(2), 83% were females. Symptoms were referred by 43% of patients: gastroesophageal reflux disease (GERD) (27.9%) and dyspepsia (24.6%), subdivided in postprandial distress (PDS) (66.7%) and epigastric pain (33.3%) syndromes. Of GERD patients, 19.7% presented concomitantly PDS. Belching was present in 8.2% and nausea and/or vomiting in 1.6% of patients. At endoscopy, one or more lesions were present in 47.1% of the patients: erosive esophagitis (5.6%), hiatal hernia (23.2%), gastroduodenal erosions (6.3%), and peptic ulcers (3.5%). At histology, 24% of patients have Helicobacter pylori infection, and its prevalence in gastroduodenal erosions and ulcers was 22.2 and 60%, respectively. Surprisingly, in patients with peptic lesions H. pylori-negative, no chronic use of NSAIDs was reported. Analyzing the coexistence of symptoms and lesions, these resulted equally distributed beyond the presence of symptoms, being present in 44.2 and 49.4% of symptomatic and asymptomatic patients, respectively.

CONCLUSIONS

The presence of symptoms cannot be considered as a valuable guide to indicate endoscopy since the majority of endoscopic lesions were asymptomatic and not H. pylori-related.

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.

CORRELATION BETWEEN PRE AND POSTOPERATIVE UPPER DIGESTIVE ENDOSCOPY IN PATIENTS WHO UNDERWENT ROUX-EN-Y GASTROJEJUNAL BYPASS

BACKGROUND

Bariatric operations have variable range of complications and postoperative benefits. Gastroesophageal reflux is considered potential factor that may result in damage to the esophageal mucosa and this subject is quite controversial in the literature.

AIM

To evaluate patients who underwent to Roux-en-Y gastrojejunal bypass correlating epidemiologic and endoscopic findings in pre and postoperative periods.

METHOD

A retrospective, paired study which evaluated 110 patients. Inclusion criteria were formal indication for bariatric surgery and patients with pre and postoperative endoscopy. Exclusion criteria were previous bariatric surgery, patients subjected to other types of bariatric surgery and those who had no pre or postoperative upper digestive endoscopy. The epidemiological variables were: sex, age, body mass index, type 2 diabetes mellitus or impaired glucose tolerance, and preoperative dyslipidemia.

RESULTS

The preoperative upper endoscopy was normal in 26.4% of the patients. Among endoscopic alterations, the hiatus hernia was the most prevalent followed by non-erosive gastritis. The postoperative upper endoscopy was normal in 40.9% and stenosis was the most prevalent followed by marginal ulcer. Correlation on pre and postoperative endoscopies, was found 100% reduction of hiatal hernias and 88% of esophagitis. There was no statistical significance in relationship to anastomotic stenosis with preoperative other variables. Conclusions . There was significant decrease in postoperative hiatus hernia, erosive esophagitis, non-erosive esophagitis, erosive gastritis and non-erosive gastritis with the operation. Stenosis of the gastrojejunostomy anastomosis was the most prevalent postoperative complication with no correlation with preoperative variables.

Prevalence of Chronic Gastritis or Helicobacter pylori Infection in Adolescent Sleeve Gastrectomy Patients Does Not Correlate with Symptoms or Surgical Outcomes

BACKGROUND

In adults undergoing gastric bypass surgery, it is routine practice to perform pre-operative testing for Helicobacter pylori infection. Evidence suggests that infection impairs anastomotic healing and contributes to complications. There currently are no data for adolescents undergoing bariatric procedures. Despite few patients with pre-operative symptoms, we noted occasional patients with H. pylori detected after sleeve gastrectomy. We reviewed our experience with our adolescent sleeve gastrectomy cohort to determine the prevalence of H. pylori infection, its predictive factors, and association with outcomes. We hypothesized that H. pylori infection would be associated with pre-operative symptoms, but not surgical outcomes.

METHODS

All patients undergoing sleeve gastrectomy at our hospital were included. We conducted a chart review to determine pre- or post-operative symptoms of gastroesophageal reflux disease GERD or gastritis, operative complications, and long-term anti-reflux therapy after surgery. Pathology reports were reviewed for evidence of gastritis and H. pylori infection.

RESULTS

78 adolescents had laparoscopic sleeve gastrectomy from January 2010 through July 2014. The prevalence of chronic gastritis was 44.9% (35/78) and 11.4% of those patients had H. pylori (4/35). Only one patient with H. pylori had pre-operative symptoms, and only 25.7% (9/35) of patients with pathology-proven gastritis had symptoms. One staple line leak occurred but this patient did not have H. pylori or gastritis. Mean patient follow-up was 10 (3-26) mos.

CONCLUSIONS

There is a moderate prevalence of gastritis among adolescents undergoing sleeve gastrectomy, but only a small number of these patients had H. pylori infection. Neither the presence of chronic gastritis nor H. pylori infection correlated with symptoms or outcomes. Thus, in the absence of predictive symptomology or adverse outcome in those who are infected, we advocate for continued routine pathologic evaluation without the required need for pre-operative determination unless or until H. pylori infection is associated with adverse surgical outcomes.

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.

Evaluating the Effect of Drain Site on Abdominal Pain after Laparoscopic Gastric Bypass Surgery for Morbid Obesity: A Randomized Controlled Trial

Background: Most morbidly obese patients complain of abdominal pain after laparoscopic gastric bypass (LGBP) surgery. In this study, the relationship between the prevalence and severity of pain and the drain site was assessed. Methods: Fifty morbidly obese patients undergoing LGBP surgery were selected, and a drain was randomly inserted postoperatively to the left 5 mm port in 25 cases and to the right in the other 25. All patients filled out a questionnaire, including a visual analog scale for the quality and quantity of pain, exacerbating and alleviating factors and its relation to patient's positioning, in the first 24 hours, first week, and first month after the operation. Result: In both groups, all patients had abdominal pain 24 hours after the operation. However, in the right-sided drain group, most patients (52%) experienced mild pain, whereas most patients (56%) in the left-sided drain group had severe pain (p=0.028). At weeks 1 and 4, there was no significant difference between the two groups in terms of severity of pain (p=0.068 and 0.875, respectively, for both times). After the first 24 hours and first week, the mean pain score was significantly lower in the right-sited drain group compared to the left-sited drain group (p=0.012 and 0.006). Conclusion: Early abdominal pain after LGBP surgery is significantly reduced in the right-sided drain group.

EVALUATION OF UPPER GASTROINTESTINAL ENDOSCOPY IN PATIENTS UNDERGOING BARIATRIC SURGERY

BACKGROUND

Obesity has become epidemic, and is associated with greater morbidity and mortality. Treatment is multidisciplinary. Surgical treatment is a consistent resource in severe obesity. The indication of preoperative upper gastrointestinal endoscopy in asymptomatic patients is controversial; however, most studies recommend its implementation in all patients.

AIM

To analyze endoscopic performance in patients who were in preoperative for bariatric surgery and compare them with control group.

METHOD

A series of 35 obese patients in preoperative period for bariatric surgery compared with a control group of 30 patients submitted to upper endoscopy. There were analyzed clinical and endoscopic data.

RESULTS

The mean age of the group of patients was 43.54 years. Most individuals in the group of patients were female with median BMI of 47.26 kg/m2 and in control group 24.21 kg/m2. The majority of patients were asymptomatic. Upper endoscopy was altered in 81.25% of asymptomatic patients. Endoscopic findings in the patient group were 57.1% resulting from peptic ulcer disease and 34.3% associated with GERD. The analysis of endoscopic findings in patients showed no significant difference in relation of the control group. The prevalence of H. pylori infection was 60% in patients.

CONCLUSION

It is recommended that the upper endoscopy should be made in all patients in the preoperative bariatric surgery period, although the degree of obesity is not related to a greater number of endoscopic findings. Obese patients do not have more endoscopic findings that non-obese individuals.

Role of endoscopy in the bariatric surgery of patients

Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett's esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett's esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.

Functional abdominal pain syndrome in morbidly obese patients following laparoscopic gastric bypass surgery

Background:

Roux-en-Y gastric bypass surgery (RYGBP) is one of the most common bariatric surgeries, which is being performed using various techniques like gastrojejunostomy by hand swen, linear or circular stapler. Abdominal pain is a common complaint following laparoscopic gastric bypass procedure (LGBP), which has different aetiologies, such as overeating, adhesion, internal herniation, bile reflux and many more. In this study LGBP was performed in an ante-colic ante-gastric pattern in a double loop manner and the prevalence and distribution of pain in morbidly obese patients undergoing LGBP was assessed.

Objectives:

The aim of this study was to analyze the distribution and frequency of post LGBP pain in morbidly obese patients.

Patients and Methods:

This study was performed on 190 morbidly obese patients referred to Hazrat Rasoul Hospital in Tehran. After LGBP, pain was measured in the following intervals: 24 hours, one week and one month after the operation. Before the operation onset, 2 mg Keflin and 5000 IU subcutaneous heparin were administered as prophylaxis. LGBP was performed using five ports including: one 11 mm port was placed 15-20 cm far from the xiphoid, one 12-mm port in mid-clavicular line at the level of camera port, one 5-mm port in subcostal area in ante-axillary region in the left, another 5-mm port in the right mid-clavicular area and a 5-mm port in sub-xyphoid. All operations were done by the same team. Staple was used for all anastomoses and hand sewn technique to close the staple insertion site. The mesenteric defect was left open and no effort was made to repair it.

Results:

The results of this study showed that 99.94 % of the patients had complains of pain in the first 24 hours of post operation, about 60% after one week and 29.5 % still had pain after one month. In addition, left upper quadrant (LUQ) was found to be the most prevalent site for the pain in 53.7% of the patients in the first 24 hours, 59.6% after one week and 16.8% after one month (except for obscure pain) with a significance of < 0.05.

Conclusions:

In this study, the authors analyzed the location and disturbance level of pain after LGBP, which could serve as a cornerstone for further researches. The authors suggest that long-term follow-up (for more than a year after operation) should be considered in future studies and also the relationship between the drainage site and pain should be investigated.

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.

The role of endoscopy in bariatrics: past, present, and future

The exponential increase in the rate of obesity and its associated co-morbidities has increased the demand for bariatric surgery. Over the past few decades, surgical weight reduction by gastric restriction, malabsorption, or a combination of both has been the preferred approach to achieve sustained weight loss in the morbidly obese. Although extremely effective, surgical procedures carry significant complications and risk with mortality rates of 1%. Because of the cost, surgical risk, and complications, there is a demand for less invasive procedures. Endoscopic approaches include placement of endoluminal space-occupying devices, stapling devices to reduce gastric volume, barrier devices to reduce small bowel absorptive area, and methods to regulate gastric emptying. Current and ongoing studies have delivered promising results across many aspects of endoscopic approaches. However, many technical obstacles still exist that have to be resolved with further research before endoscopic bariatrics can be widely deployed. At present the role of endoscopy is well established in preoperative evaluation as well as in recognition and management of many postoperative complications in bariatrics. In this article, we review the current and future endoscopic methods for weight reduction that are either in practice or in testing.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Benign, premalignant, and malignant lesions encountered in bariatric surgery

BACKGROUND

Obesity is associated with several comorbidities like diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. It is also well established that obese patients have an increased risk of several types of cancer like kidney, pancreas, endometrial, breast, and others. The bariatric surgeon needs to be aware of the problem of benign tumors and cancer in obese patients as well as the optimal management of these conditions that may be present at the time of evaluation for bariatric surgery, during the surgical procedure, and in the postoperative period.

DATABASE

A PubMed search for the words "cancer" and "bariatric surgery" and subsequent review of the abstracts identified 40 articles concerning cancerous, benign, and premalignant conditions in bariatric surgery patients. Data were then extracted from full-text articles.

CONCLUSION

Bariatric surgery decreases cancer risk especially in women. RYGB can be an effective treatment for Barrett's esophagus. Patients having esophageal cancer should not undergo bariatric surgery, while those who develop the same postoperatively are usually managed by a combined abdominal and thoracic approach (Ivor Lewis technique). Gastric cancer of the remnant stomach is usually managed by a remnant gastrectomy. A remnant gastrectomy during RYGB would be necessary in conditions that require endoscopic surveillance of the stomach like gastric polyps, intestinal metaplasia, and carcinoid tumors. Sleeve gastrectomy is an excellent option in a patient with GIST or a carcinoid who needs a bariatric operation. Preoperative endoscopy usually does not detect malignant conditions. Postoperative evaluation of the bypassed stomach is possible using various percutaneous and novel endoscopic techniques.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Helicobacter pylori eradication therapy in obese patients undergoing gastric bypass surgery--fourteen days superior to seven days?

BACKGROUND

The high prevalence of Helicobacter pylori (HP) in our obese population undergoing Roux-en-Y bypass gastric surgery (69.4%) and the concern that it may exacerbate postoperative foregut symptoms and increase gastric cancer risk led us to adopt a policy of HP systematic eradication in this group of patients. Our aim, in obese patients undergoing bypass gastric surgery, was to compare effectivity of 7- and 14-days clarithromycin-based triple therapy as the first-line treatment for HP eradication.

METHODS

Three hundred seventy-three patients [mean age 41.2 ± 10.3 years; 313 women (83.9%)] were HP positive determined by histology or urea breath test. In 2005, 94 patients (Group A) were treated with a 7-days triple therapy-proton pump inhibitor (PPI) b.i.d., clarithromycin (CL) 500 mg b.i.d., and amoxicillin (AMX) 1,000 mg b.i.d. Since 2006, 279 patients (Group B) were treated with a similar 14-days drug regimen-PPI b.i.d., CL 500 mg b.i.d., and AMX 1,000 mg b.i.d. Posttreatment HP status was assessed by C13 urea breath test 4-6 weeks after the end of therapy.

RESULTS

The eradication rates were 67.0% (Group A) and 79.9% (Group B). The eradication rate achieved with 14-days triple therapy was significantly higher than with 7-days triple therapy (OR = 1.96; 95% CI: 1.16-3.30; p = 0.016).

CONCLUSIONS

A 14-days triple therapy is more effective than 7-days triple therapy suggesting this regimen should be the first-line therapy for HP eradication in Portuguese obese patients undergoing bypass gastric surgery.

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.

A focus on surgical preoperative evaluation of the bariatric patient--the Cleveland Clinic protocol and review of the literature

Bariatric surgery is well established as a safe and effective treatment for morbid obesity and related metabolic diseases. As an elective procedure, it is critical that individuals considering bariatric surgery should be carefully selected, extensively evaluated, and optimized in order to achieve optimal outcomes. This patient population has unique and challenging issues, including an extensive range of potential medical, psychiatric, and psychological comorbidities, and often patients have unrealistic expectations of the surgery. Therefore, a multidisciplinary, comprehensive and timely assessment preoperatively is of great importance. Individual bariatric units utilise different preoperative patient evaluation protocols. There is at present no uniformly accepted or recommended practice. In this article we describe what we believe are the essential components of a preoperative bariatric surgery evaluation, with supporting evidence for each recommendation. We also present a protocol currently in practice at a high volume bariatric center of excellence; the Bariatric and Metabolic Institute in the Cleveland Clinic, Ohio.

Presurgical evaluation and postoperative care for the bariatric patient

With the increasing number of bariatric surgeries being performed, multiple specialties encounter bariatric patients. This article gives an overview of the comprehensive evaluation and preoperative preparation of a bariatric patient. Medical, psychological, and behavioral evaluation is discussed. The role of routine preoperative endoscopy is controversial but can be very important and may alter the operation performed. Immediate postoperative care is also addressed. Undergoing bariatric surgery is a lifelong commitment, and frequent follow up with reinforcement and monitoring for nutritional deficiencies is extremely important.

Abdominal pain after gastric bypass: suspects and solutions

BACKGROUND

Gastric bypass remains the mainstay of surgical therapy for obesity. Abdominal pain after gastric bypass is common and accounts for up to half of all postoperative complaints and emergency room visits. This article reviews the most important causes of abdominal pain specific to gastric bypass and discusses management considerations.

METHODS

The current surgical literature was reviewed using PubMed, with a focus on abdominal pain after gastric bypass and the known pathologies that underlie its pathogenesis.

RESULTS

The etiologies of abdominal pain after gastric bypass are diverse. A thorough understanding of their pathogenesis impacts favorably on clinical outcomes.

CONCLUSIONS

The differential diagnosis for abdominal pain after gastric bypass is large and includes benign and life-threatening entities. Its diverse causes require a broad evaluation that should be directed by history and clinical presentation. In the absence of a clear diagnosis, the threshold for surgical exploration in patients with abdominal pain after gastric bypass should be low.

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.

Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery

BACKGROUND

Obesity is becoming an epidemic health problem and is associated with concomitant diseases, such as sleep apnea syndrome and gastroesophageal reflux disease (GERD). There is no standardized diagnostic workup for the upper gastrointestinal tract in obese patients; many patients have no upper gastrointestinal symptoms, and few data are available on safety of endoscopy in morbidly obese patients.

METHODS

Sixty-nine consecutive diagnostic upper gastrointestinal endoscopies in morbidly obese patients (26 men, 43 women; mean age 43.4 +/- 10.9 years) were prospectively evaluated from January to December 2008 in an outpatient setting before bariatric procedures. Sedation was administered with propofol. Data on sedation, critical events, and examination times were recorded, as well as pathological findings.

RESULTS

The patients' mean body mass index was 47.6 +/- 7.9 (range, 35.1-73.3) kg/m(2); 17.4% reported GERD symptoms. The mean duration of the endoscopy procedure (including sedation) was 20.3 +/- 9.3 (range, 5-50) min, and the whole procedure (including preparation and postprocessing) took 58.2 +/- 19 (range, 20-120) min. The mean propofol dosage was 380 +/- 150 (range, 80-900) mg. Two patients had critical events that required bronchoscopic intratracheal O(2) insufflation due to severe hypoxemia (<60% SaO: (2)). Nearly 80% of patients had pathological findings in the upper gastrointestinal tract. Only 20% reported upper gastrointestinal symptoms. Pathologic conditions were found in the esophagus in 23.2% of the patients, in the stomach in 78.2%, and in the duodenum in 11.6%. The prevalence of Helicobacter pylori infection was 8.7%.

CONCLUSIONS

Upper gastrointestinal endoscopy can be performed safely. However, careful monitoring and anesthesiological support are required for patients with concomitant diseases and those receiving sedation. Because 80% of the patients with pathological findings were asymptomatic, every morbidly obese patient should undergo endoscopy before bariatric surgery because there may be findings that might change the surgical strategy.