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Guidelines released for endoscopy and bariatric surgery
The recommendations include specific indications for endoscopy.
The American Society for Gastrointestinal Endoscopy has issued guidelines for the use of endoscopy in both pre- and postoperative bariatric surgery patients. The guidelines are published in Gastrointestinal Endoscopy.
According to the guidelines, the number of weight-loss surgeries performed in the United States increased from 13,365 in 1998 to 102,794 in 2003 due to the growing prevalence of obesity and the success of surgical interventions.
“These guidelines were created to inform endoscopists about the current state of evidence concerning the role of endoscopy in patients who are being considered for bariatric surgery or are experiencing complications or other symptoms after their surgery,” Jason A. Dominitz, MD, MHS, chair of ASGE Standards of Practice, told Endocrine Today.
Preoperative patients
Endoscopists typically perform esophagogastroduodenoscopy in pre-bariatric surgery patients to detect or treat lesions that may affect the type of surgery performed, cause complications in the postoperative period or result in symptoms after surgery, according to the guidelines.
“Many health care professionals may not be aware of the value of considering endoscopy preoperatively as the surgery may make the management of common gastrointestinal diseases much more complex,” Dominitz said.
The need for upper endoscopy is often based on the presence of symptoms. Due to a limited amount of observational studies in patients without symptoms, the value of routine endoscopy in these patients is controversial. Though upper endoscopy in patients without symptoms may detect lesions with the potential to alter surgical management, no studies have evaluated the effect on surgical outcome, according to the guidelines.
The society found that 30% to 40% of patients scheduled for bariatric surgery present with Helicobacter pylori infection; therefore preoperative testing may be useful. The society also recommended noninvasive H. pylori testing and — if the test is positive — treatment in patients without symptoms who are not undergoing endoscopy.
Postoperative patients
In patients who have had bariatric surgery, the society recommended that endoscopists are aware of the operative procedure performed and the findings on preprocedural imaging studies. They should also understand the extent of resection and the length of surgically created limbs. The society also advised that endoscopists speak with the surgeon directly.
“Health care professionals caring for bariatric surgery patients should use these guidelines to help determine when to refer patients to endoscopists experienced with these patients in order for them to consider preoperative endoscopy or for the evaluation of suspected complications or other gastrointestinal signs and symptoms,” Dominitz said.
The society recognized the following indications for an endoscopy following gastric bypass or in patients with a previous bypass:
- Symptoms such as nausea, vomiting and abdominal pain;
- Marginal ulcers that may present with abdominal pain, bleeding or nausea;
- Gastroesophageal reflux disease, which occurs in 30% to 60% of bariatric patients;
- Fistulas which may present with marginal ulcers;
- Stenosis which is recommended to be identified using endoscopic visualization;
- Dumping syndrome;
- Bezoars which occur most commonly after gastric banding;
- Band slippage and erosion, which can occur after laparoscopic adjustable gastric banding;
- Acute or chronic bleeding and anemia;
- Diarrhea and nutritional deficiencies;
- Choledocholithiasis and endoscopic retrograde cholangiopancreatography;
- Weight regain; and
- Endoscopic treatments for obesity.
Recommendations after specific procedures
In the presence of leaks or tenuous anastomoses, air insufflations may have detrimental effects in patients in the early postoperative phase. When a leak is suspected, the society recommended that endoscopists consider contrast radiogprahy for initial diagnosis.
After Roux-en-Y gastrojejunal bypass, the pouch and suture line should be carefully examined for fistulas and ulcerations. The gastrojejunal stroma should also be assessed. Following sleeve gastrectomy, the staple line should be examined for defects and ulcerations, according to the guidelines.
After laparoscopic adjustable gastric band surgery, endoscopists should note the length of the pouch, as measured from the gastroesophageal junction to the impression of the band, to detect pouch dilatation or band slippage. According to the guidelines, the endoscopist should also look for the presence of band erosion into the gastric wall. – by Stacey L. Adams
Gastrointest Endosc. 2008;doi:10.1016/j.gie.2008.01.028.