Preoperative Esophagogastroduodenoscopy Research Articles

Upper Gastrointestinal Endoscopy in Adolescents With Severe Obesity Before Vertical Sleeve Gastrectomy.

Esophagogastroduodenoscopy (EGD) is often performed to evaluate for mucosal and anatomical abnormalities before vertical sleeve gastrectomy (SG). Little is known, however, about how prebariatric EGD in adolescents influences clinical management or outcome. Our aim was to assess if an abnormal prebariatric EGD resulted in interventions or modification of bariatric surgery. We performed a retrospective cohort study of adolescents undergoing evaluation for bariatric surgery. We obtained demographic and anthropometric data in addition to EGD findings, biopsy pathology, gastrointestinal symptoms, and surgical outcomes. An EGD was considered abnormal if either abnormal gross findings or abnormal pathology was reported. Patients were followed until a 6-week postop visit. Of 134 patients presenting for evaluation, 94 (70%) underwent preoperative EGD. Fifty-one (54%) had a normal EGD and 43 (46%) had EGD abnormalities including 7 with an anatomical abnormality and 36 with mild mucosal abnormalities. Among patients with EGD abnormalities, 22% received medical intervention including proton pump inhibitor (PPI) administration (n = 10) and Helicobacter pylori eradication (n = 11). GI symptoms were the only predictor of EGD abnormalities (odds ratio [OR] 4.9: 95% confidence interval [CI] 1.6-15.0; P < 0.001). No factors predicted likelihood of a post-EGD intervention. An abnormal EGD did not correlate with any postoperative complications. In this cohort of adolescents undergoing evaluation for SG, 46% had an abnormal EGD, of which 22% received a medical intervention. Symptoms were the only predictor of EGD abnormalities. Abnormal EGD findings were not associated with modification of the surgery or any adverse outcome.

Preoperative esophagogastroduodenoscopy in patients without reflux symptoms undergoing laparoscopic sleeve gastrectomy: utility or futility?

AimTo evaluate the value of esophagogastroduodenoscopy (EGD) as a preoperative investigation in individuals without symptoms of Gastro-Esophageal Reflux Disease (GERD) who will undergo laparoscopic sleeve gastrectomy (LSG).Materials and methodsAfter Institutional Review Board approval was obtained, patients scheduled for LSG were prospectively enrolled in the study between January 2016 and March 2018. Patients with symptoms of GERD were excluded from the study. Participants were randomly allocated to two groups: individuals who underwent EGD before the surgery as a usual routine investigation (Group A), and individuals who were scheduled without preoperative EGD (Group B). Patient demographics, endoscopic findings, endoscopic biopsy results, and histopathological findings of the resected parts of the stomach after LSG were analyzed and recorded. Additionally, operative characteristics and outcomes, and follow up findings were recorded and analyzed with appropriate statistical methods.ResultsA total of 219 individuals without symptoms of GERD underwent LSG were enrolled. Group A included 111 individuals (25 males and 86 females). Group B comprised 108 individuals (20 males and 88 females). The mean age and mean Body Mass Index (BMI) were similar in both groups. From Group A, 86 out of 111 individuals (77.5%) had no pathology identified on EGD, while 21 individuals (18.9%) were found to have areas of gastric erythema and biopsies showed active gastritis. All LSG operations were performed without any major complication. After one year, all individuals were assessed for the presence of symptomatic GERD and no significant difference was found between the two groups.ConclusionPreoperative EGD may not be mandatory for asymptomatic GERD individuals undergoing LSG as post-operative complications and early follow up for GERD symptoms are not significantly different. Further prospective studies with longer follow up are needed to evaluate the role of EGD in individuals undergoing LSG.

Use of noninvasive positive pressure ventilation in patients with severe obesity undergoing esophagogastroduodenoscopy: a randomized controlled trial

BackgroundPatients with severe obesity being considered for bariatric surgery often undergo preoperative esophagogastroduodenoscopy (EGD). Severe obesity is a risk factor for oxygen desaturation events during EGD. The use of noninvasive positive pressure ventilation (NIPPV) to reduce desaturation events during EGD among patients with severe obesity has not been studied. ObjectiveTo evaluate the use of NIPPV among patients with severe obesity undergoing EGD. SettingCommunity hospital endoscopy suite. MethodsA randomized controlled trial evaluated the use of NIPPV in patients with severe obesity undergoing EGD. Patients were randomized into treatment (NIPPV) and control (nasal cannula, NIPPV for rescue) groups. Primary endpoints were oxygen desaturation events ≤94% and oxygen desaturation events <90% requiring intervention. A secondary endpoint was the use of NIPPV as a rescue maneuver. ResultsFifty-six patients with a body mass index of 40 to 60 were randomized (n = 28 treatment and n = 28 control). A statistically significant difference was noted between the groups for desaturation events ≤94% (14.3% of treatment and 57.1% of control groups, P = .002). There was also a statistically significant difference in the risk of a desaturation event <90% requiring intervention (3.5% of treatment and 28.6% of control groups, P = .025). All patients in the control group who developed desaturation events requiring intervention were rescued with NIPPV. ConclusionsThis study demonstrated the successful use of NIPPV as an adjunct to decrease the incidence of desaturation events in patients with severe obesity undergoing EGD.

Preoperative Endoscopic and Radiologic Evaluation of Bariatric Patients: What Do They Add?

BackgroundPreoperative esophagogastroduodenoscopy (EGD) and barium swallow (BS) are commonly performed for evaluation in bariatric surgery patients. The routine use of these modalities has been controversial. MethodsA retrospective review of a prospectively maintained database was performed to include primary bariatric surgery patients between March 2013 and August 2016. ResultsTwo hundred nine patients were included. All the patients underwent preoperative EGD and BS. The mean age was 43.12 years and BMI 46.4 kg/m2. Reflux symptoms were present in 58.5% of patients. Preoperative EGD revealed abnormalities in 87.5% of patients: esophagitis (54.5%), Barrett’s esophagus (5.3%), dysplasia (1%), and gastritis (51%). Endoscopic evidence of HH was documented in 52.2% of patients while only 34% of patients had evidence of HH in their BS. Of the asymptomatic patients, 80.2% had abnormal EGD. Helicobacter pylori on biopsy was found in 17.2% patients, out of which 47.2% were asymptomatic. Based on EGD findings, the choice of surgical procedure was changed in 3.34% of patients. Repair of HH was performed in 107 patients, with 68.2% (n = 73) symptomatic patients and 31.8% (n = 34) asymptomatic patients. On ROC analysis, EGD was better predictive of the presence of HH (AUC = 0.802, OR 5.20, p = < 0.0001) and symptoms were a poor indicator for GERD. ConclusionsPreoperative EGD is abnormal in the majority of patients regardless of their symptoms. EGD is the only modality that can provide tissue sample, which can potentially determine the type of bariatric surgery. Given the low diagnostic accuracy of BS, its routine use can be eliminated.

Nasal positive pressure with the SuperNO2VA™ device decreases sedation-related hypoxemia during pre-bariatric surgery EGD.

Pre-operative esophagogastroduodenoscopy (EGD) is becoming routine practice in patients undergoing bariatric surgery. Many patients with morbid obesity have obstructive sleep apnea (OSA), which can worsen hypoxia during an EGD. In this study, we report our outcomes using the SuperNO2VA™ device, a sealed nasal positive airway pressure mask designed to deliver high-fraction inhaled oxygen and titratable positive pressure compared to conventional nasal cannula. Between June 2016 and August 2017, we conducted a prospective observational study that included 56 consecutive patients who presented for EGD prior to bariatric surgery. Airway management was done using either the SuperNO2VA™ (N = 26) device or conventional nasal cannula (N = 30). Patient demographics, procedure details, and outcomes were compared between the two groups. The SuperNO2VA™ group had a lower median age compared to the control group (38.5 vs. 48.5 years, p = 0.04). These patients had a higher body mass index (BMI) (47.4 vs. 40.5, IQR, p < 0.0001), higher ASA class (p = 0.03), and were more likely to have OSA (53.9% vs. 26.7%, p = 0.04). Desaturation events were significantly lower in the SuperNO2VA™ group (11.5% vs. 46.7%, p = 0.004) and the median lowest oxygen saturation was higher in the SuperNO2VA™ group (100% vs. 90.5%, p < 0.0001). This is the first study to report on the use of the SuperNO2VA™ device in bariatric patients undergoing pre-operative screening EGD. The use of the SuperNO2VA™ device offers a clinical advantage compared to the current standard of care. Our data demonstrate that patients with higher BMI, higher ASA classification, and OSA were more likely to have the SuperNO2VA™ device used; yet, paradoxically, these patients were less likely to have issues with desaturation events. Use of this device can optimize care in this challenging patient population by minimizing the risks of hypoventilation.

A suitable marking method to achieve lateral margin negative in endoscopic submucosal dissection for undifferentiated-type early gastric cancer.

Background and study aims Delineating undifferentiated-type early gastric cancer (UD-type EGC) from noncancerous areas is difficult. Therefore, the lateral margin negative (LM−) resection rate of endoscopic submucosal dissection (ESD) is lower for UD-type EGC than for differentiated-type EGC. This study aimed to retrospectively evaluate the effectiveness of the marking methods with circumferential biopsies in ESD for UD-type EGC. Patients and methods We analyzed the clinical outcomes of ESD in 127 patients with UD-type EGC between April 2013 and 2017. We performed diagnostic delineation of cancerous areas using magnifying endoscopy with narrow-band imaging, and four or more circumferential biopsies approximately 5 mm apart from the estimated lesion border were obtained to confirm noncancerous areas. The markings were placed on the circumferential biopsy scars, and a mucosal incision line was made outside the markings. Results Median size of the tumors and ESD specimens was 12 and 35 mm, respectively. En-bloc resection rate was 100 % (127/127), and LM− and curative resection rates were 97.6 % (124/127) and 80.3 % (102/127), respectively. Circumferential biopsy in preoperative esophagogastroduodenoscopy has successfully identified the misdiagnosis of cancerous areas of four patients (3.2 %), with three (2.4%) achieving LM− resection. LM + resection was pathologically identified in three patients (2.4 %), with all undergoing non-curative resection due to > 20-mm tumor. The proportion of patients with the shortest distance ≥ 5 mm from the lesion edge to the specimen edge was 88.2 % (112/127). Conclusion Our marking methods with circumferential biopsies may reduce LM + resections in ESD for UD-type EGC.

Role of upper gastrointestinal endoscopy before bariatric surgery

Background: The ultimate purpose of weight management in patients with obesity is to reduce the risk of related comorbidities and improve their health. Bariatric surgery appears to be cost-effective compared with the standard intervention in the management of morbid obesity. However, the role of preoperative esophagogastroduodenoscopy (EGD) remains a controversial topic. The aim of this study is to assess the incidence of abnormal findings in preoperative EGD, to evaluate the correlation between EGD findings and patient risk factors, and to evaluate EGD’s effects on the surgical management plan. Materials and Methods: A retrospective cross-sectional study was conducted on all patients who underwent bariatric surgery at Al-Hada Military Hospital, Taif, Saudi Arabia, by reviewing their medical records. Result: The study population included 227 patients (26% males and 74% females). The incidence of abnormal EGD findings was 78.9% (n = 179), and the most common result was gastritis (n = 86; 37.9%). The prevalence of this abnormal EGD finding was significantly higher in males (n = 53; 89.8%) than in females (n = 126; 75%) (P = 0.016). A multivariate logistic regression analysis showed that male sex (odds ratio [OR] = 3.11 [95% confidence interval (CI) = 1.08–8.93]; P value = 0.036) and hypothyroidism (OR = 2.39 [95% CI = 1.02–5.59]; P value = 0.044) were independent predictive factors for abnormal EGD findings. Conclusion: Almost 80% of patients who underwent EGD before bariatric surgery had abnormal findings including Helicobacter pylori infection, gastritis, hiatal hernia, or duodenitis. Nevertheless, surgical management plans were not significantly impacted by those findings. Accordingly, preoperative EGD should be performed as clinically indicated.

Impact of preoperative wireless pH monitoring in the evaluation of esophageal conditions prior to bariatric surgery in a severely obese patient population

BackgroundSleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure in the United States; however, it can be associated with development of de novo gastroesophageal reflux (GERD) or worsening of existing GERD. Preoperative esophagogastroduodenoscopy (EGD) and findings of esophagitis are commonly used as screening tool, but the alternative use of preoperative objective measurement of acid reflux has not been studied. ObjectiveThe aim of this study was to evaluate if preoperative objective measurement of acid reflux by using wireless pH monitoring (WPHM) could have an impact on surgical planning and outcomes. SettingAcademic Center of Excellence. MethodsRetrospective review of a prospectively collected database of 43 adult obese patients with reflux symptoms who underwent outpatient EGD and WPHM between September 2011 and September 2017. ResultsChange in planned surgical management from SG to Roux-en-Y-gastric bypass with the use of WPHM occurred in 21.0% (n = 9) of patients. Only 2.3% (n = 1) developed de novo GERD after SG. Nonerosive reflux disease was the most common esophageal condition on preoperative EGD. EGD, as a single diagnostic tool, appeared insufficient to diagnose acid reflux and help with the decision planning in this patient population. ConclusionsBased on objective data obtained by measurement of GERD, using preoperative WPHM compared with preoperative EGD alone aids in a better patient selection for either SG or Roux-en-Y-gastric bypass. Our cohort with preoperative WPHM required no surgical conversions or revisions.

Preoperative Evaluation in Bariatric Surgery.

An adequate preoperative workup is critical for the success of bariatric surgery. A key component of the preoperative evaluation involves a comprehensive patient education about surgical outcomes and the postoperative behavioral regimen required. A complete medical evaluation should include the study of the cardiovascular, pulmonary, and gastrointestinal systems as well as a metabolic status assessment. The nutrition professional should be in charge of the nutritional assessment, preoperative weight loss efforts, and diet education regarding postoperative eating behaviors. A psychological evaluation is also needed because psychosocial factors have a significant impact on the long-term outcomes of bariatric surgery, including adherence to recommended postoperative lifestyle regimen, emotional adjustment, and weight loss outcomes. We recommend preoperative abdominal ultrasound to assess for biliary tract pathology, steatosis, fibrosis, and presence of nonalcoholic steatohepatitis. A routine preoperative esophagogastroduodenoscopy is also recommended to evaluate common gastrointestinal disorders associated with obesity. Preoperative weight loss should be strongly encouraged.

Serological biomarker testing helps avoiding unnecessary endoscopies in obese patients before bariatric surgery

BackgroundTo assess the value of serological biomarker testing as a substitute for esophagogastroduodenoscopy (EGDS) in pre-operative assessment of patients referred for bariatric surgery.MethodsSixty-five obese patients with a mean age of 43 years (range: 21–65) and a mean body mass index (BMI) of 44 (range: 36–59) were studied. The patients were tested with a four-biomarker panel: pepsinogen I and II, gastrin-17 (basal and stimulated), and Helicobacter pylori (HP) antibodies (GastroPanel®, Biohit Oyj, Finland). On the basis of the biomarker test, the patients were classified into the HS (healthy stomach) group (n = 22) with the normal biomarker profile and the NHS (non-healthy stomach) group (n = 43). The classification of patients into HS and NHS was evaluated against the gold standard, i.e. EGDS with biopsies.ResultsThe concordance (Cohen’s kappa) between the biomarker test and gastric histology was 0.68; 95% CI 0.504–0.854, with an overall agreement of 84.6% (95% CI 73.9–91.4%). In the NHS group, all 43 patients had biopsy-confirmed chronic gastritis: 39 non-atrophic HP-gastritis, 4 atrophic antrum gastritis (AGA) of moderate severity.In the HS group only 6 patients had mild superficial H.pylori negative gastritis. Of the 22 HS subjects with the normal biomarker profile, 20 (31% of all 65) had no complaints either, while the remaining two had reflux symptoms with esophagitis. In the NHS group 10 patients had esophagitis and 8 had also reflux symptoms.ConclusionsThe normal biomarker profile is an excellent surrogate for healthy stomach, implicating that pre-operative EGDS could have been avoided in 31% of our asymptomatic bariatric surgery patients who had the normal biomarker profile.

Is preoperative gastroscopy necessary before sleeve gastrectomy and Roux-en-Y gastric bypass?

BackgroundConsensus on the necessity of esophagogastroduodenoscopy (EGD) before bariatric surgery is lacking. Recommendations and practices vary by country and unit. Several reports have expressed concerns on gastroesophageal reflux disease (GERD) and its consequences after sleeve gastrectomy (SG) and the risk of leaving a premalignant lesion in the excluded stomach after Roux-en-Y gastric bypass (RYGB). ObjectivesWe explored the number and types of clinically significant findings in preoperative EGDs and how they associate with preexisting GERD-symptoms (SG) and premalignant lesions (RYGB). We also studied how many reoperations were performed due to postoperative GERD in SG-patients. SettingUniversity hospital. MethodsWe investigated preoperative EGD-findings and gastrointestinal symptoms before bariatric surgery in all patients with a primary bariatric operation in our unit between December 2007 and May 2016. ResultsWe performed 1474 operations: 1047 (71.0%) RYGB, 407 (27.6%) SG, and 20 (1.4%) others. One thousand two hundred seventy-five (86.5%) preoperative EGD reports were analyzed: 647 (50.7%) EGDs were completely normal. Altogether, 294 patients (23.0% of total) had a clinically significant finding that was relevant for SG (hiatal hernia, esophagitis, Barrett’s esophagus, esophageal dysplasia), 144 (49.0%) of whom reported gastrointestinal symptoms. Twenty patients (1.6%) had a significant finding relevant for RYGB (peptic ulcer, atrophic gastritis, gastrointestinal stromal tumor), and 6 (30%) reported gastrointestinal symptoms. Thirteen (3.2%) SGs were converted into RYGB due to GERD. ConclusionsPreoperative EGD is indicated before SG but not before RYGB for asymptomatic patients without a risk for gastric pathology.

Erratum to: Is Routine Preoperative Esophagogastroduodenoscopy Screening Necessary Prior to Laparoscopic Sleeve Gastrectomy? Review of 1555 Cases and Comparison with Current Literature.

Erratum to: Is Routine Preoperative Esophagogastroduodenoscopy Screening Necessary Prior to Laparoscopic Sleeve Gastrectomy? Review of 1555 Cases and Comparison with Current Literature.

The utility of routine esophagogastroduodenoscopy before laparoscopic Roux-en-Y gastric bypass

BackgroundThe routine use of esophagogastroduodenoscopy (EGD) before laparoscopic Roux-en-y gastric bypass (LRYGB) is debatable. Various studies have reported high diagnostic yield of routine EGD before LRYGB to detect pathologies that could alter surgical management. However, other studies have found that preoperative EGD did not identify significant pathologies that changed clinical management; therefore, it is not indicated in asymptomatic patients. ObjectivesWe aimed to study the utility of routine EGD in patients before LRYGB. SettingAcademic teaching hospital, (Royal Alexandra Hospital, Canada). MethodsA retrospective review of patients undergoing LRYGB with 1 surgeon at our hospital from May 2014 to March 2016 was completed. EGD findings were compared with surgical gastrojejunal specimen pathology and postoperative complications. ResultsThere were 116 patients who underwent EGD before LRYGB with 113 reported EGDs, of which 46.0% were normal, 40.7% had findings that did not result in a change of management, and 13.3% had findings resulting in a change of management. In the gastrojejunal specimen, 16 patients (14.2%) were found to have chronic gastritis. The relative risk of patients having gastrojejunal gastritis was 5.1 (P<.0005) for patients with gastritis on EGD and 5.1 (P<.0005) for patients with Helicobacter pylori infection on EGD. After surgery, 18 patients (15.9%) had complications. Preoperative EGD findings were not associated with postoperative complications. ConclusionBased on the findings from this study, we recommend using less invasive screening in the routine workup of patients awaiting LRYGB and reserving EGD for symptomatic patients.

An alternative view on the necessity of EGD before sleeve gastrectomy

BackgroundEsophagogastroduodenoscopy (EGD) is particularly recommended for choosing a surgical method to be used with asymptomatic patients and for the assessment of symptomatic patients prior to sleeve gastrectomy. The presence of hiatal hernia, for instance, is a relative contraindication. EGD is used for malignancy scanning as well as surgical planning, but seems inefficient in determining postoperative complications. ObjectiveOur aim was to investigate the effectiveness of the pathological evaluation of endoscopic biopsies obtained with esophagogastroduodenoscopy (EGD) according to Sydney classification prior to sleeve gastrectomy in identifying the risk of staple line leak, independently of clinical diagnosis. SettingBakırköy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery. MethodsPatients who underwent laparoscopic sleeve gastrectomy between January 2014-December 2016 received preoperative EGD as per the clinic’s protocol and upon obtaining ethics board approval and patient consent. Biopsies were taken from the patients according to the Sydney protocol. The pathology results were examined retrospectively by considering the exclusion criteria. The results were given in line with the Sydney classification, and patients with and without Staple Line Leak were statistically compared. ResultsA total of 630 patients were enrolled in the study. Of these, 71.1% (n = 448) were female and 28.9% (n = 182) were male. Mean age was 38.9 years (17–68), mean body weight was 130.8kg (94–240) and body mass index (BMI) values were 47.4kg/m2 (36–106). In evaluation of median values, no statistically significant relationship was found between staple line leak and H. pylori occurrence grade (P = 0.438; P>0.05), activation grade (P = 0.568; P>0.05) or intestinal metaplasia grade (P = 0.319; P>0.05). Atrophy (P = 0.001; P<0.01) and chronic inflammation grade (P = 0.026; P<0.05) were significantly higher in Staple Line Leak patients. ConclusionsEGD prior to sleeve gastrectomy and biopsies obtained in line with the Sydney protocol predict Staple Line Leak risk.

Incidental Finding of Gastrointestinal Stromal Tumors during Laparoscopic Sleeve Gastrectomy in Obese Patients.

The frequency of incidental pathology found during laparoscopic bariatric surgery has been estimated to be 2%. Gastrointestinal stromal tumors (GISTs) are infrequent lesions and account for less than 1% of all digestive tract tumors. The reported incidence of this type of tumors during bariatric surgery is around 0.8%. The objective of this study was to evaluate incidence, characteristics, and evolution of incidentally found GISTs in patients undergoing laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity. A retrospective analysis from a prospectively collected database was conducted. Demographic data, clinical data, laboratory tests, preoperative esophagogastroduodenoscopy (EGD), postoperative pathology report from surgical specimen with tumor markers, and patient's outcomes were evaluated. From June 2006 to January 2014, 915 patients underwent LSG at our institution. Five (0.5%) patients were found to have incidental GIST. There were four (80%) women; average age was 59.6±6.3years (range 46-63). None of them had symptoms that served as orientation for preoperative diagnosis. EGD findings were non-suggestive of this pathology in any of these cases. Superficial chronic gastritis was the most common finding in the endoscopic biopsy (60%). All the tumors found in the surgical specimen were of low or very low risk of malignancy, with less than 5 mitoses per 50 fields, less than 2cm in diameter, and disease-free surgical margins. Cluster of differentiation (CD) 117 and CD 34 were positive in 100% of the cases. None of the patients required adjuvant therapy after the surgery. At 5-year follow-up, all patients were asymptomatic and disease free. The incidence of unsuspected GIST in LSG specimens in our series was low and similar to what has been reported. The lack of symptoms and the preoperative EGD findings were not suggestive of this diagnosis in any case. The degree of tumor malignancy was low in all patients and LSG was the definitive treatment, without recurrence at 5-year follow-up.

Left ventricular assist devices and gastrointestinal evaluation: Results of a consecutive case series

AimsTo evaluate the benefit of preoperative gastrointestinal endoscopic evaluation in patients undergoing continuous flow left ventricular assist devices (CF-LVADs) implantation. Methods and resultsA retrospective review of all fifty-three patients undergoing CF-LVADs at West-German Heart and Vascular Center, University of Duisburg-Essen was performed. A routine preoperative esophagogastroduodenoscopy was performed in seven patients to assess gastrointestinal (GI) bleeding. None of the patients had GI bleeding at the time. All patients received HeartWare CF-LVAD (HVAD, HeartWare Inc., Framingham, MA, USA). Six of the patients had relevant endoscopic findings and received therapy accordingly. None of these patients developed GI bleeding in the first 30days after CF-LVAD implantation. ConclusionPreoperative GI evaluation in patients undergoing elective CF-LVAD implantation might be beneficial in reducing GI bleeding postoperatively.

Efficiency of preoperative esophagogastroduodenoscopy in identifying operable hiatal hernia for bariatric surgery patients

BackgroundGastroesophageal reflux (GERD) is a symptom frequently found in obese patients, and often is related to the presence of a hiatal hernia (HH). Surgeons may evaluate for the presence of HH on esophagogastroduodenoscopy (EGD). However, preoperative endoscopic presence or absence of a significant HH does not always correlate with intraoperative findings. ObjectiveTo compare the rate of detection of repairable HH between clinical, endoscopic, and intraoperative methods SettingIndependent, university-affiliated teaching hospital MethodsA retrospective chart review of all consecutive patients who had undergone a primary bariatric procedure sleeve gastrectomy, gastric bypass, or biliopancreatic diversion/duodenal switch with routine preoperative EGD in a single institution from 2009–2013 was performed. Data points included the diagnosis of GERD/heartburn/proton pump inhibitor or histamine antagonist from history, the diagnosis of HH from preoperative EGD, and the diagnosis of HH intraoperatively that merited repair. Results1570 consecutive patients were included in the study. Eight hundred fifty-seven (55%) had diagnosis of GERD or heartburn, and 713 (45%) were asymptomatic (negative for GERD or heartburn). Hiatal hernia repair was performed in 153 (18%) patients with the diagnosis of GERD or heartburn and in 107 (15%) patients without the diagnosis of GERD and or heartburn. In all, 434 (28%) out of 1570 patients had a finding of HH on EGD; 204 (47%) were repaired. On endoscopy, 326 (75%) were defined as small, 87 (20%) as moderate, and 21(5%) as large HH. Of these, repairs were done on 128 (39%), 60 (70%), and 16 (76%). The sensitivity of detecting repairable HH by clinical indicators such as GERD or heartburn was 55% (P = .123) and sensitivity of EGD findings was 78% (P = .000). Specificity was 46% and 82%, respectively. ConclusionSmall HH are over-diagnosed with EGD, as most do not require repair. However, moderate and large HH are accurately detected.

Is Preoperative Esophagoduodenoscopy Required in all Patients Prior to Bariatric Surgery?

Introduction: Globally, the number of bariatric operations is steadily increasing. It has also been proven that obesity is associated with several diseases of the upper gastrointestinal tract. However, it remains unclear whether the preoperative diagnostic work-up prior to bariatric procedures should generally include esophagogastroduodenoscopy (EGD). The aim of this study is to clarify if subgroups of patients planned for bariatric surgery benefit from preoperative EGD. Methods: This retrospective study included 264 consecutive patients undergoing primary gastric bypass (199) or sleeve gastrectomy (65) between January 2004 and June 2012. EGD was performed in all patients before surgery. In patients with pathological findings (n = 220), a histological sample was obtained and analyzed. Results: Pathological findings were present in 79.1% of patients. The majority (78%) showed gastritis without clinical significance. These pathological findings were independent from the patients' body mass index, age, or se...

Usefulness of Upper Endoscopy for Pre-bariatric Surgery Clearance: A Look at a Predominantly Minority Population

Introduction: Obesity has reached epidemic proportions in the US. More than third the U.S population is estimated to have a BMI of > 30. As per CDC, the prevalence of obesity is highest in African Americans. The annual medical cost of obesity in the U.S. was estimated at $147 billion in 2008 U.S. dollars. In recent years, bariatric surgery is garnering increasing attention as a modality of weight reduction. From 1994 to 2005, there was a tenfold increase in the number of bariatric surgeries performed in the United States and it is expected to be one of the most common procedures in the next twenty years. Many physicians perform pre-operative esophagogastroduodenoscopy (EGD) before performing a bariatric surgery. Finding significant pathology on endoscopy could potentially alter the course of management and the patient's eligibility for bariatric surgery. However, due to a lack of studies the true efficacy of performing an endoscopy in this case remains unknown. Methods: In this retrospective study, we reviewed all upper endoscopies done for pre-operative evaluation of bariatric surgery over a period of two years from December 2012 to December 2014. Outcome data of endoscopic and pathological finding were analyzed. Results: 119 patients were included in the study. The average age was 39 years. 86.5% were female. 54.6% were African Americans and 13.4% were Hispanics. The average BMI was 48.7, 48.2 and 47.2 in the total population, African Americans and Hispanics respectively. Chronic gastritis was the most common finding on pathology (74.7% total study population, 76.9% African Americans and 68.7% Hispanics). 42.8% of total study population had reactive gastropathy which was more common in African Americans than in Hispanics (46.1% Vs 25 %). H. pylori was more common in Hispanics than African Americans (43.7% vs 35.3% respectively). Hiatus hernia was present in 28.5% of total population, 46.1% of African Americans and 18.7% of Hispanics. 10.9% of total population had gastric ulcers. All ulcers were superficial, white based and non-bleeding. 50% of the gastric ulcers had positive H. pylori. Intestinal metaplasia was found in 4.2 % of population. There was no significant difference in endoscopic and pathological finding in patients with BMI < 40 vs. 40-50 vs. > 50. Conclusion: This study appears to indicate an important role for upper endoscopy prior to bariatric surgery particularly in a minority population.

Hybrid push-pull endoscopic and laparoscopic full thickness resection for the minimally invasive management of gastrointestinal stromal tumors: a pilot clinical study.

Background. Gastric gastrointestinal stromal tumors (GISTs) that are predominantly endophytic or in anatomically complex locations pose a challenge for laparoscopic wedge resection; however, endoscopic resection can be associated with a positive deep margin given the fourth-layer origin of the tumors. Methods. Patients at two tertiary care academic medical centers with gastric GISTs in difficult anatomic locations or with a predominant endophytic component were considered for enrollment. Preoperative esophagogastroduodenoscopy (EGD), endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA), and cross-sectional imaging were performed. Eligible patients were offered and consented for hybrid and standard management. Results. Over ten months, four patients in two institutions with anatomically complex or endophytic GISTs underwent successful, uncomplicated push-pull hybrid procedures. GIST was confirmed in all resection specimens. Conclusion. In a highly selected population, the hybrid push-pull approach was safe and effective in the removal of complex gastric GISTs. Endoscopic resection alone was associated with a positive deep margin, which the push-pull technique manages with a laparoscopic, full thickness, R0 resection. This novel, minimally invasive, hybrid laparoscopic and endoscopic push-pull technique is a safe and feasible alternative in the management of select GISTs that are not amenable to standard laparoscopic resection.