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The Role of Endoscopy in the Bariatric Surgery Patient

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The Role of Endoscopy in the Bariatric Surgery Patient GUIDELINE The role of endoscopy in the bariatric surgery patient This is one of a series of statements discussing the use of ist to take a course of action that varies from the recom- GI endoscopy in common clinical situations. The Stan- mendations and suggestions proposed in this document. dards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text in conjunction with representatives from the Society of INTRODUCTION Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Society for Metabolic and Bariatric Surgery This document is an update of the 2008 publication “ (ASMBS). In preparing this document, MEDLINE and entitled The Role of Endoscopy in the Bariatric Surgery ”2 PubMed databases were used to search for publications be- Patient. The purpose of this document is to update endo- tween January 1980 and December 2013 pertaining to this scopists on the utility of endoscopy in the management topic by using the key words “bariatric surgery” and of patients considering bariatric surgery and those who “endoscopy.” The search was supplemented by accessing have undergone a bariatric procedure. A recent ASGE tech- the “related articles” feature of PubMed with articles iden- nology publication discussed current bariatric endoluminal fi techniques.3 Body mass index (BMI) is calculated as ti ed on MEDLINE and PubMed as the references. Addi- 2 2 tional references were obtained from the bibliographies weight/height (kg/m ) and is commonly used to classify of the identified articles and from recommendations of adults as overweight (BMI 25.0-29.9) and obese R expert consultants. When few or no data were available (BMI 30.0). In 2010, 68% of adults older than 20 years of from well-designed prospective trials, emphasis was given in the United States were overweight or obese, 36% were frankly obese, and 6% had a BMI R40.4 By 2030, 40% of to results from large series and reports from recognized ex- 5 perts. Weaker recommendations are indicated by phrases the United States population is expected to be obese. such as “We suggest.,” whereas stronger recommenda- Obesity is associated with an increased risk of morbidity “ . ” and mortality.6-11 In recognition of these risks and the evi- tions are stated as We recommend . The strength of in- 12-14 dividual recommendations was based on both the dence of risk reduction associated with weight loss, aggregate evidence quality (Table 1)1 and an assessment bariatric surgery is endorsed as an appropriate therapy of the anticipated benefits and harms. in carefully selected individuals with severe obesity R R ASGE position statements for appropriate use of endos- (BMI 40 or those with a BMI 30 and serious comorbid conditions) when dietary, behavioral, and pharmaco- copy are based on a critical review of the available 15,16 data and expert consensus at the time that the documents therapy interventions have failed. are drafted. Further controlled clinical studies may be Bariatric surgery in appropriately selected patients fi needed to clarify aspects of this document. This document results in a signi cant and durable weight loss and an may be revised as necessary to account for changes in improvement in weight-related comorbidities. Bariatric technology, new data, or other aspects of clinical practice procedures cause weight loss via gastric volume restriction and is solely intended to be an educational device to pro- or malabsorption or through a combination of the 2 and vide information that may assist endoscopists in their associated hormonal changes (Table 2, Figs. 1-3). providing care to patients. This document is not a rule For the purposes of this document, surgical descriptors and should not be construed as establishing a legal stan- such as restrictive and malabsorptive are used; however, dard of care or as encouraging, advocating, requiring, these terms may be overly simplistic and likely do not or discouraging any particular treatment. Clinical deci- encompass the complete physiological effects of bariatric fi sions in any particular case involve a complex analysis surgery. Behavioral modi cation, learned through coun- of the patient’s condition and available courses of action. seling and education, is also an important component for Therefore, clinical considerations may lead an endoscop- the long-term success of any weight loss intervention. This is 1 important reason why surgical and endoscopic weight loss procedures should be offered only as compo- nents of a multidisciplinary weight management team approach. Historically, the most commonly used restrictive ª Copyright 2015 by the American Society for Gastrointestinal Endoscopy, bariatric surgical procedure was the laparoscopic adjust- the American Society of Metabolic and Bariatric Surgery, and the Society of American Gastrointestinal and Endoscopic Surgeons able gastric band (LAGB); however, in the modern era, 0016-5107/$36.00 sleeve gastrectomy (SG) has supplanted LAGB in this re- http://dx.doi.org/10.1016/j.gie.2014.09.044 gard. Vertical banded gastroplasty (VBG) was popular in www.giejournal.org Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1063 Role of endoscopy in the bariatric surgery patient with postsurgical anatomy, including information on the TABLE 1. GRADE system1 for rating the quality of equipment needed for successful completion of diagnostic evidence for guidelines and therapeutic procedures and tips on accessing distant or excluded portions of the GI tract in patients who have Quality of undergone RYGB. A central tenet surrounding the practice evidence Definition Symbol of endoscopy in patients before or after bariatric surgery is 4444 High quality Further research is very unlikely the need for close consultation or coordination with the to change our confidence in the estimate of effect surgeon/surgical team by the endoscopist if the endoscop- ist is not part of the bariatric surgery team. Moderate Further research is likely to have 444B quality an important impact on our confidence in the estimate of effect and may change the PREOPERATIVE ENDOSCOPIC EVALUATION estimate OF THE BARIATRIC SURGERY PATIENT Low quality Further research is very likely to 44BB have an important impact on Preoperative endoscopy with EGD can identify patients our confidence in the estimate with asymptomatic anatomic findings that may alter surgical of effect and is likely to change planning. Patients with symptoms of GERD, such as heart- the estimate burn, regurgitation, dysphagia, or any postprandial symp- Very low Any estimate of effect is very 4BBB toms that suggest a foregut pathology and/or who quality uncertain chronically use antisecretory medications, should have an 18 Adapted from Guyatt et al.1 upper GI endoscopic evaluation before bariatric surgery. Multiple published studies have demonstrated that routine EGD before surgery can identify a variety of conditions including hiatal hernia, esophagitis, ulcers, and tumors.19,20 Although the majority of patients with abnormalities in these TABLE 2. Mechanism of weight loss for common studies were asymptomatic, endoscopic findings resulted in obesity surgeries an alteration of the surgical approach or delay in surgery 19-22 Procedure Mechanism ranging from less than 1% to 9% of patients. A barium contrast study may be a useful alternative as it can provide Laparoscopic adjustable Restrictive 23 gastric band information complementary to endoscopy. The presence of a hiatal hernia and endoscopic signs of reflux esophagitis Vertical banded gastroplasty Restrictive represent a relative contraindication to SG because of an Sleeve gastrectomy Restrictive; hormonal increased risk of the development of de novo GERD-type alteration symptoms and esophageal mucosa injury after SG. Surgeons Sleeve gastrectomy with Restrictive/maldigestive; advocate hiatal hernia reduction and crural closure in pa- duodenal switch/ hormonal alteration tients with hiatal hernia undergoing any weight loss opera- biliopancreatic diversion tion.24 It is useful for surgeons planning weight loss Roux-en-Y gastrojejunal Restrictive/maldigestive; interventions to know the measured size of any hiatal hernia, bypass hormonal alteration reported in centimeters, both as the length of the hernia and the gap between the diaphragmatic crura, with the latter measurement obtained via intraoperative endoscopy. Helicobacter pylori infection is present in 23% to 70% of the early to mid-1980s, but it is no longer routinely used. patients scheduled for bariatric surgery.25,26 There are con- SG is an effective restrictive-type bariatric operation, which flicting data for preoperative testing and treatment of Hpylori is also associated with gut peptide alterations, and when with respect to related surgical outcomes, and additional converted to duodenal switch and biliopancreatic diver- studies are needed. A retrospective study of 260 patients sion, the result becomes both restrictive and malabsorp- who underwent RYGB found Hpyloriinfection at more tive. The Roux-en-Y gastrojejunal bypass (RYGB) is also than twice the rate among the 7% of patients in whom mar- both restrictive and malabsorptive. A thorough discussion ginal ulcers subsequently developed (32% vs 12%, P Z of hormonal changes induced by these various weight .02).27 Another retrospective study of 183 patients evaluating loss interventions is beyond the scope of this document. the benefits of preoperative screening and treatment of Hpy- It is useful, however, to understand the anatomic alter- lori demonstrated a higher incidence
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