Endoscopy Plays an Important Preoperative Role in Bariatric Surgery

Obesity Surgery, 14, 1367-1372 Endoscopy Plays an Important Preoperative Role in Bariatric Surgery Ravi N. Sharaf; Elizabeth H. Weinshel; Edmund J. Bini; Jonathan Rosenberg; Alex Sherman; Christine J. Ren Division of Gastroenterology and Department of Surgery, New York University School of Medicine, New York, NY, USA Background: The role of upper endoscopy (EGD) in obese patients prior to bariatric surgery is controversial. The aim of this study was to evaluate the diagnostic yield and cost of routine EGD before bariatric surgery. Methods: The medical records of consecutive obese patients who underwent EGD prior to bariatric surgery between May 2000 and September 2002 were reviewed. Two experienced endoscopists reviewed all EGD reports, and findings were divided into 4 groups based on predetermined criteria: group 0 (normal study), group 1 (abnormal findings that neither changed the surgical approach nor postponed surgery), group 2 (abnormal findings that changed the surgical approach or postponed surgery), and group 3 (results that were an absolute contraindication to surgery). Clinically important findings included lesions in groups 2 and 3. The cost of EGD (US $430.72) was estimated using the endoscopist fee under Medicare reimbursement. Results: During the 28-month study period, 195 patients were evaluated by EGD prior to bariatric surgery. One or more lesions were identified in 89.7% of patients, with 61.5% having a clinically important finding. The prevalence of endoscopic findings using the classification system above was as follows: group 0 (10.3%), group 1 (28.2%), group 2 (61.5%), and group 3 (0.0%). Overall, the most common lesions identified were hiatal hernia (40.0%), gastritis (28.7%), esophagi- This study was presented in part at the Annual Meeting of the American Society for Gastrointestinal Endoscopy, Digestive Disease Week, Orlando, FL, USA, May 18, 2003 (Gastrointest Endosc 2003;57:AB120). This study was supported by NIH, NCRR GCRC M01RR00096. Reprint requests to: Elizabeth Weinshel, MD, Chief, Gastroenterology Section, VA New York Harbor Healthcare System, 423 East 23rd Street, New York, NY 10010, USA. Fax: (212) 951-3481; e-mail: Elizabeth.Weinshel@med.va.gov © FD-Communications Inc. tis (9.2%), gastric ulcer (3.6%), Barrett's esophagus (3.1%), and esophageal ulcer (3.1%). The cost of performing routine endoscopy on all patients prior to bariatric surgery was US $699.92 per clinically important lesion detected. Conclusions: Routine upper endoscopy before bariatric surgery has a high diagnostic yield and has a low cost per clinically important lesion detected. Key words: Operative surgical procedures, gastrointestinal endoscopy, morbid obesity, bariatric surgery Introduction Obesity, defined as a body mass index (BMI) ≥30 kg/m2, is the most common chronic disease in the United States.1 Data collected from 1999-2000 by the National Health and Nutrition Examination Survey revealed that 30.9% of American adults aged 20-74 years were obese, compared to 15.0% of Americans in the same age group in data collected from 1976-1980.2 Obese individuals are at increased risk for many health problems including cancer, hypertension, heart disease, type II diabetes mellitus, obstructive sleep apnea, gastroesophageal reflux and others.3 Morbidly obese individuals (BMI ≥40 kg/m2) have the additional co-morbidity of decreased life expectancy.4 It is estimated that 810% of American women and 5% of American men are morbidly obese and that morbid obesity accounts for nearly $99 billion in annual U.S. health-care costs.3,5 Obesity Surgery, 14, 2004 1367 Sharaf et al Non-surgical options for treatment of morbid obesity include low or very low calorie diets, behavior modification, exercise, and medications. Patients may lose weight initially through these approaches but often fail to maintain weight loss.4 Surgical options (bariatric surgery) are often considered for morbidly obese patients who have been unable to lose weight via non-surgical approaches, patients with BMI ≥40 kg/m2, and those with BMI >35 kg/m2 with obesity-related co-morbidities.6 There are two categories of bariatric surgery for severe obesity. Restrictive procedures (vertical banded gastroplasty and gastric banding) decrease the size of the stomach by division or partition. Malabsorptive procedures (biliopancreatic diversion [BPD] with/without duodenal switch [DS]) bypass a significant portion of the gastrointestinal tract so that nutrients cannot be completely absorbed. Some procedures such as the Roux-en-Y gastric bypass have both restrictive and malabsorptive features. We have previously reviewed the utility of radiologic assessment of the upper gastrointestinal tract in the preoperative assessment of patients who are to undergo bariatric surgery.7 Esophagogastroduodenoscopy (EGD) is performed prior to bariatric surgery by some bariatric centers. However, the optimal preoperative assessment of candidates for bariatric surgery is not well defined. The aim of this study was to evaluate the diagnostic yield and cost of routine EGD prior to bariatric surgery. Methods Patient Population Consecutive patients who underwent EGD prior to bariatric surgery between May 2000 and September 2002 were identified by reviewing the medical records from the practice of a single surgeon (CJR). Patient selection was based upon the NIH Consensus Statement4 requiring BMI ≥40 kg/m2 or BMI >35 kg/m2 with significant co-morbidity. All patients were enrolled in a comprehensive bariatric surgery program which included nutritional and psychologic counseling. Patients underwent one of four laparoscopic procedures: adjustable gastric banding (LAGB), gastric bypass, BPD, or BPD/DS. 1368 Obesity Surgery, 14, 2004 Study Design Data was collected by reviewing medical records using a standard data collection sheet. Preoperative data collected included age, gender, ethnicity, BMI, presence of upper gastrointestinal (GI) symptoms, current medication use, current cigarette and alcohol use, laboratory tests, and EGD findings. Upper GI symptoms recorded included the presence of current heartburn, reflux, nausea, vomiting, and abdominal pain. This retrospective chart review study was approved by our institutional review board. EGD Data Two experienced endoscopists (EHW, EJB) reviewed all EGD reports independently, and the findings were categorized into 4 groups based on predetermined criteria (Table 1). If there was disagreement between the gastroenterologists’ categorizations, the reports were reviewed together and a decision was made by consensus. The criteria for the categories were determined a priori with the surgeon (CJR) based on her clinical practices. Clinically important findings included lesions in groups 2 and 3. In instances where there was more Table 1. Classification system for endoscopic findings Group 0: No findings Normal study Group 1: Abnormal findings that do not change surgical approach/postpone surgery Mild esophagitis, gastritis, and/or duodenitis Esophageal webs Group 2: Findings that change the surgical approach / postpone surgery Mass lesions (mucosal/submucosal) Ulcers (any location) Severe erosive esophagitis, gastritis, and/or duodenitis Barrett’s esophagus Bezoar Hiatal hernia (any size) Peptic stricture Zenker's diverticula Esophageal diverticula Arteriovenous malformations Group 3: Absolute contraindications to surgery Upper GI cancer Varices Preoperative Endoscopy in Bariatric Surgery than one finding on EGD, the most clinically significant lesion was considered the primary diagnosis, upon which all subsequent statistical analyses were based. Outcomes The primary aim of this study was to determine the prevalence of clinically important lesions found on EGD prior to bariatric surgery. Secondary aims included determination of predictors of clinically important lesions and the cost per clinically important lesion detected by endoscopy. The cost of EGD (US $430.72) was estimated using the endoscopist fee under Medicare reimbursement (2002). Statistical Analysis Continuous variables were compared using a Student t-test or a nonparametric test, as appropriate. Categorical variables were compared using the Chi square or Fisher's exact test. A two-tailed Pvalue <0.05 was considered statistically significant. All data are expressed as mean (SD). Statistical analysis was performed using a commercially available software package (SPSS version 11.5 for Windows; SPSS Inc, Chicago, IL). Results Table 2. Patient characteristics (n=195) Age, years Female gender Race Caucasian Black Hispanic Other BMI BMI category29 Moderate obesity (30.0-34.9 kg/m2) Severe obesity (35.0-39.9 kg/m2) Morbid obesity (40.0-49.9 kg/m2) Super obese (≥50.0 kg/m2 )30 GERD symptoms H2-blocker/PPI use Current smoker Current alcohol use Hemoglobin, g/dL * Glucose, mg/dL * 158 (81.0%) 19 (9.7%) 15 (7.7%) 3 (1.5%) 48.9 (8.3) 0 19 (9.7%) 101 (51.8%) 75 (38.5%) 62 (31.8%) 37 (19.0%) 26 (13.3%) 71 (36.4%) 13.8 (1.4) 102.6 (42.6) *Data available for only 159 patients. BMI = body mass index, GERD = gastroesophageal reflux disease, H2 = histamine-2 receptor, PPI = proton pump inhibitor. Table 3. Lesions Identified on EGD and impact on bariatric surgery Lesion Hiatal hernia Prevalence Result 78 (40.0%) 10 (5.1%) 9 (4.6%) 7 (3.6%) Crural repair/ reduction of hernia Medical treatment, postpone surgery Medical treatment, postpone surgery Await biopsy results, medical treatment, repeat endoscopy Await biopsy results, medical treatment, repeat endoscopy Await biopsy results, medical treatment, verify healing Await H. pylori results, medical treatment Await biopsy results Study gastric emptying During the 28-month study period, a total of 220 patients underwent EGD prior to bariatric surgery, and medical records of 195 were available for review. Clinical characteristics are shown in Table 2. The majority of patients were Caucasian females with an average age of 41.2 years. Gastritis (erosive) Esophagitis (erosive) Gastric ulcer EGD Findings Barrett’s esophagus 6 (3.1%) Esophageal ulcer 6 (3.1%) Duodenal ulcer 2 (1.0%) 1 (0.5%) 1 (0.5%) One or more lesions were identified in 89.7% of patients, with 61.5% having a clinically important finding (Table 3). The prevalence of endoscopic findings using the classification system in Table 1 was as follows: group 0 (10.3%), group 1 (28.2%), group 2 (61.5%), and group 3 (0.0%). The most common lesions identified were hiatal hernias (40.0%), gastritis (28.7%), esophagitis (9.2%), gas- 41.2 (9.3) 153 (78.5%) Esophageal stricture Bezoar Obesity Surgery, 14, 2004 1369 Sharaf et al tric ulcers (3.6%), Barrett’s esophagus (3.1%), and esophageal ulcers (3.1%). In no patients were UGI cancer or esophageal varices identified. The cost of performing routine endoscopy on all patients prior to bariatric surgery was US $699.92 per clinically important lesion detected. Predictors of Clinically Important Lesions A comparison between patients with and without clinically important lesions is shown in Table 4. There were no significant differences between patients with and without clinically important lesions with regard to age, gender, ethnicity, BMI, presence of current upper GI symptoms, present H2blocker/proton pump inhibitor (PPI) use, current cigarette and alcohol use, or hemoglobin and glucose levels. Surgical Procedures Performed Although 195 medical records were reviewed, only 183 patients had laparoscopic surgery. Twelve patients who initially underwent preoperative screening did not have surgery by September 2002, the end of the study period. Of patients who had laparoscopic surgery, the distribution of endoscopic findings by surgery type is shown in Table 5. In gen- eral, patients with erosive esophagitis, gastritis or ulcers found on EGD were treated for 4-6 weeks with PPIs and treated for Helicobacter pylori, when present. Testing for Helicobacter pylori was done uniformly, but results were not collated in this paper. Repeat endoscopy that revealed endoscopic improvement resulted in bariatric surgery. The patient with a bezoar had a gastric emptying study, which was normal. Patients with hiatal hernias >2 cm were readily identified intraoperatively and crural repairs were performed. Discussion Upper GI symptoms were present in 31.8% of our patients. Other published studies have evaluated the prevalence of upper GI symptoms in morbidly obese patients, with ranges of 10% to 87%.8-19 General population estimates of UGI symptom prevalence are between 25% and 51%.20-24 Our results fall within this broad range of published data. The most common lesions identified in our patients were hiatal hernia, gastritis, and esophagitis. Our results are consistent with other published reports describing the prevalence of endoscopic findings in severely obese patient populations.8- Table 4. Comparison of patients with and without clinically important lesions Clinically important lesion (n = 120) No clinically important lesion (n = 75) P-Value 41.7 (9.7) 92 (76.7%) 40.5 (8.6) 61 (81.3%) 0.41 0.44 0.16 100 (83.3%) 11 (9.2%) 6 (5.0%) 3 (2.5%) 48.6 ± 8.4 34 (28.3%) 22 (18.3%) 20 (16.7%) 49 (40.8%) 13.9 ± 1.5 103.8 ± 43.2 58 (77.3%) 8 (10.7%) 9 (12.0%) 0 (0.0%) 49.4 ± 8.2 28 (37.3%) 15 (20.0%) 6 (8.0%) 22 (29.3%) 13.5 ± 1.4 100.7 ± 41.9 Age (years) Female gender Race Caucasian Black Hispanic Other BMI GERD symptoms H2-blocker/PPI use Current smoker Current alcohol use Hemoglobin, g/dL Glucose, mg/dL 0.52 0.19 0.77 0.08 0.10 0.08 0.65 BMI = body mass index, GERD = gastroesophageal reflux disease, H2 = histamine-2 receptor, PPI = proton pump inhibitor 1370 Obesity Surgery, 14, 2004 Preoperative Endoscopy in Bariatric Surgery Table 5. Distribution of endoscopic findings in those patients who had surgery (n=183) Type of Surgery LASGB (n=26) Roux-en-Y gastric bypass (n=109) BPD/BPD-DS (n=48) 10,14,16-18 Group 0 (number of patients) Group 1 (number of patients) Group 2 (number of patients) 11.5% (3) 11.0% (12) 8.30% (4) 38.5% (10) 25.7% (28) 33.3% (16) 50.0% (13) 63.3% (69) 58.3% (28) We also found, as have others,8,16-18 a lack of correlation between patient symptoms and endoscopic findings. None of the demographic, laboratory and other clinical data were helpful in predicting which patients will have clinically important lesions on EGD. There is controversy over the role of preoperative EGD prior to bariatric surgery. Albert and colleagues,3 suggest that upper endoscopy is indicated only in patients with peptic ulcer disease or those who have anatomic changes to their stomachs secondary to prior surgery. Cowan et al25 recommend that all patients undergoing bariatric procedures have preoperative EGD, particularly since after surgery, gastric and/or duodenal mucosa may not be within reach of the endoscope. With respect to LAGB and VBG respectively, Frigg et al17and Verset et al18 advocate EGD prior to bariatric surgery because of the high prevalence of upper GI lesions that often necessitate medical therapy or provide information influencing operative procedure. Furthermore, Frigg and colleagues17 specifically express their reluctance to perform surgery on an altered GI mucosa. Referring to patients undergoing LAGB and fixed gastric banding respectively, Angrisani et al15 and Viste et al26 state that preoperative EGD is standard procedure. Flejou and others,16 with regard to VBG, suggest that endoscopy is indicated to establish baseline gastric pathology before surgery. Finally, Ghassemian27 states that EGD is not part of his preoperative gastric bypass protocol. Given the high percentage of patients with clinically important lesions and the lack of predictors, our data show the benefit of routine EGD in patients prior to laparoscopic LAGB, Roux-en-Y gastric bypass, and BPD/BPD-DS. While no EGD findings were absolute contraindications to surgery (Group 3), the findings often revealed pathology that necessitated medical attention (thus delaying surgery) or had an impact on surgical approach (i.e. repair of hiatal hernia). Preoperative EGD may be particularly beneficial in patients undergoing gastric bypass or BPD/BPD-DS after which gastric and/or duodenal mucosa is no longer within reach of the endoscope. Because of the high incidence of pathology, we believe a baseline documentation of upper GI histology may be important if future GI symptoms arise. Our study has several limitations which should be noted. Our data would have been strengthened by having a single endoscopist do all procedures, which was not possible with our retrospective study design. The study would also have been strengthened by having a review of EGD pathology results. We also had no information on the incidence of EGD-related complications. We note that it is possible that the lack of consensus in the literature on the role of preoperative EGD before bariatric surgery may be due to differences in opinion as to what constitutes a clinically important lesion. Surgical opinion varies as to whether mucosal changes or hiatal hernia are indications to postpone surgery or change the surgical approach.15,17,27,28 At our center, all hiatal hernias >2 cm were repaired regardless of the presence of symptoms, with the expectation that this will prevent the development of gastroesophageal reflux disease (GERD) after surgery. 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