Screening Esophagogastroduodenoscopy Before Laparoscopic Sleeve Gastrectomy: Results in 819 Patients

Abstract

Aim:

The routine use of esophagogastroduodenoscopy (EGD) during the preoperative evaluation of surgical weight loss candidates is controversial. The aim of this study is to evaluate the findings of preoperative EGD in patients who are scheduled for a primary laparoscopic sleeve gastrectomy (LSG). The probable effect of these findings on the medical and surgical strategy that was followed is assessed.

Methods:

Findings of EGD obtained from consecutive LSG candidates and all data were prospectively recorded and retrieved from the database.

Results:

A total of 819 patients underwent EGD successfully. Mean age and body mass index were 38 ± 11.3 and 43.17 ± 7.2 kg/m², respectively. Fifty-eight percent were female. EGD of 263 (32.1%) patients was normal and 687 (84%) patients were asymptomatic. At least one abnormal finding was detected in 65% of the asymptomatic patients. Abnormal findings that did not change the surgical strategy were found in 550 patients (67.2%). Findings such as gastritis or duodenitis that changed the medical management before surgery were found in 309 patients (38.2%). Helicobacter pylori was positive in 218 (26.6%) patients but eradication treatment was not applied in the preoperative period. No pathology was detected that would create absolute contraindication or change the type of surgery in any patient. Only technical modifications were required in 13% due to hiatal hernia. The timing of the planned surgery has changed in only 6 patients (0.74%) (early stage neuroendocrine tumor, leiomyoma, severe ulcer).

Conclusions:

Routine EGD performed before LSG did not change the planned bariatric option in any patient, but led to 13% rate of technical modifications due to the presence of hiatal hernia. At least one abnormal finding was detected in 65% of asymptomatic patients. Due to endoscopic findings, the rate of patients who started medical acid-suppression treatment in the preoperative period was 38%.

Introduction

Bariatric surgery is the most effective treatment against morbid obesity.^1,2 Among a variety of surgical options, laparoscopic sleeve gastrectomy (LSG) has become the most popular choice in recent years.^3,4 The routine use of preoperative esophagogastroduodenoscopy (EGD) during the evaluation of bariatric surgery candidates is controversial. The European Association of Endoscopic Surgery (EAES) recommends EGD before bariatric surgery for all patients.⁵ In contrast, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommend EGD if gastric pathology is suspected.⁶

EGD is thought to be important in terms of revealing some gastric pathologies that may change the treatment strategy before surgery. Especially, inability to reach the remnant stomach is an important problem in patients undergoing gastric bypass. Many believe that this situation necessitates preoperative EGD. In a systematic review, including benign pathologies, the rate of endoscopic findings leading to changes in surgical treatment was determined as 8% in bariatric surgical patients.⁷ When only premalignant and malignant pathologies are considered, this rate decreases to 0.4%.⁷

The primary aim of this study is to evaluate the EGD findings of consecutive patients who are scheduled for LSG due to morbid obesity. Furthermore, the probable impact of these findings on the medical and surgical strategy that was implemented is investigated.

Materials and Methods

The study was approved by the Institutional Ethics Committee (ATADEK-2020-12/3). All patients were informed about the study in detail, and written consents were obtained. All data, including EGD findings that were recorded from consecutive LSG candidates, were prospectively recorded and retrieved from the database.

Preoperative workup

All patients were evaluated by a multidisciplinary team. This team consists of surgeons, dietitians, a psychologist, a psychiatrist, a cardiologist, pulmonologist, an endocrinologist, and an anesthetist. Detailed blood analysis, abdominal ultrasound, chest x-ray, cardiac echo and lung function tests were done as routine preoperative assessment.

Esophagogastroduodenoscopy

All patients underwent EGD (Olympus GIF-H180J) before surgery by the 2 senior authors (A.G.T, M.A.Y), who are also endoscopists. In the presence of an anesthesiologist, with sedation anesthesia (0.05 mg/kg midazolam, 1–2 mg/kg propofol), esophagus, stomach, and duodenum were checked for pathologies such as hiatal hernia, esophagitis, gastritis, ulcers, polyps, and neoplasms. Esophagitis is classified according to Los Angeles classification.⁸ No biopsies are taken from esophagitis spikes unless a Barrett's disease is suspected. All Barrett-like lesions are multiply biopsied routinely.

Our standard preoperative protocol when assessing esophagogastric junction before laparoscopic antireflux^9–12 and bariatric surgery¹³ have been already reported. Hiatal hernia is defined endoscopically as a more than 2 cm separation of the cranially displaced esophagogastric junction, using the Hill classification, which relies on the endoscopic aspect of the gastroesophageal valve seen from a retroflexed position.¹⁴ A separation more than 5 cm is regarded as a giant hernia.

Gastric biopsies were taken to investigate the presence of Helicobacter pylori infection in all patients. Urease test was also a routine. Before LSG, no eradication therapy was applied if H. pylori was detected in an otherwise healthy stomach.

EGD findings were classified similar to the four groups that were suggested by Sharaf et al.¹⁵ We modified this classification since we did not change the LSG option even if we detected a hiatal hernia or esophagitis in preoperative EGD. Groups can be summarized as “normal EGD findings”, “abnormal EGD findings that did not change the surgical approach or postpone surgery” (i.e., hiatal hernia, esophagitis, gastritis, duodenitis, H. pylori (+), benign polyps or <1 cm superficial ulceration at any location), “EGD findings that changed the surgical approach or postponed surgery” (i.e., varicose veins >1 cm or multiple ulcerations at any location), or “EGD findings that were contraindications to surgery.”

Surgery

All operations were done by the 2 senior authors (A.G.T., M.A.Y.). Using an optical trocar for first entry, with a five-trocar technique, an sleeve gastrectomy over a bougie, starting 3–4 cm away from the pylorus was performed. The entire length of the staple line was reinforced using 6″ barbed suture by continuous suturing (V-Loc 180; Medtronic, Minneapolis, MN).

Results

Between January 2012 and April 2019, 819 patients scheduled for LSG underwent EGD. All patients eventually had a primary LSG. Mean age and body mass index (BMI) were 38 ± 11.3 and 43.17 ± 7.2 kg/m², respectively. Fifty-seven percent were female. BMI of 64.2% of the patients was over 40 kg/m². Ninety percent of the patients had at least two or more comorbidities. EGD was successfully performed on each patient without complications. Endoscopic findings are shown in Table 1.

Table 1.

Endoscopic Findings and their Distribution According to Strategies

Finding	n (%)
Normal EGD (no effect on strategy)	263 (32.1)
Abnormal EGD (without effect on strategy)
Hiatal hernia	107 (13)
LES failure	20 (2.5)
Polyp	23 (2.8)
Esophagitis	249 (30.4)
LA/A	110 (13.4)
LA/B	139 (17)
Gastritis	245 (29.9)
Helicobacter pylori (+)	218 (26.6)
Gastric erosion	19 (2.3)
Duodenitis	32 (3.9)
Duodenal erosion	13 (1.6)
Abnormal EGD (with effect on strategy)
Severe gastric ulcer	0
Severe duodenal ulcer	2 (0.24)
Suspicious lesion	4 (0.5)
Abnormal EGD (contraindicating surgery)	0

EGD, esophagogastroduodenoscopy; LA, Los Angeles classification.

Gastric polyps were detected in 23 (2.8%) patients. These were all inflammatory polyps. Incidental gastric lesions were detected in 4 patients as reported previously.¹⁶ In 1 patient, multiple mucosal lesions were detected in the antrum and corpus localizations and in two 4–5 mm nodules, the pathology identified neuroendocrine tumors.¹⁶ Submucosal lesions less than 1 cm in the gastric corpus were detected in 2 patients and were excised. Pathology was leiomyoma. In the last patient, a suspicious ulcer was detected at a single point in the gastric corpus. The pathology result was benign. The planned LSG was applied to these 4 patients, although with a certain delay, but all lesions were removed by LSG.

Multiple duodenal ulcers were detected in 2 patients on whom surgery was delayed, since medical therapy was prioritized. The planned LSG was performed after ensuring that the ulcers were healed with a control EGD.

Hiatal hernia was detected in 107 (13%, 3–8 cm) patients, including a case with an intrathoracic stomach.¹⁷ Esophagitis was detected in 249 (30.4%, 110/LA-A, 139/LA-B) patients, and gastritis in 245 patients (29.9%). No Barrett's were diagnosed among 14 suspected biopsies. H. pylori was positive in 218 (26.6%) patients and not treated if asymptomatic. Acid suppression was initiated preoperatively in patients with gastritis/duodenitis (38.2%). Helicobacteria treatment was applied preoperatively to 2 ulcer patients.

In the preoperative period, when the patients were questioned for gastroesophageal reflux disease (GERD), 132 (16%) were symptomatic and 687 (84%) were asymptomatic. In 59 (45%) of symptomatic patients, no erosive esophagitis/hiatal hernia was detected in EGD. Esophagitis/hiatal hernia was detected in 55%. On the other hand, esophagitis/hiatal hernia was detected in 30.1% of asymptomatic patients (Table 2). In terms of all pathologies, the rate of detecting at least one abnormal finding in endoscopy for asymptomatic patients was 65%.

Table 2.

Preoperative Endoscopic Findings in Symptomatic and Asymptomatic Patients Due to Gastroesophageal Reflux Disease

	No esophagitis n (%)	LA-A esophagitis n (%)	LA-B esophagitis n (%)	Hiatal hernia without esophagitis n (%)	Hiatal hernia with esophagitis n (%)	Total n (%)
Preoperative symptomatic patients for GERD, n (%)	59 (7.2)	23 (2.8)	20 (2.4)	8 (0.9)	22 (2.7)	132 (16)
Preoperative asymptomatic patients for GERD, n (%)	480 (58.6)	66 (8.1)	64 (7.9)	23 (2.8)	54 (6.6)	687 (84)
Total, n (%)	539 (65.8)	89 (10.9)	84 (10.3)	31 (3.7)	76 (9.3)	819 (100)

GERD, gastroesophageal reflux disease; LA, Los Angeles classification.

Discussion

The value of routine EGD before bariatric surgery remains controversial. EGD is an invaluable diagnostic tool in detecting upper gastrointestinal lesions sometimes allowing preoperative treatment if detected. Our study revealed that, in 68% of patients scheduled for LSG, abnormal findings were found in EGD. The most common findings were gastritis, esophagitis, hiatal hernia, and H. pylori (+).

In literature, the rate of detection of abnormal findings in EGD before bariatric surgery varies between 4.6% and 89.7%, and similar lesions were identified.¹⁸ The review of 30 studies showed a 16.8% rate of change of the routine surgical strategy (delay or change in surgical option) based on preoperative EGD findings. The most common causes included gastritis and H. pylori infection treatment.¹⁸

Although we detected gastritis/duodenitis in almost 40% of the patients and initiated treatment before surgery, differing from others, Helicobacter eradication was not applied routinely in the preoperative period since the advantages of H. pylori eradication in asymptomatic patients is controversial. American Society for Metabolic and Bariatric Surgery guidelines do not provide a clear message as well.¹⁹ On the other hand, obese patients showed a significantly lower rate of eradication than controls, at least to the 7 day regimens, with BMI being an independent risk factor for eradication failure.²⁰

Multiple studies have shown no correlation between patient symptoms and endoscopic findings^15,18 when evaluating GERD. In our study, when patients were questioned for GERD in the preoperative period, 16% were symptomatic. Esophagitis and/or hiatal hernia were detected in 55% of symptomatic patients and 30.1% of asymptomatic patients.

Obesity is an independent risk factor for GERD.²¹ Due to weight loss, GERD disappears in most patients after LSG, on the other hand, de novo GERD occurs in some patients.²² In this study group, when the patients were evaluated after LSG in terms of GERD, the rate of de novo GERD in asymptomatic patients was 8.3%. In symptomatic patients, GERD rate was 27% at follow-up. Actually, this is another study topic.

If we detect hiatal hernia or esophagitis in preoperative EGD in patients scheduled for LSG, we do not change the type of operation. However, we do crus repair in patients with hiatal hernia during the operation. In this respect, preoperative EGD guided us to be more vigilant when investigating the presence of hiatal hernia in surgery. By doing that, we detected hiatal hernia in 13% of patients in preoperative EGD, and performed crus repair as well as LSG in these patients.

In a meta-analysis, considering only the premalignant and malignant pathologies, the rate of EGD findings leading to change in surgical treatment before bariatric surgery was reported to be 0.4%.⁷ In our study, we detected multiple fundic gland polyps in 2.8% of patients without potential for malignancy. Furthermore, suspicious-looking incidental lesions in stomach were detected in 4 patients. One of them was a multiple neuroendocrine tumor, 2 were leiomyomas, and 1 was a benign ulcer. Under the guidance of preoperative endoscopic dye-spotting, LSG was successfully performed in these patients with the complete removal of all detected lesions as previously reported.¹⁶ There was a short, but planned delay of the LSG.

Furthermore, multiple duodenal ulcers were detected in 2 patients. Medical treatment was given to these patients and then EGD was repeated after 2 months. The planned LSG was performed after ensuring the duodenal ulcers have healed. No pathology was found, that would create an absolute contraindication or change the type of surgery in any patient. The timing of the planned surgery has changed in only 6 patients (0.74%).

Conclusion

Routine EGD performed before LSG did not change the surgical option in any patient. However, it led to a 13% technical modification rate due to identification of a significant hernia thereby affecting the approach for also performing a proper hiatal hernia repair. The planned timing of surgery was changed in only 0.73%. At least, one abnormal finding was detected in 65% of the asymptomatic patients.

Due to endoscopic findings, the rate of patients who started acid suppression in the preoperative period was 38%. Importantly, preoperative EGD identified four neoplastic lesions in 3 patients, which otherwise would be overlooked. It also enabled spot marking of these lesions thereby allowing complete removal when doing a LSG.

Whether cases with GERD must be denied LSG in favor of gastric bypass is a controversial issue and is beyond our scope. Proponents of gastric bypass, therefore, should appreciate more routine EGD before surgery to identify esophagitis, Barrett's disease, hiatal hernias, the probable incidental neoplasms, and active ulcer disease.

Footnotes

Disclosure Statement

The authors have no commercial associations that might be a conflict of interest in relation to this article.

Funding Information

No funding was received for this article.

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