Kshitij Kakar, MD, Vikas Singhal, MD, Leena Khaitan, FACS. University Hospitals- Case Medical Center, Cleveland.
INTRODUCTION: Obesity is a major medical problem in the United States (US). Prevalence of obesity is rising and according to the National Health and Nutrition Examination Survey in 2009-2010, 35.7% of US adults were obese. Minimally invasive bariatric surgery is becoming an increasingly important tool to combat this epidemic. The most commonly performed procedures include the Roux-EN-Y gastric bypass, laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding. Many patients may have pathology in the proximal gastrointestinal (GI) tract that is not clinically evident prior to bariatric surgery. Currently, preoperative endoscopic evaluation of the proximal GI tract is not the standard of care and is performed only selectively in most centers. The purpose of our study was to determine the diagnostic yield of routine esophagogastroduodenoscopy (EGD) before bariatric surgery and the extent to which this changes medical or surgical management.
METHODS: We performed a retrospective analysis of upper endoscopy reports, and operative and medical management of patients undergoing bariatric surgery during the period from January 2011- December 2012. Patient factors including age, sex, body mass index (BMI) and presence of upper GI symptoms were tabulated. Positive findings including esophagitis, gastritis, duodenitis, hiatal hernia and presence of ulcers or polyps were assessed. Patient charts were reviewed for the operative procedure performed as well as medical and surgical modifications based on the EGD findings.
RESULTS: Three hundred and twenty six patients (52 males and 274 females) underwent bariatric surgery during the period from January 2011- December 2012 (age 19-75 years). Of these, EGD reports were available for 260 patients who were included in the data analysis. 46 patients (17.7%) had established gastroesophageal reflux disease. The most common finding was presence of a hiatal hernia in 71 (27.3%) patients. Other findings included gastritis in 66 (25.4%), esophagitis in 33 (12.7%), polyps in 27 (2 esophageal, 23 gastric and 2 duodenal, 10.4%) duodenitis in 23 (8.8%), and ulcers in 8 (7 gastric and 1 duodenal, 3.1%) patients. 19 (7.3%) patients were hence placed on proton pump inhibitors before surgery. Findings of severe GERD prompted patients to be counseled for a Gastric bypass rather than the Sleeve gastrectomy. 34 patients (13.1%) had a hiatal hernia that required repaired at the time of their bariatric surgery. One patient was found to have a carcinoid tumor on the EGD and consequently underwent a lymph node dissection during surgery.
CONCLUSION: Preoperative EGD provides useful information in patients undergoing bariatric surgery and helps to diagnose previously unknown pathology. In our study 56 (21.5%) patients who had an EGD required some form of modification in management based on the endoscopy. The findings of our study suggest that routine EGD should become the standard of care in all patients undergoing bariatric surgery.