|Year : 2019 | Volume
| Issue : 1 | Page : 15-20
Role of upper gastrointestinal endoscopy before bariatric surgery
Hadeel S Ashour1, Arif Khurshid1, Owaid Almalki1, Walaa N Al-Harthi1, Amer M Al-Nefaie2, Atheer M Altalhi3
1 Department of Surgery, Al-Hada Military Hospital, Taif, Saudi Arabia
2 College of Medicine, Taif University, Taif, Saudi Arabia
3 Department of Emergency Medicine, Alnoor Specialist Hospital, Makkah, Saudi Arabia
|Date of Submission||21-Mar-2022|
|Date of Decision||15-May-2022|
|Date of Acceptance||24-May-2022|
|Date of Web Publication||02-Aug-2022|
Hadeel S Ashour
Department of Surgery, Al-Hada Military Hospital, Taif
Source of Support: None, Conflict of Interest: None
Background: The ultimate purpose of weight management in patients with obesity is to reduce the risk of related comorbidities and improve their health. Bariatric surgery appears to be cost-effective compared with the standard intervention in the management of morbid obesity. However, the role of preoperative esophagogastroduodenoscopy (EGD) remains a controversial topic. The aim of this study is to assess the incidence of abnormal findings in preoperative EGD, to evaluate the correlation between EGD findings and patient risk factors, and to evaluate EGD’s effects on the surgical management plan. Materials and Methods: A retrospective cross-sectional study was conducted on all patients who underwent bariatric surgery at Al-Hada Military Hospital, Taif, Saudi Arabia, by reviewing their medical records. Result: The study population included 227 patients (26% males and 74% females). The incidence of abnormal EGD findings was 78.9% (n = 179), and the most common result was gastritis (n = 86; 37.9%). The prevalence of this abnormal EGD finding was significantly higher in males (n = 53; 89.8%) than in females (n = 126; 75%) (P = 0.016). A multivariate logistic regression analysis showed that male sex (odds ratio [OR] = 3.11 [95% confidence interval (CI) = 1.08–8.93]; P value = 0.036) and hypothyroidism (OR = 2.39 [95% CI = 1.02–5.59]; P value = 0.044) were independent predictive factors for abnormal EGD findings. Conclusion: Almost 80% of patients who underwent EGD before bariatric surgery had abnormal findings including Helicobacter pylori infection, gastritis, hiatal hernia, or duodenitis. Nevertheless, surgical management plans were not significantly impacted by those findings. Accordingly, preoperative EGD should be performed as clinically indicated.
Keywords: Bariatric surgery, EGD, GERD, morbid obesity, upper GI endoscopy
|How to cite this article:|
Ashour HS, Khurshid A, Almalki O, Al-Harthi WN, Al-Nefaie AM, Altalhi AM. Role of upper gastrointestinal endoscopy before bariatric surgery. Saudi J Obesity 2019;7:15-20
|How to cite this URL:|
Ashour HS, Khurshid A, Almalki O, Al-Harthi WN, Al-Nefaie AM, Altalhi AM. Role of upper gastrointestinal endoscopy before bariatric surgery. Saudi J Obesity [serial online] 2019 [cited 2022 Nov 28];7:15-20. Available from: https://www.saudijobesity.com/text.asp?2019/7/1/15/353154
| Introduction|| |
Morbidly obese patients are two to three times more susceptible to upper gastrointestinal diseases than patients with normal body mass index (body mass index (BMI)). Some of these diseases may change the preoperative surgical plan, postpone, cancel, or change surgery, or modify the approach. Examples include Helicobacter pylori infection, reflux esophagitis, and hiatus hernia. Although these conditions can be identified by preoperative esophagogastroduodenoscopy (EGD), routine preoperative EGD may expose patients to unnecessary risk. Therefore, the role of preoperative EGD remains a controversial topic. The incidences of abnormal preoperative EGD findings have been reported as 80%, 56%, and 51% in different studies.,, The percentages of patients who had changes in surgical management plans because of the significant EGD findings have been reported as 1.7%, 63.8%, 9.5%, and 11%, the most observed finding was H. pylori infection that postpone the surgery because of eradication treatment.,,,
The guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) recommend preoperative EGD for patients with gastroesophageal reflux disease (GERD) or symptoms such as heartburn, regurgitation, or dysphagia and chronically using antisecretory medications. Likewise, the American Society for Metabolic and Bariatric Surgery (ASMBS) recommends preoperative EGD if clinically indicated. On the other hand, the European Association for Endoscopic Surgery (EAES) recommends preoperative endoscopy for all patients undergoing bariatric surgery.
The aim of this study is to assess the incidence of the abnormal findings in preoperative EGD, to assess the correlation between EGD findings and patient risk factors, and to assess EGD’s effect on the surgical management plan.
| Materials and methods|| |
A retrospective cross-sectional study was conducted on all patients who underwent bariatric surgery at Al-Hada Military Hospital, Taif, Saudi Arabia, by reviewing their medical records from 2015 to 2020. The data collected from patient files were medical record numbers, age, gender, preoperative BMI, comorbidities, past medical history, type of surgery, length of hospital stay, readmission, reoperation, revision, adverse events, EGD findings, and previous history of surgery.
Data management and analysis
The data were entered into a personal computer and analyzed using the Statistical Package for the Social Sciences (SPSS) version 21. All variables were coded before entry and checked before analysis. A descriptive analysis was performed on all data and associations between variables. Logistic regression was used to determine any risk factors associated with abnormal EGD findings.
| Results|| |
The study population included a total sample of 227 patients with 26% males and 74% females. The incidence of abnormal EGD findings was 78.9% (n = 179). The most common finding was gastritis (37.96%), followed by H. pylori (26.7%), hiatal hernia (16.23%), duodenitis (9.16%), peptic esophagitis (4.45%), stomach polyps (2.36%), duodenal ulcer (2.09%), stomach ulcer (1.05%), and multiple abnormal EGD findings (55.1%, n = 125 patients; [Figure 1]). The prevalence of abnormal EGD findings was significantly higher in males (89.8%) than in females (75%) (P = 0.016). The prevalence was higher in the age group of 18–39 years, those who had BMI ≥ 40, and nonsmokers, but the association was not statistically significant (P > 0.05; [Table 1]).
When the prevalence of abnormal EGD findings was assessed with comorbidities, it was found that patients who had hypothyroidism had significantly more abnormal EGD findings (81.8%) than those who did not have hypothyroidism (76.5%) (P = 0.012). Other comorbidities such as diabetes mellitus, hyperlipidemia, obstructive sleep apnea, hypertension, coronary artery disease, and GERD did not show any statistically significant relationship (P > 0.05; [Table 2]).
Multivariate logistic regression analysis showed that male sex (odds ratio [OR] = 3.11 [1.08–8.93], P = 0.036) and hypothyroidism (OR = 2.39 [1.02–5.59], P = 0.044) were independent predictive factors for abnormal EGD findings [Table 3].
The most common type of bariatric surgery performed was sleeve gastrectomy (laparoscopic/open) (n = 221), followed by mini-gastric bypass (n = 5), and roux-en-Y bypass (laparoscopic/open) (n = 1). When assessing the effects of endoscopic findings on surgery, 91.6% were not affected, whereas 8.4% had their surgery delayed (4% due to H. Pylori eradication treatment; the remaining reasons were not documented). [Table 4] shows the distribution of abnormal EGD findings and factors related to surgery and hospitalization.
| Discussion|| |
In this study, 78.9% of the patients who had preoperative EGD had abnormal findings. In comparison, prior studies reported incidences of 61%, 56%, and 51%, respectively.,, However, this number is lower than that in a previous Middle Eastern study that showed abnormal findings in 89% of cases. The most common findings in preoperative EGD were gastritis, followed by H. pylori, hiatal hernia, and duodenitis. Although their order of prevalence may differ from one study to another, gastritis, hiatal hernia, and duodenitis are usually the most common findings in preoperative EGD.,,, Nevertheless, a significant variation was reported in the incidence of H. pylori, which ranges from 3.4% and 3.7% in some studies, to 48% in another study.
One of the most common pathological findings that could force surgeons to alter the surgical management or the type of surgery is H. pylori infection., However, many claim that H. pylori screening or eradication protocols are not essential for asymptomatic patients as they would increase the financial strains arising from unnecessary tests and delays in surgery.,H. pylori was detected in 26.7% of the patients, and hiatal hernia was seen in 16.23%. Epidemiological data show that the H. pylori infection rate exceeds 50% globally and is one of the serious gastric diseases that affect surgery outcomes. The decision to perform bariatric surgery for obese patients needs multidisciplinary consultation, and it is very much essential to evaluate the risk/benefit ratio for patients.
The current findings showed that male sex and hypothyroidism are independent risk factors for abnormal EGD findings. Studies have reported that males have a higher incidence of postoperative complications after bariatric surgery.,, The sex differences of postoperative complications are unclear, but a possible reason could be that males undergo bariatric surgery much later in life with a higher disease burden and more comorbidities than females. Even though functional status improves after bariatric surgery, the presence of gastrointestinal comorbidities might increase the rate of postoperative complications.
However, studies report that older patients have higher morbidity and mortality rates after bariatric surgery., A 22% reduction in life expectancy was reported for 25-year-old morbidly obese people compared with normal healthy people, and they lost almost 12 years of life. Individuals with obesity are at risk for or have increased comorbidities such as type 2 diabetes, hypertension, cardiovascular diseases, hyperlipidemia, obstructive sleep apnea, asthma, varicose veins, degenerative problems of the back and lower weight-bearing extremities, depression, and cancer.,
In this study, abnormal EGD findings did not show any significant impact on the surgical management. It has been suggested that preoperative EGD should be considered optional based on the symptoms and risk factors. It has also been recommended that both preoperative EGD and detailed clinical examination improve the patient selection for bariatric surgery. A retrospective cohort study done in Saudi Arabia among patients who had undergone bariatric surgery for weight loss reported a readmission rate of 8%, and the rate was higher among patients who were older, diabetic, had obstructive sleep apnea, and had dyslipidemia. Studies show that the common complaints about readmission after bariatric surgery include malaise (abdominal pain, nausea/vomiting, dehydration), fever, and technical complications such as site leak, intra-abdominal infection, drainage of the abscess, and bleeding.,,
Gould et al. reported that technical complications are more common with patient-specific risk factors such as increased BMI, central obesity, and male sex. Technical complications differ with the type of bariatric surgery, and it has been reported that open techniques have more incidence of these complications than laparoscopic surgeries. The lower incidence of readmission, revisional surgery, and other postoperative complications in this study may be due to almost all surgeries (98.4%) involving laparoscopic sleeve gastrectomy (LSG). Both Roux-en-Y Gastric Bypass (RYGB) and LSG are popular bariatric surgery techniques that are currently used worldwide, and studies show no statistically significant difference in regular and excessive weight loss between the two types.,, LSG is considered a safe, efficient technique with reduced morbidity, mortality, and complications.
This study has some limitations. Information bias could be possible because of the retrospective nature, and the generalizability of the findings may be limited as this was a single-center study. As most of our patients had undergone the LSG technique, it was difficult to compare the surgical management and postoperative complications. Also, we were unable to compare and identify the differences in readmission rates and their reasons.
For future studies, we recommend using a larger sample and overcoming the bias of including patients from a single center by doing a multicenter study. We also recommend the involvement of different types of bariatric surgeries in larger numbers to enable comparison between their postoperative complications as well as to identify the rate of readmission and its statistical significance.
| Conclusion|| |
In conclusion, almost 80% of patients who underwent EGD before bariatric surgery had abnormal findings including H. pylori infection, gastritis, hiatal hernia, or duodenitis. Nevertheless, surgical management plans were not significantly impacted by those findings. Accordingly, preoperative EGD should be performed as clinically indicated.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]