Should We Perform Preoperative Endoscopy Routinely in Obese Patients Undergoing Bariatric Surgery?

Abstract

Background:

The aim of the present study was to investigate and discuss the incidence of gastric anomalies and pathologies among bariatric surgery patients who underwent preoperative endoscopic evaluation.

Methods:

Between March 2013 and March 2015, a series of obese patients, who underwent esophagogastroduodenoscopy (EGD) before bariatric surgery (sleeve gastrectomy or Roux-en-Y gastric bypass), were enrolled in the study. The demographic features, endoscopic diagnoses, gastric biopsies, and surgical data were retrospectively evaluated.

Results:

The study included 157 patients (108 female and 49 male) with a mean age of 43 years. The mean body mass index was 48 kg/m². Abnormal findings were observed in 67% of the patients of whom only 17% were symptomatic. Endoscopic findings were as follows: gastritis: 54%, esophagitis: 10%, hiatal hernia: 17%, gastric ulcer: 5%, and others: 3%. Helicobacter pylori infection was investigated in 125 patients and detected in 62%. Gastric biopsies were performed in 148 patients, with chronic inflammation found in 65%, inflammatory activity in 32%, and intestinal metaplasia in 2%. While endoscopic findings changed medical management or delayed surgical procedure in 54% of the patients, it altered the surgical procedure in one patient due to heterotopic pancreatic tissue.

Conclusion:

The results of our study show that there is a broad spectrum of gastrointestinal diseases (67%) with an impact on perioperative management in over half of the obese patients (54%). Given the high diagnostic yield of gastric disorders from our findings, we recommend routine EGD for patients scheduled to undergo bariatric surgery.

Introduction

Obesity has substantially attracted interest as one of the major health issues worldwide over the past two decades.^1–4 Bariatric surgery, which has gained popularity in Turkey in the last decade, remains superior to nonsurgical treatments regarding short-term benefits in surrogate markers of obesity-related metabolic diseases.⁵ Due to the several common comorbidities associated with overweight and obesity, preoperative assessment of these patients is of great importance to provide promising results in the postoperative period. Every institute has its protocol for preoperative evaluation of these patients undergoing bariatric surgery. Regarding all the components of this protocol, the surgical procedure is most associated with the upper gastrointestinal endoscopy (esophagogastroduodenoscopy [EGD]). However, routine endoscopy for obese patients admitted to bariatric surgery is still a matter of discussion. While some studies advocate EGD to be performed routinely in the preoperative period, others do not recommend it in the absence of symptoms.

Obesity 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, nonalcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma.⁶ Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. Therefore, American Society for Gastrointestinal Endoscopy (ASGE) recommends EGD for symptomatic patients preoperatively (Level 2C).^7,8 Since gastrointestinal symptoms do not correspond to the extent of gastric lesions, EGD still poses a dilemma for asymptomatic patients. In their updated report in 2015, this issue was still presented as conflicting.⁹ In general, despite its close relationship with a wide range of gastric disorders, patients infected with H. pylori are asymptomatic, and no specific clinical signs have been described. H. pylori infection remains an important health problem in Turkey where its prevalence in the community is reported to be over 76%.¹⁰

The value of a routine EGD before bariatric surgery in obese patients remains controversial. However, the chosen procedure or timing of operation might be changed if specific pathological upper gastrointestinal findings are detected preoperatively. In this study, we aimed to investigate the incidence of gastric anomalies and pathologies in obese patients undergoing bariatric surgery and determine if it is required routinely.

Patients and Methods

We performed a retrospective chart review of 157 obese patients who underwent bariatric surgery between March 2013 and March 2015. In all patients, preoperative evaluation that included a standardized cardiac assessment protocol, pulmonary, psychological, and nutritional evaluations, as well as psychological and nutritional counseling on an outpatient basis, was performed. All patients underwent routine preoperative EGD. All EGDs were performed by surgeon-endoscopists. Most of the patients had their endoscopic procedures without sedation. Sedation was used based on patient requirements or request.

Our center's institutional review board approved the study and written informed consent for EGD was obtained from all patients. Data collection included demographic features, gastrointestinal symptoms–particularly obesity (if present), endoscopic findings, histopathological findings of gastric biopsy, surgical procedure, and postoperative period. In addition, the cost of EGD (inpatient/outpatient) was recorded.

Endoscopic findings were recorded into a prospectively maintained database at the end of each endoscopic procedure. The rate of H. pylori infection and its relationship with postoperative complications were also evaluated. H. pylori density was graded histologically according to the Sydney system (normal, mild, moderate, and marked). In those patients with marked H. pylori density and gastric or duodenal ulcer with any density of H. pylori, lansoprazole (30 mg b.i.d.), clarithromycin (500 mg b.i.d.), and amoxicillin (1 g b.i.d.) were given for 1 week and then 30 mg lansoprazole once daily was continued for an additional 3 weeks.

EGD findings were classified as follows: Group 0 = normal findings; Group 1a = abnormal findings that did not change surgical approach or postpone surgery (hiatal hernia, gastric or duodenal polyps); Group 1b = abnormal findings that changed the medical management, but did not change the surgical approach or delay the surgery (gastritis, duodenitis, and esophagitis); Group 1c = abnormal findings that changed the surgical approach or postponed the surgery (severe →1 cm- or multiple ulcerations); and Group 1d = abnormal findings that were absolute contraindications to surgery. Those patients who had multiple disorders that fit different groups were classified considering the highest group level.

Statistical analysis was performed using Fisher's exact test for categorical data and t-test for count data. p-Values less than 0.05 were considered statistically significant.

Results

Demographic features are shown in Table 1. Typical symptoms associated with gastric disorders (n = 33) were observed in 28 patients (17%). Dyspepsia symptoms were mild (gastritis) in 15 patients and moderate or severe (peptic/duodenal ulcer) in 9 patients. Reflux symptoms were present in nine patients.

Table 1.

Demographic Features of the Patients Undergoing Bariatric Surgery (n = 157)

Mean age ± SD (range), years	43 ± 4 (20–65)
Gender (F/M)	108/49
BMI, mean ± SD (range), kg/m²	48 ± 8 (37–101)
BMI category
Severe obesity (35–39.9 kg/m²)	14 (9%)
Morbid obesity (40–49.9 kg/m²)	96 (61%)
Super morbid obesity (50 or above kg/m²)	47 (30%)
Gastrointestinal symptoms	28^a/157 (17.8%)
Abnormal findings in preoperative gastroscopy^b	106/157 (67%)
Surgical procedure
Laparoscopic sleeve gastrectomy	126 (80.2%)
Bypass procedure	31 (19.7%)

Thirty-three different symptoms were present in 28 patients.

In 106 patients, 155 abnormal findings were observed.

BMI, body mass index.

Endoscopic findings were abnormal in 106 (67.5%) patients, while remaining patients (n = 51) had totally normal endoscopic findings. Abnormal findings (155 findings in 106 patients) were as follows: gastritis (54%), esophagitis (10%), hiatal hernia (17%), gastric ulcers (5%), and others (duodenal ulcer, polypoid mass, 3%) (Table 2). The majority of the findings (94%) were related to peptic disorders and gastroesopheal reflux disease (GERD). However, no patient had esophageal or gastric varices. No endoscopy-related complication was observed. Only 16% patients underwent EGD with sedation. The average cost of EGD was 98.6 US dollars per patient, which was higher (123 US dollars) for outpatient EGD.

Table 2.

Endoscopic Features and Histopathological Examination of Gastric Biopsies

Findings on endoscopy (n = 106/157, 67%)	n (%)
Group 0 = normal	51 (32)
Group 1a	21 (13)
Hiatal hernia	17 (10.8)
Polypoid mass	4 (2.5)
Group 1b	74 (47)
Gastritis, duodenitis	61 (38)
Esophagitis	13 (8)
Group 1c	11 (7)
Gastric or duodenal ulcer	9 (5.7)
Others	2 (1.2)
Group 1d	0
Abnormal findings on endoscopic biopsy (n = 148)
Chronic gastritis	97
Helicobacter pylori (+/−) (n = 125)	78^a/47
Intestinal metaplasia	3
Others^b	3

Thirty-four percent of H. pylori infections were mild density.

Foveolar hyperplasia.

Gastric biopsies (148/157, 94%) showed chronic inflammation and gastritis (n = 97, 65%), intestinal metaplasia (2%), and others (foveolar hyperplasia). Gastric malignancy and glandular atrophy were not found in any patient. H. pylori infection was investigated in 125 patients and detected in 62%. All patients with marked and moderate H. pylori density and with clinical symptoms (n = 57) were given eradication therapy before surgery. Both gastric and duodenal polyps were hyperplastic.

A total of 106 (67.5%) patients had 155 abnormal findings. Considering the effects of the endoscopic results on the preoperative or operative management of these patients, classifications were as follows: 51 patients (32%) had normal endoscopy result (Group = 0), 21 had abnormal findings that did not change the surgical approach or postpone the surgery (Group 1a), in 74 patients, only medical management was altered, whereas surgical approach or timing of surgery did not change (Group 1b), and 11 had abnormal findings that changed the surgical approach (n = 1, 0.6%) or postponed the surgery (n = 10) (Group 1c). One patient whose surgical approach was changed into bypass procedure instead of sleeve gastrectomy had the submucosal tumor located in the antrum (Fig. 1). Histopathological examination confirmed this lesion as heterotopic pancreatic tissue (type II). No endoscopic finding presented as an absolute contraindication for bariatric surgery (Group 1d). In 63 asymptomatic patients (40%), endoscopic findings that altered the medical management (n = 63) or surgical approach (n = 1) or timing of surgery (n = 2) were observed. In other words, more than half of the patients who had abnormal endoscopic findings were asymptomatic and detected by EGD. Regarding all asymptomatic cases (n = 129), half of patients required preoperative medical management or change in timing of surgery or surgical approach.

FIG. 1.

Endoscopic image revealing a 12-mm gastric submucosal tumor located in the antrum. It was confirmed as heterotopic pancreas after histopathological examination.

One hundred twenty-six patients underwent laparoscopic sleeve gastrectomy, while 31 patients underwent gastric bypass surgery. The postoperative complication rate was 2.5% (n = 4). Staple-line leak in two patients and pneumonia, hematoma, and trocar site hernia in one patient each were observed. Both patients with postoperative leakage were with sleeve gastrectomy and managed with percutaneous drainage and antibiotics. Only one patient identified with postoperative hematoma required reoperation. There was no association between H. pylori infection and postoperative complications (p = 0.162). The mortality was nil.

Discussion

Although routine preoperative EGD is still not involved in the guidelines on the preoperative assessment for patients undergoing bariatric surgery, a wide range of rates (31–80%) for abnormal findings in routine preoperative endoscopy in these patients have been reported so far.^11–14 Undoubtedly, patients with symptoms of GERD or peptic ulcer disease or any postprandial symptoms related to gastric pathology should have an EGD evaluation.⁸ Both European Association for Endoscopic Surgery and ASGE recommend EGD for obese patients admitted to bariatric surgery, particularly in symptomatic patients.^7,15 However, the importance and necessity of “routine EGD” before bariatric surgery in asymptomatic patients are still a matter of discussion. In most patients, there is no correlation between symptoms and endoscopic findings. This is the reason routine preoperative EGD is considered for detecting both possible lesions and inflammation.^16,17 There have been many studies suggesting that routine preoperative EGD can identify a variety of conditions, including a hiatal hernia, esophagitis, ulcers, and tumors, even in asymptomatic patients who made up the majority of cases.^13,18–20 And these findings in asymptomatic patients may alter the timing or type of surgery.⁹ Likewise, in our study, 67% of the patients who had routine EGD were found to have abnormal endoscopic findings, but only 17% of the patients were symptomatic. It means that three in four patients diagnosed with abnormal endoscopic findings were initially asymptomatic. In addition, considering all asymptomatic patients, half of them required medical management before surgery or had delay in surgical treatment or surgical management changes.

Endoscopic findings included gastric or esophageal ulcers, hiatal hernia, esophagitis, and other rare conditions. The majority of the results (94%) in our series were related to peptic disorders and GERD, as most of the series were also noted. One of the most common findings in EGDs was gastritis, and most of them had concomitant H. pylori infection. This finding was present in 17% to 70% of patients scheduled for bariatric surgery.^14,21,22 Our result with a rate of 62% H. pylori infection was compatible with the literature. Considering the high prevalence of H. pylori infection¹⁰ combined with a moderate incidence of gastric cancer in Turkey (10 in 100,000 persons), we decided to perform routine EGD since our study sample had a mean age of 40 years.

There are conflicting data about the adverse effect of H. pylori on surgical outcomes. As Hartin et al. demonstrated a higher incidence of postoperative perforation in the unscreened/untreated group of patients with RYGB compared to those screened and treated if H. pylori infection was found positive,²³ Rasmussen et al.²⁴ reported the twofold increase in marginal ulcers in those who underwent RYGB with H. pylori positive. On the contrary, Papasavas et al.²⁵ found no association between marginal ulcers or pouch gastritis in a similar patient population. Likewise, in a patient group undergoing sleeve gastrectomy, no postoperative adverse effect related to H. pylori status was observed.²⁶ In our study, there were also no adverse events, including leak or other complications associated with H. pylori infection. According to our study results, the rate of surgical complications was quite lower (2%) than that reported in the literature with rates ranging between 1% and 6%.^27–29 This can be related to our routine preoperative protocol, including testing and eradication of H. pylori before bariatric surgery. However, ASGE in their 2015 report noted that testing and eradication of H. pylori before bariatric surgery should be individualized.⁹

Endoscopic findings may result in the change in the surgical treatment plan or timing of surgery at rates ranging between 0.2% and 9%.^{11,12,18,19,30} The presence of a hiatal hernia and endoscopic signs of reflux esophagitis represent a relative contraindication to sleeve gastrectomy because of an increased risk of the development of de novo GERD-type symptoms and esophageal mucosal injury. Concomitant surgical repair, including hiatal hernia reduction, and crural closure are recommended in patients with a hiatal hernia undergoing any weight loss operation.³¹ Since we did not observe any patients with severe symptoms due to GERD or with the large hiatal hernia that would have required surgical repair, no additional intervention was performed. In addition, no malignant lesion was found in any EGD. Only in one patient (0.6%) was a planned sleeve gastrectomy changed into bypass procedure due to suspicious findings of heterotopic pancreatic tissue in the antrum. It was confirmed as gastric pancreatic tissue (Type I heterotopic pancreas) postoperatively.

One reason to investigate whether EGD should be performed or not, is the drawbacks in addition to some benefits of EGD. One of the concerns of performing routine preoperative upper endoscopy is the risk of sedation, particularly in this patient population. Cardiopulmonary complications are the most serious adverse reactions associated with conscious sedation at the time of EGD, with a mortality rate of 0.03% and a severe morbidity rate of 0.54%.³² In our series, only 16% patients underwent EGD with sedation. Other restraining factors included invasiveness and risk of perforation. Gomez recommended less invasive methods to screen gastrointestinal disorders.³³ Nevertheless, in their series, there was not too much extra information supplied by EGD. Medical management was changed in 15% patients, while EGD altered surgical approach in only 1.7% patients. As we did not observe any complication related to EGDs, medical management changed in 47% of the patients, whereas findings in 7% postponed the surgery. Besides all these, the cost is another issue. In Turkey, EGD is around 100 US dollars using the endoscopist fee under healthcare reimbursement. So, it is not too expensive compared to other countries and does not cost too much.

Conclusion

In this study, we investigated whether routine preoperative EGD is of use or not, since an identified pathology may change the course and extent of the procedure. As a result, preoperative EGD yielded a high prevalence of gastrointestinal diseases even in asymptomatic patients. Although a change in surgical approach was needed in a few cases, delay in surgery occurred in a substantial number of the patients. Another issue is that for a bariatric patient population with a high average age (over 40 years) and high incidence of H. pylori infection, the risk of cancer may be high as well. Therefore, we recommend routine gastroscopy when associated morbidity and cost involved for the EGD procedure are considerably low. This study inspired to investigate of the efficacy of eradication therapy, which is still controversial, and so we have initiated prospective randomized study to assess this issue.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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