Routine Upper Gastrointestinal Research Articles

Routine Upper Gastrointestinal Series Post-bariatric Surgery: Predictors, Usage, and Utility.

To investigate usage and utility of routine upper gastrointestinal (UGI) series in the immediate post-operative period to evaluate for leak and other complications. Single institution IRB-approved retrospective review of patients who underwent bariatric procedure between 01/08 and 12/12 with at least 6-month follow-up. Out of 135 patients (23%) who underwent routine UGI imaging, 32% of patients were post-gastric bypass (127) versus 4% of sleeve gastrectomy (8). In patients post-gastric bypass, 22 were found with delayed contrast passage, 3 possible obstruction, 4 possible leak, and only 1 definite leak. In patients post-sleeve gastrectomy, 2 had delayed passage of contrast without evidence of a leak. No leak was identified in 443 patients (77%) who did not undergo imaging. The sensitivity and specificity of UGI series for the detection of leak in gastric bypass patients were 100% and 97%, respectively, and the positive and negative predictive values were 20% and 100%, respectively. On univariate and multivariate analysis, sleeve gastrectomy patients (OR 0.4 sleeve vs bypass; P < 0.01) and male patients (OR 0.4M vs F; P 0.02) were less likely to undergo routine UGI series (OR 0.4M vs F; P 0.02). Routine UGI series may be of limited value for the detection of anastomotic leaks after gastric bypass or sleeve gastrectomy and patients should undergo routine imaging based on clinical parameters. Gastric bypass procedure and female gender were factors increasing the likelihood of routine post-operative UGI. Further larger scale analysis of this important topic is warranted.

How many tests does it take? Minimizing preoperative testing prior to surgical placement of gastrostomy tubes in children.

Gastrostomy tubes (GTs) provide life-saving enteral access for children. Although upper gastrointestinal (UGI) series and impedance studies (ISs) detect gastroesophageal reflux disease (GERD) or malrotation, their benefit for preoperative evaluation of asymptomatic patients requiring GT placement is controversial. This study investigated the value of routine preoperative testing and whether specific patient characteristics could guide the selective use of these studies. The charts of children who underwent GT placement from 2003 to 2019 were reviewed retrospectively. Demographics, preoperative evaluation, and postoperative course were evaluated. Three hundred forty-three patients underwent GT placement, 61% with preoperative testing. Seven of 190 UGI (4%) series demonstrated malrotation, and 39 of 141 (28%) ISs revealed severe GERD. Although all malrotations were surgically addressed, only 59% (23/39) of IS-proven GERD cases prompted simultaneous fundoplication. Age <1 year was associated with a positive UGI series (6.7% positive vs 1.0%; P < 0.05), but no other patient characteristics were associated with either positive UGI series or IS. Elimination of the 96% of UGI series that did not alter care represented a cost savings of $89,487-$229,665 and avoided the radiation exposure from testing; elimination of the 84% of ISs that did not alter eventual treatment would have saved $127,776-$266,563. Routine preoperative evaluation with UGI series and IS can increase healthcare costs without substantially altering care. The only patients potentially benefiting from routine UGI series were <1 year old. Instead, a targeted, symptom-based preoperative evaluation may streamline the process by decreasing preoperative testing and minimizing cost and radiation exposure.

Prevalence of Asymptomatic Hiatal Hernia in Obese Patients During Preoperative Upper Gastrointestinal Endoscopy Assessments and Correlation With Body Mass Index.

IntroductionIn obese patients, hiatal hernia (HH) can be asymptomatic or may present with one or few symptoms, such as heartburn, nausea, or vomiting. Routine upper gastrointestinal (GI) endoscopy is the most frequent method used to determine the presence of any abnormalities, including HH. This study aimed to assess the prevalence of asymptomatic HH in obese patients during routine upper GI endoscopy assessments and to examine the correlation with body mass index (BMI).Materials and methodsThis was an observational, retrospective cohort study conducted at King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia. The data were extracted from the medical records and electronic charts of all obese patients who underwent preoperative upper GI endoscopy assessment between January 2017 and December 2019. Data were tabulated in Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) Version 21 (IBM Corp., Armonk, NY, USA).ResultsAmong the 690 obese patients, HH was found in 103 (14.9%) patients. The chi-square test revealed that abdominal pain (X2=3.885; p=0.049), shortness of breath (X2=8.057; p=0.005), vomiting (X2=4.302; p=0.038), nausea (X2=4.090; p=0.043), and other HH symptoms (X2=3.897, p=0.048) were the most frequently reported HH related symptoms, but BMI was not (X2=2.126; p=0.345). In the multivariate regression model, the use of PPI (proton-pump inhibitor) medication (adjusted OR [AOR]=0.237; 95% CI=0.074-0.760; p=0.023) was found to be higher in those with HH. Vomiting (AOR=1.722; 95% CI=1.025-2.890; p=0.040) and nausea (AOR=1.698; 95% CI=1.012-2.849; p=0.045) were the most frequently reported symptoms related to HH.ConclusionAsymptomatic HH among obese patients is not widely prevalent in our region. The use of PPI medications was found to decrease the symptoms associated with HH, such as vomiting and nausea. However, there was no evidence linking BMI to the development of HH.

Deep learning-based anatomical site classification for upper gastrointestinal endoscopy

PurposeUpper gastrointestinal (GI) endoscopic image documentation has provided an efficient, low-cost solution to address quality control for endoscopic reporting. The problem is, however, challenging for computer-assisted techniques, because different sites have similar appearances. Additionally, across different patients, site appearance variation may be large and inconsistent. Therefore, according to the British and modified Japanese guidelines, we propose a set of oesophagogastroduodenoscopy (EGD) images to be routinely captured and evaluate its efficiency for deep learning-based classification methods.MethodsA novel EGD image dataset standardising upper GI endoscopy to several steps is established following landmarks proposed in guidelines and annotated by an expert clinician. To demonstrate the discrimination of proposed landmarks that enable the generation of an automated endoscopic report, we train several deep learning-based classification models utilising the well-annotated images.ResultsWe report results for a clinical dataset composed of 211 patients (comprising a total of 3704 EGD images) acquired during routine upper GI endoscopic examinations. We find close agreement between predicted labels using our method and the ground truth labelled by human experts. We observe the limitation of current static image classification scheme for EGD image classification.ConclusionOur study presents a framework for developing automated EGD reports using deep learning. We demonstrate that our method is feasible to address EGD image classification and can lead towards improved performance and additionally qualitatively demonstrate its performance on our dataset.

Modifiable Factors to Prevent Prolonged Length of Stay after Sleeve Gastrectomy

Early discharge after laparoscopic sleeve gastrectomy (SG) is common and safe, but two-thirds of patients are still hospitalized longer than 1day. The purpose of this study was to evaluate factors associated with early discharge at a single institution with intention to discharge on postoperative day 1. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing SG at an academic hospital between 2010 and 2016. The primary outcome measure was length of stay (LOS). Multivariate logistic regression was used to identify independent predictors of prolonged LOS. A total of 367 patients undergoing SG were included. Two hundred eighty-seven (78%) were women and 294 (80%) were Caucasian. Mean age was 45.5years and mean body mass index (BMI) was 48.7kg/m2. One hundred twenty-three patients (33.5%) had a LOS ≤ 1day. Compared to patients staying ≥ 2days, early discharge patients had significantly lower BMI, creatinine, and American Society of Anesthesiologists class, were more likely to be White, married, haveprivate insurance, and were more likely to have a morning start and no postoperative upper gastrointestinal (UGI) swallow study. Regression analysis demonstrated several independent predictors of prolonged LOS including institutional experience (OR 0.5, p < 0.001), case start time (OR 0.6, p = 0.04), and routine UGI swallow (OR 8.8, p < 0.0001) postoperatively. LOS after SG is affected by multiple factors, including patient health, socioeconomic status, case order, and postoperative management. Optimization of these may allow for improvement in preoperative education and streamlined postoperative pathways, resulting in reduced LOS.

Utility of Immediate Postoperative Upper Gastrointestinal Contrast Study in Bariatric Surgery.

Routine use of postoperative upper gastrointestinal (UGI) contrast studies after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) is controversial. We sought to determine the usefulness of routine UGI contrast studies during postoperative day (POD) 1 in patients who underwent bariatric surgery. We performed a retrospective study of patients who underwent SG or RYGB between January 1, 2016, and October 31, 2017. Demographics, surgical data, and immediate surgical adverse effects were collected. We compared patients who underwent routine UGI contrast studies on POD 1 versus patients who did not. A total of 284 patients were analyzed; 197 (69.4%) patients underwent RYGB, while 87 (30.6%) underwent SG. Routine UGI contrast study was performed in 96 (48.7%) patients in the RYGB group versus 31 (35.6%) in the SG group. The overall adverse effect rate was 2 (0.7%); postoperative UGI contrast study was negative in both cases. Mean (SD) length of stay (LOS) for patients who underwent UGI contrast study versus those who did not was similar in the RYGB group (1.8 [1.6] days vs 1.8 [0.9] days, respectively) and the SG group (2 [1.18] days vs 1.9 [0.9] days). The average cost of a postoperative UGI contrast study was $600, resulting in an additional overall cost of $76,800. Use of routine UGI contrast studies after bariatric procedures does not appear to add clinical value for the detection of leaks. Furthermore, systematic use of postoperative UGI contrast studies neither seem to reduce LOS, nor appear to increase procedure costs.

Identification of clinical parameters to increase the diagnostic yield of the non-emergent upper gastrointestinal series in pediatric outpatients.

Outpatient, non-emergent upper gastrointestinal (GI) series are frequently requested in children with no surgical history who have nonspecific symptoms such as abdominal pain, failure to thrive and vomiting. The positive yield of an upper GI series in these patients, and, thus, its utility, has not been studied. We evaluated the incidence of positive upper GI findings in children without a history of GI pathology or abdominal surgery in order to identify clinical indications associated with a greater diagnostic yield. Findings of upper GI series performed between October 2015 and October 2017 in three institutions in children younger than 18years of age were retrospectively reviewed. The upper GI series protocol for each institution was also reviewed. Children with a medical or surgical GI history, children with insufficient history in the chart and those with an incomplete upper GI series were excluded from the study. Exam indications, patient demographics and clinical history were obtained from the electronic medical records. Of 1,267 children who underwent outpatient upper GI series, 720 (median age: 2years) had no GI history and were included in the study. The most common indications were non-bilious vomiting (62%), reflux symptoms (28%) and abdominal pain (20%). Upper GI series were normal in 605/720 cases (84%), including 25/26 children with reported bilious emesis. Of the 115 positive studies, 78 (68%) showed only gastroesophageal reflux (GER) (median age: 11months). Of the remaining 37 studies, 19 demonstrated esophageal findings. One case of malrotation without midgut volvulus was identified in a patient who presented with dysphagia and reflux symptoms. Using a multinomial logistic regression model and adjusting for other variables, reflux symptoms and younger patient age were independent predictors of GER on upper GI series (relative risk ratios of 2.2 and 0.9, respectively). Dysphagia and/or foreign body sensation and older patient age were independent predictors of the presence of esophageal findings (relative risk ratios of 3.3 and 1.1, respectively). The yield of routine upper GI series in children with nonspecific symptoms, such as abdominal pain and vomiting, and no surgical history is low. Diagnostic yield was improved in older children and in those complaining of dysphagia and/or foreign body sensation. Routine upper GI series should be avoided in clinically well children with symptoms only of uncomplicated GER and no significant GI history. In children with a history of dysphagia and/or foreign body sensation, an esophagram/barium swallow can suffice.

Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy

BackgroundGastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient. ObjectiveDetermine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population. SettingUniversity hospital, France, public practice. Material and methodsThis study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies. ResultsA total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1–245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0–86). Uniform gastric shape was acquired after 30–32 SG procedures. ConclusionRoutine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.

Eliminating routine upper gastrointestinal contrast studies after sleeve gastrectomy decreases length of stay and hospitalization costs

BackgroundRecent series have shown the lack of value of routine upper gastrointestinal (UGI) contrast studies on postoperative day 1 or 2 for the detection of gastric leak (GL) after sleeve gastrectomy (SG). Despite this finding, many centers still perform routine early UGI contrast studies after SG. No series has evaluated the impact of eliminating this examination on the overall management of patients undergoing SG. ObjectivesTo evaluate the impact of UGI contrast studies on SG management. SettingUniversity hospital, France, public practice. MethodsThis study was an ambispective study of a cohort of patients who underwent primary SG between January 2014 and December 2014 (n = 267). Two consecutive groups were compared: patients with routine UGI contrast studies on postoperative day 1 (UGI+group, n = 154) and patients without routine UGI contrast studies (UGI−group, n = 113). The efficacy endpoint of the study was the overall impact of not performing routine UGI contrast studies (length of hospital stay, radiological data, rehospitalization data, and economic assessment). ResultsThe overall complication rate was 9.3% and no deaths were observed. The GL rate was 1.5%. The mean hospital stay was 1.8 days (2.1 days versus 1.5 days; P = .57). Routine UGI contrast studies did not detect any cases of GL or gastric stenosis. After UGI contrast studies, 56 patients complained of events related to UGI contrast studies (36.4%). A total of 27 computed tomography scans were performed during the first 3 postoperative months (16 in the UGI+group (10.4%) versus 11 in the UGI−group (9.7%); P = .52). Twelve patients were rehospitalized (7 and 5; P = .6). The median length of rehospitalization was 7 days (7 and 5 days; P = .6). Overall cost per patient during SG hospitalization was $5,219 in the UGI+group and $3,678 in the UGI−group (P = .01). ConclusionEliminating routine UGI contrast studies was associated with decreased length of hospital stay and cost of SG procedures. Larger series are required to show that not performing routine UGI contrast studies has no impact on the postoperative complication rate and the management of these complications.

Should We Perform Routine Upper Gastrointestinal Endoscopy Before Cholecystectomy?

In some patients, there is not any symptomatic relief after cholecystectomy due to the overlap of the symptoms of biliary and gastroduodenal pathologies known as postcholecystectomy syndrome. The aim of this study was to assess the effectiveness of upper gastrointestinal (UGI) endoscopy in reducing the possibility of postcholecystectomy syndrome. This retrospective study was conducted in 194 cases. In patients sampled for histopathologic examination, screening for Helicobacter pylori and intestinal metaplasia was carried out with Giemsa stain and PAS–Alcian stain. Patients who did not undergo UGI endoscopy before operation were designated as Group A (n = 100) and those who underwent routine UGI endoscopy before operation were called Group B (n = 94). Symptomatic relief after cholecystectomy and endoscopic findings were evaluated. Thirty-one of the 39 patients diagnosed with H. pylori, underwent eradication treatment. Seven of the 31 patients undergoing H. pylori eradication during the preoperative period had ongoing symptoms at the postoperative period. On the other hand, only 2 of 8 patients who did not undergo H. pylori eradication during the preoperative period had unremitting symptoms during the postoperative period. Only three of 100 patients who did not receive a UGI endoscopy during the preoperative period had unremitting symptoms during the postoperative period. The main outcome of the study is to evaluate the necessity of performing routine UGI endoscopy before cholecystectomy. Our results show that it is not necessary, because if you take biliary colic as the one and only symptom of indication for cholecystectomy, the ratio of postcholecystectomy syndrome is 3% to 5% and the reason is 50% organic.

Upper Digestive Endoscopy Prior to Bariatric Surgery in Morbidly Obese Patients - A Retrospective Analysis

Aim: Obesity has become one of the world’s major public health problems. It is now accepted that bariatric surgery is a far better option than nonsurgical treatments for morbid obese patients. Routine upper gastrointestinal (GI) endoscopy as a complementary method for evaluation of bariatric patient’s status prior to surgery is still a matter of debate. Aim of the study was to evaluate the importance of routine upper GI endoscopy before bariatric surgery. Material and methods: A clinical retrospective study was carried out on a series of 77 patients referred for bariatric surgery between 2012 and 2015 in our surgical unit. We reviewed the medical records of all patients, endoscopy diagnosis, histopatological reports on gastric endoscopic biopsies and the colonisation with H. pylori. Result: The patients in our study had a median age of 39.25 years and a BMI (body mass index) ranging from 33.3 to 60.5 kg/m2 (median of 44.66 kg/m2). Upper GI endoscopy was performed in all patients before bariatric surgery, regardless of upper gastrointestinal simptomatology. Chronic gastritis was found on upper GI endoscopy prior to bariatric surgery in 36.3% of cases and Helicobacter pylori infection was identified in 26% of cases. 6.5% of the patients were diagnosed with hiatal hernia, a hyperplastic gastric polyp, a intragastric pancreatic tissue ectopy and a case of gastric cancer were also detected. Conclusion: Although preoperative endoscopy rarely diagnose pathological conditions that may change the surgical approach, we believe that, for a complete work-out of these patients, gastroenterology consultation and upper GI endoscopy should be mandatory prior to bariatric surgery.

Methylene Blue or Upper GI, Which is More Effective for Detecting Leaks in Gastric Bypass Patients?

Postoperative leaks from the staple lines are a serious complication after laparoscopic Roux-en-Y gastric bypass (RYGB) that results in morbidity and could even lead to mortality. Bariatric surgeons have several tools to assess this adversity. There have been debates as to which method is more superior and furthermore whether these methods should be routinely or selectively used. The aim of our study is to evaluate and compare whether methylene blue or upper gastrointestinal (UGI) study is more effective in detecting an anastomotic leak after RYGB. Between May 2013 and March 2014, 119 patients underwent laparoscopic RYGB. Linear staplers were used to create the gastrojejunostomy and the jejunojejunostomy. All patients underwent routine UGI studies and methylene blue challenges on postoperative day 1. A retrospective review of a prospectively collected database was performed for all patients. Of the 105 patients in this study there were 83 females (79.0%) and 22 males (21.0%). Mean age was 45.2±10.7 years (range, 21 to 66 y) and mean preoperative body mass index was 47.8±7.9 kg/m (range, 35.7 to 76.4 kg/m) at the time of procedure. Mean length of hospital stay was 3.2±6.0 days (range, 1 to 53 d).Four (3.8%) patients were found to have leaks postoperatively, but no leakage was detected in any of the initial routine UGI studies or methylene blue challenges. Both patient were diagnosed with clinical signs and underwent oversewing of the leak sites. UGI studies and methylene blue challenges had no significant difference in detecting a postoperative leak. Furthermore, these tests may have limited utility and may warrant adjuncts to aid in leak detection.

The utility of radiological upper gastrointestinal series and clinical indicators in detecting leaks after laparoscopic sleeve gastrectomy: a case-controlled study.

Leak after laparoscopic sleeve gastrectomy (LSG) often presents after hospital discharge, making timely diagnosis difficult. This study evaluates the utility of radiological upper gastrointestinal (UGI) series and clinical indicators in detecting leak after LSG. A retrospective case-controlled study of 1762 patients who underwent LSG from 2006 to 2014 was performed. All patients with radiographically confirmed leaks were included. Controls consisted of patients who underwent LSG without leak, selected using a 10:1 case-match. Data included baseline patient characteristics, surgical characteristics, and UGI series results. Clinical indicators including vital signs, SIRS criteria, and pain score were compared between patients who developed leak and controls. Of 1762 LSG operations, 20 (1.1%) patients developed leaks and were compared with 200 case-matched controls. Three patients developed leak during their index admission [mean=1.3days, range (1, 2)], while the majority (n=17) were discharged and developed symptoms at a mean of 17.1days [range (4, 63)] postoperatively. Patients diagnosed with leak were similar to controls in baseline and surgical characteristics. Contrast extravasation on routine postoperative UGI identified two patients with early leaks, but was negative in the remainder (89%). Patients with both early and delayed leaks demonstrated significant clinical abnormalities at the time of leak presentation, prior to confirmatory radiographic study. In multiple regression analysis, independent clinical factors associated with leak included fever [OR 16.6, 95% CI (4.04, 68.10), p<0.0001], SIRS criteria [OR 7.0, 95% CI (1.47, 33.26), p=0.014], and pain score ≥9 [OR 19.1, 95% CI (1.38, 263.87), p=0.028]. Contrast extravasation on routine postoperative radiological UGI series may detect early leaks after LSG, but the vast majority of leaks demonstrate normal results and present 2-3weeks after discharge. Therefore, clinical indicators (specifically fever, SIRS criteria, and pain score) are the most useful factors to raise concern for leaks prior to confirmatory radiographic study and may be used as criteria to selectively obtain UGI studies after LSG.

Experience of imaging following laparoscopic sleeve gastrectomy.

We aimed to report our experience with upper gastrointestinal (UGI) contrast studies and computed tomography (CT) swallow studies after laparoscopic sleeve gastrectomy, and comment on the merits of each modality. Retrospective review of all patients undergoing laparoscopic sleeve gastrectomy (LSG) in a New Zealand hospital between 2011 and 2014 was conducted. Over this time period, routine UGI was replaced by CT swallow studies. All medical records and radiology were reviewed and pertinent findings reported. Seventy-nine patients underwent LSG over this time period and one patient had to be excluded; 48 (61.5%) had a UGI study and 30 patients (38.5%) had CT swallow. There were no leaks in this study and no leaks became clinically significant. Sixteen of 30 patients (53.3%) undergoing CT swallow had significant incidental findings demonstrated on axial imaging that required follow-up. CT swallow can provide the same information as a UGI but has a significant rate of incidental findings. The rate of incidental pathology on CT is higher than that quoted in the general population. In a bariatric population, this may allow early detection and treatment of co-existent pathology.

Diagnostic Yield and Clinical Implications of Preoperative Upper Gastrointestinal Endoscopy in Morbidly Obese Patients Undergoing Bariatric Surgery.

Upper gastrointestinal (UGI) endoscopy in patients undergoing bariatric surgery is controversial. It is recommended routinely by some authors to detect benign or malignant pathology that mostly remains asymptomatic. Others recommend selective use, suggesting not much impact on surgical management of detected pathology, especially in asymptomatic patients. The aim of this study was to evaluate the diagnostic yield and impact of pathological findings on routine UGI endoscopy before bariatric surgery in a cohort of morbidly obese Indian patients. We retrospectively reviewed preoperative screening UGI endoscopy reports of 283 patients who underwent bariatric surgery from February 2012 to August 2014. Data were collected on clinical information, UGI endoscopic findings, Helicobacter pylori testing, and management. Ten patients gave a history of gastroesophageal reflux, and the rest had no specific UGI complaints. Fifty-four had no abnormal findings. One hundred ninety-six had a lax lower esophageal hiatus, hiatal hernias of <5 cm, Grade I-II esophagitis, or mild to moderate gastritis or duodenitis that did not have an impact on surgery. Thirty-one had severe erosive gastritis or duodenitis, or polyposis that delayed surgery for treatment and review of biopsies. A large hiatal hernia >5 cm changed surgical plan to Roux-en-Y gastric bypass from a sleeve gastrectomy in 2 cases. None had varices or malignancy. Preoperative UGI endoscopy yielded a high proportion of endoscopic abnormalities even in asymptomatic patients. Surgery was delayed to treat severe mucosal lesions and to investigate polypoidal findings in the majority. A change in surgical approach and surveillance for malignancy was needed in a few cases.

The utility of routine postoperative upper gastrointestinal swallow studies following laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) has grown in popularity in recent years for the treatment of morbid obesity. Controversy exists regarding the usefulness of upper gastrointestinal (UGI) swallow studies on the first postoperative day in detecting possible complications. The aim of our study was to determine the efficacy and cost benefit of routine UGI studies on the first postoperative day following LSG. We retrospectively reviewed the hospital's records to identify patients who underwent LSG between January 2012 and June 2013. All patients had iodine-based contrast swallow study on the first postoperative day. Reports from all imaging studies and medical files were retrospectively reviewed, and complications were recorded. The Institutional Review Board waived the requirement for informed consent. During the study period, 722 patients underwent LSG. Mean BMI was 43 kg/m(2) (range 25-70). Of the 722 UGI studies, 721 were normal. The 1 abnormal study showed complete obstruction due to an incarcerated hiatal hernia. Five patients presented with a leak (0.7%). UGI swallow studies failed to detect any of the leaks resulting in a sensitivity of 0%. All leaks were apparent on computed tomography (CT) scans on postoperative days 2, 5, 7, 23, and 90. The total cost of the UGI swallow studies was $180,500. Performing routine UGI studies on the first postoperative day following LSG is clearly not cost beneficial. UGI contrast studies are not efficient to screen for suture line leaks. We recommend obtaining a CT scan when there is clinical suspicion for a complication.

Laparoscopic prosthetic hiatal reinforcement for large hiatal hernia repair

Large hiatal hernia (LHH) is defined by a hiatal defect larger than 6cm; repair is indicated whenever it becomes symptomatic. As the risk of recurrence after most techniques is relatively high, laparoscopic repair with prosthetic reinforcement of the hiatus has been proposed to reduce the recurrence rate. Our technique and outcomes are reported. Laparoscopic prosthetic hiatal reinforcement was performed in 58 patients between August 1997 and October 2009. Prolene(®), Mersilene(®), Goretex(®), and Parietex(®) were the four types of prosthetic material used. Since January 2004, the double-sided V shaped Crurasoft(®) mesh was introduced. Surgical evaluation was based on anatomical and functional criteria: the anatomical results included the presence of recurrent hiatal hernia or esophageal stricture as evaluated by an upper gastrointestinal (UGI) series; functional evaluation was based on a questionnaire concerning long-term patient satisfaction according to the Visick score. Median follow-up was 51 months. Postoperative UGI series were performed during the initial hospitalization in 37 patients: results were judged to be satisfactory. A routine follow-up UGI series was obtained at 8 months and one year in 46 patients. Two patients underwent reoperation for lower esophageal stricture at 6 months and 16 months. Forty-five patients (77.6%) were reevaluated. Of these, 29 patients (64.4%) were free of symptoms with a good quality of life, eight patients (17.7%) complained of moderate dysphagia and two patients (4.4%) had severe dysphagia. Four patients (8.9%) had moderate pyrosis while severe pyrosis requiring long term PPI treatment was observed in three patients (6.7%). No prosthesis-induced ulceration or perforation was noted. Late follow-up UGI series, performed in 21 patients, showed two patients with severe stricture and a single case of recurrence, but neither of these patients required surgical management. The addition of mesh reinforcement to surgical repair of large hiatal defects is safe and beneficial in terms of quality of life.

Utility of Routine Versus Selective Upper Gastrointestinal Series to Detect Anastomotic Leaks After Laparoscopic Gastric Bypass

In up to 4% of laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures, anastomotic leaks occur. Early detection of gastrointestinal leakage is important for successful treatment. Consequently, many centers advocate routine postoperative upper gastrointestinal (UGI) series. The aim of this study was to determine the utility of this practice after LRYGB. Eight hundred four consecutive patients undergoing LRYGB from June 2000 to April 2010 were analyzed prospectively. The first 382 patients received routine UGI series between the third and fifth postoperative days (group A). Thereafter, the test was only performed when clinical findings (tachycardia, fever, and drainage content) were suspicious for a leak of the gastrointestinal anastomosis (group B; n = 422). Overall, nine of 804 (1.1%) patients suffered from leaks at the gastroenterostomy. In group A, four of 382 (1%) patients had a leak, but only two were detected by the routine UGI series. This corresponds to a sensitivity of 50%. In group B, the sensitivity was higher with 80%. Specificities were comparable with 97% and 91%, respectively. Routine UGI series cost only 1.6% of the overall costs of a non-complicated gastric bypass procedure. With this leak rate and sensitivity, US $86,800 would have to be spent on 200 routine UGI series to find one leak which is not justified. This study shows that routine UGI series have a low sensitivity for the detection of anastomotic leaks after LRYGB. In most cases, the diagnosis is initiated by clinical findings. Therefore, routine upper gastrointestinal series are of limited value for the diagnosis of a leak.

Should inspection of the laryngopharyngeal area be part of routine upper gastrointestinal endoscopy? A prospective study

Examination of the laryngopharyngeal area is not always performed during routine upper gastrointestinal (UGI) endoscopy although initial studies reported pathological findings in 0.9-3.5% of cases. The aim of this study was to prospectively evaluate the accuracy of screening the laryngopharyngeal area during routine UGI endoscopy, before insertion of endoscope into the oesophagus, to avoid a misinterpretation of trauma-related hyperaemia or erythema as signs of laryngitis. The study included 1297 patients undergoing elective UGI endoscopy, asymptomatic in the laryngopharyngeal area, who underwent a carefully structured examination of the laryngopharyngeal area, videotaped for later blinded review. If pathological findings were suspected, patients were referred to otorhinolaryngologists for additional evaluation. In all cases the DVDs were reviewed by two ear, nose, and throat (ENT) specialists blinded to the endoscopic findings. In 1130 (87.12%) patients the examination was performed successfully before insertion of the endoscope into the oesophagus. Gastro-oesophageal reflux disease (GORD) symptoms were present in 254 (22.5%) patients, and erosive oesophagitis was documented in 89 (7.9%) patients. In 44 (3.89%) patients the pathology was suspected by the endoscopist and confirmed by the otorhinolaryngologists. Moreover, 8 (0.71%) patients were found to have laryngeal pathology in the DVDs reviewed by the ENT specialists, further confirmed by laryngoscopy. Sensitivity, specificity, positive, and negative predictive values were 84.61%, 100%, 100%, and 99.26%, respectively, for detecting laryngeal abnormalities by the endoscopist. The most important findings were leukoplakia (n=4), posterior laryngitis (n=16), Reinke's oedema (n=2), and hyperkeratosis of arytenoid folds (n=2). A strict correlation emerged between GORD and posterior laryngitis (75%) and between GORD and Reinke's oedema (100%), documented by pHmetry. A significant association was also observed between heavy smoking and leukoplakia (75%), and hypertrophy of pharyngeal tonsils (100%), respectively. All other findings were lesions without clinical significance. Screening examination of the laryngopharyngeal area should be part of each UGI endoscopy revealing important laryngeal pathology.

Use of upper gastrointestinal studies after laparoscopic gastric bypass

We appreciate the interest of Rodriguez-Cuellar et al. in our previous publication [1]. Their insightful comments underscore the controversy about routine radiological tests after laparoscopic Roux-en-Y gastric bypass (LRYGB). We agree that computed tomography (CT) scan has better sensitivity and specificity than upper gastrointestinal (UGI) studies, partly due to the modality and partly due to radiologist experience. Unfortunately, many of our patients cannot fit into our current CT scan machine, and we are fortunate to have an experienced radiologist to help with our UGI studies. Another excellent point brought up by the authors is that leak rates after LRYGB in experienced hands is low (under 1%). We have seen the learning curve effect ourselves when our first 300 LRYGB cases were examined [2]. In our personal experience, UGI studies may not have ‘‘helped’’ in the last year due to the lack of any leaks after LRYGB. However, even with a low incidence, a leak carries a 50% mortality. The cost in terms of human life and dollars due to a leak cannot be ignored. Early diagnosis can and will decrease mortality and morbidity. From our data, routine UGI series can help in this early diagnosis. Clinical signs and symptoms may not be enough to diagnose all leaks early, but neither are UGI studies; they are just another piece of data to help guide clinical care. Some ‘‘late’’ leaks probably start ‘‘slowly’’ when clinical signs and symptoms do not suggest any issues. In these patients, UGI may be helpful. How many of these patients exist? Fortunately, I do not have enough leaks to give you an exact incidence. We have had patients with no or few clinical signs that had a positive UGI which led to early operative treatment (\24 hours after surgery) with no resulting major morbidity after their reoperation. I do not know what would happen if there was a delay in the diagnosis. To be honest, as Rodriguez-Cuellar et al. suggested, leak rates are under 1%. Due to low rates, sensitivity rates may not be precise, thus the large variation reported in the literature. One should not feel that UGI study can take the place of good clinical judgment. Again, UGI study should be examined as an important but not the only piece of data. The reason we still perform routine UGI studies after LRYGB is that in some cases an UGI study may diagnose a leak before clinical signs and symptoms become obvious. The reason not to perform routine UGI studies is cost and patient discomfort. The cost of a delayed diagnosis of a leak needs to be considered when performing only selective UGI studies. Due to the current controversy, standard of care still involves either routine or selective UGI studies after LRYGB. Our personal recommendation is to utilize UGI studies routinely at least for surgeons in their learning curve. To suggest that UGI studies are not needed for this group of surgeons seems a bit nonchalant since a leak is a major cause of mortality after LRYGB. Even in experienced hands, an UGI study may help avoid the disastrous consequences of a delay in diagnosis of a leak after LRYGB. A. K. Madan (&) H. H. Stoecklein D. S. Tichansky Department of Surgery, University of Tennessee Health Science Center, 956 Court Ave., Room G210, Memphis, TN 38163, USA e-mail: amadan@utmem.edu