Surgery for Obesity and Related Diseases ] (2015) 00–00
Letter to the Editor
In 2014, the manuscript titled “Is Esophagogastroduodenoscopy Before Roux-en-Y Gastric Bypass or Sleeve Gastrectomy Mandatory?” was published in Surgery for Obesity and Related Disease and concluded that preoperative detection of upper digestive tract disease by means of esophagogastroduodenoscopy (EGD) is not necessary because its yield is very low [1]. However, for some of the short- and long-term postoperative complications, such as anastomotic leakage or marginal ulceration, conditions found at EGD such as gastritis or preoperative ulcers could be of influence [2,3]. Therefore, the aim of this additional study was to investigate whether preoperatively discovered abnormalities at EGD screening had any influence on shortterm (within 30 d) and/or long-term postoperative complications.
46.5 kg/m2) before primary LRYGB or LSG. As previously published, in 266 patients (51.1%) at least 1 abnormality was discovered, such as gastritis (24.1%), esophagitis (16.5%), ulcers (1%), and Barrett’s esophagus (1%). The mean follow-up period was 30.2 months (⫾12.7). One or more postoperative complications occurred in 98 patients (18.2%), of whom 48 patients (9.2%) experienced these within 30 days after surgery. Some patients suffered from both a short- and long-term complication. Complications ranged in severity from wound infection to anastomotic leakage. There was no significant association between the findings on EGD and postoperative complications (Tables 1 and 2). No significant difference between postoperative complications in general (P ¼ .1) or within 30 days (P ¼ .2) was detected between patients receiving PPIs or not (n ¼ 237 from August 2011 onward). All patients infected with H. pylori before surgery received eradication therapy; however, preoperative eradicated infection did not predispose for any of the postoperative complications.
Patients and methods
Discussion
Between December 2007 and August 2012, all patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were screened for upper digestive tract disease by EGD. Results of these EGDs; histopathologic examination if applicable; baseline characteristics such as age, gender, body mass index, co-morbidities, and intoxications; and all postoperative complications were entered in a consecutive database that was retrospectively reviewed for this study. At the start of this cohort, Helicobacter pylori screening was not routinely performed; this became standardized from August 2011. Additionally, also starting from August 2011, all patients received a 6-month course of prophylactic proton pump inhibitors (PPIs). All analysis were performed with SPSS 21.0 (IBM Corp., Armonk, NY, USA), a 2-sided P value o .05 was considered statistically significant.
This study found that in addition to screening for (pre-) malignant findings, no rationale exists for preoperative EGD with respect to postoperative complications after primary LRYGB or LSG. Although a subanalysis found that preoperative (eradicated) infection with H. pylori did not cause complications either, detection and subsequent
Comment on: Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory?
Results Preoperative EGD was performed in 523 patients (400 [76.5%] female, mean age 44.3 yr, mean body mass index
Table 1 Analysis of outcome of EGD and short-term complications (o30 d) Outcome preoperative EGD
No complications, N ¼ 474 (n [%])
Abnormal outcome 243 (51.3) Bulbitis 23 (4.9) Esophagitis 79 (16.7) Gastric ulcer 5 (1.1) Gastritis 116 (24.5) Hiatal hernia 107 (22.6) HP positive (326 74 (25.3) patients) Schatzki’s ring 10 (2.1)
Complications, N ¼ 48 (n [%])
P
22 0 7 0 10 6 10
.5 .3 .8 1.0 .7 .1 .5
(45.8) (0) (14.6) (.0) (20.8) (12.5) (30.3)
1 (2.1)
EGD ¼ esophagogastroduodenoscopy; HP ¼ Helicobacter pylori.
http://dx.doi.org/10.1016/j.soard.2015.06.001 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
1.0
U. K. Coblijn et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
2
Table 2 Analysis of outcome of EGD and long-term complications Outcome preoperative EGD
No complications, N ¼ 465 (n [%])
Complications, N ¼ 59 (n [%])
P
Abnormal outcome Bulbitis Esophagitis Gastric ulcer Gastritis Hiatal hernia HP positive (326 patients) Schatzki’s ring
239 22 75 5 115 101 80 10
26 1 11 0 11 12 4 1
.5 .5 .6 1.0 .4 1.0 .3 1.0
(51.4) (4.7) (16.1) (1.1) (24.7) (21.7) (26.8) (2.2)
(45.6) (1.8) (19.3) (0) (19.3) (21.1) (14.8) (1.8)
EGD ¼ esophagogastroduodenoscopy; HP ¼ Helicobacter pylori.
eradication of H. pylori is justified because infection can cause gastric ulcers and even gastric malignancies in nonbariatric patients; however, this screening can be performed with H2 breathing or feces tests [4,5]. These results indicate that preoperative EGD has no value in prediction or prevention of postoperative complications.
U.K. Coblijn, M.D., S.D. Kuiken, M.D., Ph.D., B.A. van Wagensveld, M.D., Ph.D. Department of Surgery, Sint Lucas Andreas Hospital Amsterdam, Netherlands References [1] Schigt A, Coblijn U, Lagarde S, Kuiken S, Scholten P, van Wagensveld B. Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory? Surg Obes Relat Dis 2014;10(3):411–7 [2] Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445–54. [3] Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 1999;9 (1):22–7. [4] Graham DY. History of Helicobacter pylori, duodenal ulcer, gastric ulcer and gastric cancer. World J Gastroenterol 2014;20(18):5191–204. [5] Korkmaz H, Kesli R, Karabagli P, Terzi Y. Comparison of the diagnostic accuracy of five different stool antigen tests for the diagnosis of Helicobacter pylori infection. Helicobacter 2013;18:384–91.
http://dx.doi.org/10.1016/j.soard.2015.06.001
Letter to the Editor
In 2014, the manuscript titled “Is Esophagogastroduodenoscopy Before Roux-en-Y Gastric Bypass or Sleeve Gastrectomy Mandatory?” was published in Surgery for Obesity and Related Disease and concluded that preoperative detection of upper digestive tract disease by means of esophagogastroduodenoscopy (EGD) is not necessary because its yield is very low [1]. However, for some of the short- and long-term postoperative complications, such as anastomotic leakage or marginal ulceration, conditions found at EGD such as gastritis or preoperative ulcers could be of influence [2,3]. Therefore, the aim of this additional study was to investigate whether preoperatively discovered abnormalities at EGD screening had any influence on shortterm (within 30 d) and/or long-term postoperative complications.
46.5 kg/m2) before primary LRYGB or LSG. As previously published, in 266 patients (51.1%) at least 1 abnormality was discovered, such as gastritis (24.1%), esophagitis (16.5%), ulcers (1%), and Barrett’s esophagus (1%). The mean follow-up period was 30.2 months (⫾12.7). One or more postoperative complications occurred in 98 patients (18.2%), of whom 48 patients (9.2%) experienced these within 30 days after surgery. Some patients suffered from both a short- and long-term complication. Complications ranged in severity from wound infection to anastomotic leakage. There was no significant association between the findings on EGD and postoperative complications (Tables 1 and 2). No significant difference between postoperative complications in general (P ¼ .1) or within 30 days (P ¼ .2) was detected between patients receiving PPIs or not (n ¼ 237 from August 2011 onward). All patients infected with H. pylori before surgery received eradication therapy; however, preoperative eradicated infection did not predispose for any of the postoperative complications.
Patients and methods
Discussion
Between December 2007 and August 2012, all patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were screened for upper digestive tract disease by EGD. Results of these EGDs; histopathologic examination if applicable; baseline characteristics such as age, gender, body mass index, co-morbidities, and intoxications; and all postoperative complications were entered in a consecutive database that was retrospectively reviewed for this study. At the start of this cohort, Helicobacter pylori screening was not routinely performed; this became standardized from August 2011. Additionally, also starting from August 2011, all patients received a 6-month course of prophylactic proton pump inhibitors (PPIs). All analysis were performed with SPSS 21.0 (IBM Corp., Armonk, NY, USA), a 2-sided P value o .05 was considered statistically significant.
This study found that in addition to screening for (pre-) malignant findings, no rationale exists for preoperative EGD with respect to postoperative complications after primary LRYGB or LSG. Although a subanalysis found that preoperative (eradicated) infection with H. pylori did not cause complications either, detection and subsequent
Comment on: Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory?
Results Preoperative EGD was performed in 523 patients (400 [76.5%] female, mean age 44.3 yr, mean body mass index
Table 1 Analysis of outcome of EGD and short-term complications (o30 d) Outcome preoperative EGD
No complications, N ¼ 474 (n [%])
Abnormal outcome 243 (51.3) Bulbitis 23 (4.9) Esophagitis 79 (16.7) Gastric ulcer 5 (1.1) Gastritis 116 (24.5) Hiatal hernia 107 (22.6) HP positive (326 74 (25.3) patients) Schatzki’s ring 10 (2.1)
Complications, N ¼ 48 (n [%])
P
22 0 7 0 10 6 10
.5 .3 .8 1.0 .7 .1 .5
(45.8) (0) (14.6) (.0) (20.8) (12.5) (30.3)
1 (2.1)
EGD ¼ esophagogastroduodenoscopy; HP ¼ Helicobacter pylori.
http://dx.doi.org/10.1016/j.soard.2015.06.001 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.
1.0
U. K. Coblijn et al. / Surgery for Obesity and Related Diseases ] (2015) 00–00
2
Table 2 Analysis of outcome of EGD and long-term complications Outcome preoperative EGD
No complications, N ¼ 465 (n [%])
Complications, N ¼ 59 (n [%])
P
Abnormal outcome Bulbitis Esophagitis Gastric ulcer Gastritis Hiatal hernia HP positive (326 patients) Schatzki’s ring
239 22 75 5 115 101 80 10
26 1 11 0 11 12 4 1
.5 .5 .6 1.0 .4 1.0 .3 1.0
(51.4) (4.7) (16.1) (1.1) (24.7) (21.7) (26.8) (2.2)
(45.6) (1.8) (19.3) (0) (19.3) (21.1) (14.8) (1.8)
EGD ¼ esophagogastroduodenoscopy; HP ¼ Helicobacter pylori.
eradication of H. pylori is justified because infection can cause gastric ulcers and even gastric malignancies in nonbariatric patients; however, this screening can be performed with H2 breathing or feces tests [4,5]. These results indicate that preoperative EGD has no value in prediction or prevention of postoperative complications.
U.K. Coblijn, M.D., S.D. Kuiken, M.D., Ph.D., B.A. van Wagensveld, M.D., Ph.D. Department of Surgery, Sint Lucas Andreas Hospital Amsterdam, Netherlands References [1] Schigt A, Coblijn U, Lagarde S, Kuiken S, Scholten P, van Wagensveld B. Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory? Surg Obes Relat Dis 2014;10(3):411–7 [2] Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445–54. [3] Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg 1999;9 (1):22–7. [4] Graham DY. History of Helicobacter pylori, duodenal ulcer, gastric ulcer and gastric cancer. World J Gastroenterol 2014;20(18):5191–204. [5] Korkmaz H, Kesli R, Karabagli P, Terzi Y. Comparison of the diagnostic accuracy of five different stool antigen tests for the diagnosis of Helicobacter pylori infection. Helicobacter 2013;18:384–91.
http://dx.doi.org/10.1016/j.soard.2015.06.001
