Surgery for Obesity and Related Diseases ] (2014) 00–00
Editorial comment
Comment on: “Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory?” Received February 16, 2014; accepted February 24, 2014
It is a privilege to have the opportunity to comment on the study by Dr. Schigt et al. [1] and the need for upper esophagogastroduodenal (EGD) endoscopy before bariatric surgery. The authors have made a commendable effort reviewing and analyzing their own consecutive experience within a new, suggested EGD classification system based on the need for preoperative intervention. The question of preoperative endoscopy has controversial clinical implications and a significant potential financial effect. Upper endoscopy is a relatively simple and well-tolerated diagnostic procedure performed by surgeons and gastroenterologists, but not without rare complications in the obese [2]. The cost of endoscopy is also significant, as demonstrated in this study, and may be more expensive in other countries [3]. The authors demonstrate a significant expense in routine EGD per clinically relevant lesion in their country, and that expense could be even much higher in other healthcare systems with or without anesthesia. It seems that routine EGD in all patients is not likely to prove economically prudent in most countries. Certainly late discovery of occult malignancy or serious gastric ulcer pathology could have devastating clinical and financial consequences in gastric bypass patients, yet no series to date has been large enough to review this clinical or financial effect. Although there is good evidence that EGD reveals abnormal findings in roughly half of the patients, including in this series, the risk of esophagogastric cancer is still very low, even in the obese [4], and data on serious remnant stomach pathology after gastric bypass is scarce [5]. Furthermore, there is evidence that surgical weight loss likely reduces the risk of gastric cancer [6]. Identifying a population at risk for serious remnant pathology is difficult, as discussed in this study, and again would require a much larger population. As the authors point out, only increasing age seems to be consistently related to a higher chance of disease. Ulcer disease after gastric bypass is not uncommon, and it is generally accepted that risk factors of nonsteroidal antiinflammatory drug use, tobacco use, and H. pylori should be eliminated before surgery. Proton pump inhibitors are also
highly effective in treatment of most ulcer disease after gastric bypass. Direct visualization and biopsy of mucosa is undoubtedly the most accurate method for identifying upper gastrointestinal (GI) pathology, but today we practice in a surgical era with increasing precision in radiologic imaging and growing highly-specific noninvasive methods in serology (i.e., H. pylori). Upper endoscopy is always available to evaluate the postoperative gastroesophageal junction and pouch. Retrograde biliopancreatic limb endoscopy, double balloon endoscopy, percutaneous gastrostomy, and a laparoscopic assisted transgastric approach can also provide potential diagnostic and therapeutic tools used for the bypassed limb [5]. With all of these factors in mind, the benefit of preop EGD may not seem to support the screening expense or provide major clinical advantage in all patients before gastric bypass. Some evaluation of the upper GI tract via EGD or an upper GI contrast study may be appropriate in symptomatic patients, although direct correlation between pathology and symptoms is not clear-cut. If EGD is performed, I do strongly support bariatric surgeons performing their own endoscopy. Based on the presented data, however, EGD is not likely to change management in an asymptomatic patient considering gastric bypass, and there is no subset of patients that can be identified as best for EGD. A similar question can be asked if EGD is mandatory in patients considered for other restrictive procedures like sleeve gastrectomy or adjustable gastric band. Although the gastroesophageal junction is accessible after these procedures, pathology identified here (Barrett’s disease, reflux esophagitis, etc.) may respond better to gastric bypass. Although EGD did not change procedure choice in this series on primarily gastric bypass candidates, proximal gastroesophageal findings could have more effect on management of those originally considered candidates for sleeve or band procedures.
http://dx.doi.org/10.1016/j.soard.2014.02.024 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Peter F. Lalor, M.D. F.A.C.S., F.A.S.M.B.S.* Wood County Hospital Bowling Green, Ohio
2
P. F. Lalor / Surgery for Obesity and Related Diseases ] (2014) 00–00
References [1] Schigt A, Coblijn UK, Lagarde SM, et al. Is esophagogastroduodenoscopy prior to Roux-en-y gastric bypass or sleeve gastrectomy mandatory? Surg Obes Relat Dis Epub 2014. [2] Kuper MA, Kratt T, Kramer KM, et al. Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery. Surg Endosc 2010;24:1996–2001. [3] Johnson JM, Carter TM, Schwartz RW, Gagliardi J. P24: preoperative upper endoscopy in patients undergoing laparoscopic
* Correspondence: Peter F. Lalor, M.D., F.A.C.S., F.A.S.M.B.S., Wood County Hospital, 960 W. Wooster St., Suite 116, Bowling Green, OH 43402. E-mail: [email protected]
Roux-en-Y gastric bypass is not mandatory. Surg Obes Relat Dis 2007;3:307. [4] Yang P, Zhou Y, Chen B, et al. Overweight, obesity and gastric cancer risk: results from a meta-analysis of cohort studies. Eur J Cancer 2009;45:2867–73. [5] Scozzari G, Trapani R, Toppino M, Marino M. Esophagogastric cancer after bariatric surgery: systematic review of the literature. Surg Obes Relat Dis 2013;9:133–42. [6] Menendez P, Padilla D, Villarejo P, Menendez JM, Lora D. Does bariatric surgery decrease gastric cancer risk? Hepatogastroenterology 2012;59:409–12.
Editorial comment
Comment on: “Is esophagogastroduodenoscopy before Roux-en-Y gastric bypass or sleeve gastrectomy mandatory?” Received February 16, 2014; accepted February 24, 2014
It is a privilege to have the opportunity to comment on the study by Dr. Schigt et al. [1] and the need for upper esophagogastroduodenal (EGD) endoscopy before bariatric surgery. The authors have made a commendable effort reviewing and analyzing their own consecutive experience within a new, suggested EGD classification system based on the need for preoperative intervention. The question of preoperative endoscopy has controversial clinical implications and a significant potential financial effect. Upper endoscopy is a relatively simple and well-tolerated diagnostic procedure performed by surgeons and gastroenterologists, but not without rare complications in the obese [2]. The cost of endoscopy is also significant, as demonstrated in this study, and may be more expensive in other countries [3]. The authors demonstrate a significant expense in routine EGD per clinically relevant lesion in their country, and that expense could be even much higher in other healthcare systems with or without anesthesia. It seems that routine EGD in all patients is not likely to prove economically prudent in most countries. Certainly late discovery of occult malignancy or serious gastric ulcer pathology could have devastating clinical and financial consequences in gastric bypass patients, yet no series to date has been large enough to review this clinical or financial effect. Although there is good evidence that EGD reveals abnormal findings in roughly half of the patients, including in this series, the risk of esophagogastric cancer is still very low, even in the obese [4], and data on serious remnant stomach pathology after gastric bypass is scarce [5]. Furthermore, there is evidence that surgical weight loss likely reduces the risk of gastric cancer [6]. Identifying a population at risk for serious remnant pathology is difficult, as discussed in this study, and again would require a much larger population. As the authors point out, only increasing age seems to be consistently related to a higher chance of disease. Ulcer disease after gastric bypass is not uncommon, and it is generally accepted that risk factors of nonsteroidal antiinflammatory drug use, tobacco use, and H. pylori should be eliminated before surgery. Proton pump inhibitors are also
highly effective in treatment of most ulcer disease after gastric bypass. Direct visualization and biopsy of mucosa is undoubtedly the most accurate method for identifying upper gastrointestinal (GI) pathology, but today we practice in a surgical era with increasing precision in radiologic imaging and growing highly-specific noninvasive methods in serology (i.e., H. pylori). Upper endoscopy is always available to evaluate the postoperative gastroesophageal junction and pouch. Retrograde biliopancreatic limb endoscopy, double balloon endoscopy, percutaneous gastrostomy, and a laparoscopic assisted transgastric approach can also provide potential diagnostic and therapeutic tools used for the bypassed limb [5]. With all of these factors in mind, the benefit of preop EGD may not seem to support the screening expense or provide major clinical advantage in all patients before gastric bypass. Some evaluation of the upper GI tract via EGD or an upper GI contrast study may be appropriate in symptomatic patients, although direct correlation between pathology and symptoms is not clear-cut. If EGD is performed, I do strongly support bariatric surgeons performing their own endoscopy. Based on the presented data, however, EGD is not likely to change management in an asymptomatic patient considering gastric bypass, and there is no subset of patients that can be identified as best for EGD. A similar question can be asked if EGD is mandatory in patients considered for other restrictive procedures like sleeve gastrectomy or adjustable gastric band. Although the gastroesophageal junction is accessible after these procedures, pathology identified here (Barrett’s disease, reflux esophagitis, etc.) may respond better to gastric bypass. Although EGD did not change procedure choice in this series on primarily gastric bypass candidates, proximal gastroesophageal findings could have more effect on management of those originally considered candidates for sleeve or band procedures.
http://dx.doi.org/10.1016/j.soard.2014.02.024 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Peter F. Lalor, M.D. F.A.C.S., F.A.S.M.B.S.* Wood County Hospital Bowling Green, Ohio
2
P. F. Lalor / Surgery for Obesity and Related Diseases ] (2014) 00–00
References [1] Schigt A, Coblijn UK, Lagarde SM, et al. Is esophagogastroduodenoscopy prior to Roux-en-y gastric bypass or sleeve gastrectomy mandatory? Surg Obes Relat Dis Epub 2014. [2] Kuper MA, Kratt T, Kramer KM, et al. Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery. Surg Endosc 2010;24:1996–2001. [3] Johnson JM, Carter TM, Schwartz RW, Gagliardi J. P24: preoperative upper endoscopy in patients undergoing laparoscopic
* Correspondence: Peter F. Lalor, M.D., F.A.C.S., F.A.S.M.B.S., Wood County Hospital, 960 W. Wooster St., Suite 116, Bowling Green, OH 43402. E-mail: [email protected]
Roux-en-Y gastric bypass is not mandatory. Surg Obes Relat Dis 2007;3:307. [4] Yang P, Zhou Y, Chen B, et al. Overweight, obesity and gastric cancer risk: results from a meta-analysis of cohort studies. Eur J Cancer 2009;45:2867–73. [5] Scozzari G, Trapani R, Toppino M, Marino M. Esophagogastric cancer after bariatric surgery: systematic review of the literature. Surg Obes Relat Dis 2013;9:133–42. [6] Menendez P, Padilla D, Villarejo P, Menendez JM, Lora D. Does bariatric surgery decrease gastric cancer risk? Hepatogastroenterology 2012;59:409–12.
