July 25, 2008 The American Society for Gastrointestinal Endoscopy (ASGE) has issued guidelines on the role of endoscopy in the bariatric surgery patient. The rising prevalence of obesity in the United States and the success in surgical interventions led to a marked increase in the number of weight-loss surgeries performed in the U.S., from 13,365 in 1998 to 102,794 in 2003.
Endoscopy is a procedure that uses an endoscope, a thin, flexible tube with a light and a lens on the end to look into the esophagus, stomach, duodenum, small intestine, colon, or rectum, in order to diagnose or treat a condition. There are many types of endoscopy, including colonoscopy, sigmoidoscopy, gastroscopy, enteroscopy, and esophogogastroduodenoscopy (EGD).
The guideline, "Role of Endoscopy in the Bariatric Surgery Patient," was prepared by the ASGE Standards of Practice Committee. The guidelines discuss endoscopy in the preoperative patient and the postoperative patient, and appear in the July issue of GIE: Gastrointestinal Endoscopy.
"Obesity in this country is a major health problem that contributes to increased morbidity, mortality and a host of diseases. Bariatric surgery results in durable and significant weight loss," said Jason A. Dominitz, MD, MHS, chair of ASGE's Standards of Practice Committee. "Endoscopy plays an important role in the preoperative bariatric patient to detect and/or treat lesions in the gastrointestinal tract that might potentially affect the type of surgery performed. In addition, endoscopy is used to diagnose and treat many of the postoperative symptoms or conditions the patient may develop."
The role of upper endoscopy in the preoperative evaluation of patients undergoing bariatric surgery may be based, in part, on the presence or absence of symptoms. The rationale for performing an EGD is to identify and treat lesions that affect the type of surgery performed, cause complications in the immediate postoperative period, or result in symptoms after surgery.
When an endoscopy is considered in a patient who has had bariatric surgery, the endoscopist should be aware of the operative procedure performed, the findings on preprocedural imaging studies and they must understand the expected anatomy. The guidelines advise direct communication with the surgeon if possible. Endoscopy in the postoperative patient may be used to evaluate and treat a variety of conditions including: symptoms of nausea, vomiting and abdominal pain; marginal ulcers; gastroesophageal reflux disease (GERD); gastric leaks and gastrogastric fistulas; stenosis (abnormal narrowing of the stomach or intestine); dumping syndrome (rapid emptying from the stomach into the small bowel); bezoars (food that forms into a hard mass); band erosion or slippage; bleeding and anemia; diarrhea and nutritional deficiencies; choledocholithiasis (the presence or formation of gallstones); and weight regain.
Summary and recommendations
- Bariatric surgical intervention presents new challenges to the endoscopist:
- An upper endoscopy should be performed in all patients with upper-GI-tract symptoms who are to undergo bariatric surgery.
- Upper endoscopy should be considered in all patients who are to undergo a Roux-en-Y gastrojejunal bypass (RYGB), regardless of the presence of symptoms.
- In patients without symptoms and who are not undergoing an endoscopy, noninvasive H pylori testing followed by treatment, if positive, is recommended.
- In patients without symptoms and who were undergoing gastric banding, a preoperative upper endoscopy should be considered to exclude large hernias that may change the surgical approach.
- An endoscopic evaluation is useful for diagnosis and management of postoperative bariatric surgical symptoms and complications.
- An endoscopic retrograde cholangiopancreatography (ERCP) is difficult in patients who had a RYGB, and a magnetic resonance cholangiopancreatography (MRCP) should be performed in cases where other noninvasive imaging studies are inconclusive. An ERCP in RYGB patients should be selectively performed.
The ASGE Guideline, "Role of Endoscopy in the Bariatric Surgery Patient," is available at: http://asge.org/WorkArea/showcontent.aspx?id=4628
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