Adrian Dan, MD, Rathna Shenoy, MD, Jesse Clanton, MD, Michael Subichin, MD, Ashley Bohon, Marta Makusewski, Mark Pozsgay, MD, S M Thompson, MD, Arjun Venkataramani, MD, Corey Sievers, MD, John Zografakis, MD. Summa Health System.
Introduction:
Bariatric surgery is regarded as the most effective therapy in the treatment of morbid obesity and associated co-morbid conditions. The diagnosis of upper gastrointestinal pathology in bariatric patients is an essential component of the preoperative work up. Identifying such conditions preoperatively allows for proper preparation and avoidance of intraoperative pitfalls. In addition, the anatomical changes following some bariatric procedures render portions of the gastrointestinal tract inaccessible to surveillance endoscopic exams. A study was undertaken to determine the frequency of gross endoscopic and pathological diagnoses in a large sample of morbidly obese patients undergoing work-up for weight loss surgery as well as the association of such conditions and body mass index (BMI).
Methods:
This IRB approved study was conducted at a university-affiliated tertiary care center with a high volume bariatric program. Upper gastrointestinal endoscopy was routinely performed on all patients undergoing a preoperative bariatric work up by fellowship trained surgeons with extensive endoscopic experience. A retrospective chart review of 1,000 consecutive patients was performed, including both the dictated endoscopy report as well as pathology results. Data collected included age, sex, pre-operative BMI, gross descriptive endoscopic diagnoses and microscopic pathological diagnoses. Confidence intervals for proportions were calculated using a modified Wald method. Student’s T-test was used to determine associations between endoscopic findings and BMI.
Results:
One thousand consecutive patients were reviewed. Patients had a mean BMI of 48 Kg/m2 and 79% were female. Of this sample, 99% had at least one diagnostic finding on endoscopy, 90% had at least 2 diagnoses and 64% had 3 or more diagnoses. The most common gross descriptive finding was gastritis found in 63.1% of patients (95% CI 0.600, 0.660), while 52.9% of patients had a pathologic diagnosis of gastritis (95% CI 0.498, 0.560). Other common descriptive and pathologic abnormalities included: 23.3% hiatal hernia (95% CI 0.208, 0.260), 9.5% esophagitis (95% CI 0.078, 0.115), 2.4% peptic ulcer disease (95% CI 0.016-0.036), 3.7% duodenitis (95% CI 0.027, 0.051), 5.7% gastric erosions (95% CI 0.044, 0.073), 3.1% Barrett’s esophagus (95% CI 0.022, 0.044), 9.7% gastric polyps (95% CI 0.080, 0.117), 1.2% Schatski ring (95% CI 0.007, 0.021), 29.5% gastropathy (95% CI 0.268, 0.324), 15% foveolar hyperplasia (95% CI 0.129, 0.174), and 7.1% H. pylori infection (95% CI 0.057, 0.089). There was no significant difference between pre-operative BMI and any of the above endoscopy findings (all p-value >0.05)
Conclusions:
This is the largest study to date evaluating the incidence of upper GI pathology in the morbidly obese. Although upper GI pathology is ubiquitous in the morbidly obese population, BMI is not directly associated with abnormalities in this large sample of pre-operative patients. These findings emphasize the value of routine performance of pre-operative EGD on all bariatric surgery candidates.
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