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The value of routine gastroscopy before laparoscopic Roux-en-Y gastric bypass surgery in Chinese patients
Surgery for Obesity and Related Diseases ] (2014) 00–00
Original article
The value of routine gastroscopy before laparoscopic Roux-en-Y gastric bypass surgery in Chinese patients Hong-Meng Wong, M.D., Wah Yang, M.D., Jingge Yang, M.D., Cunchuan Wang, M.D., Ph.D.* Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangdong Province, China Received September 16, 2013; accepted June 22, 2014
Abstract
Background: Obesity is closely related to upper gastrointestinal diseases. China has a high incidence of gastropathy. Postoperative examination of the distal stomach becomes extremely difficult after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). Whether preoperative routine gastroscopy should be performed at all remains controversial. The objective of this study was to explore the value of routine gastroscopy before performing LRYGB in Chinese patients. Methods: The preoperative gastroscopy reports of 180 patients who had undergone LRYGB for morbid obesity and/or metabolic syndrome in the Department of Gastrointestinal Surgery of our hospital from January 2009 to August 2013 were retrospectively analyzed. Results: Gastroscopy showed chronic superficial gastritis (n ¼ 159, 88.3%), reflux esophagitis (n ¼ 19, 10.6%), erosion (n ¼ 69, 38.3%), hiatal hernia (n ¼ 5, 2.8%), gastric ulcer (n ¼ 3, 1.7%), duodenal ulcer (n ¼ 32, 17.8%), and gastric polyps (n ¼ 10, 5.6%). Conclusion: It is useful to perform gastroscopy before LRYGB. The findings of this investigation can help physicians to develop tailored therapies and procedures and thus improve the prognosis considerably. Gastroscopy should be routinely performed in Chinese patients who are planning to undergo bariatric surgery. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Gastroscopy; Gastric bypass; Morbid obesity; Metabolic syndrome; Bariatric surgery
Bariatric surgery has been widely recognized as the most effective treatment for morbid obesity [1]. Originating in the 1950s, it can effectively reduce patients’ weights in a sustainable and steady manner. Along with the rise of laparoscopic surgery, laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the treatment of choice for morbid obesity in the United States because of the relative balance of its weight-reducing effectiveness and surgeryassociated risks [2]. In 1994, Wittgrove et al. [3] introduced the procedure of LRYGB. In 2004, the first LRYGB was * Correspondence: Cunchuan Wang, Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, 613 Huangpu Avenue West, Guangzhou 510630, Guangdong Province, China. E-mail: [email protected]
performed in our hospital and so far 4300 patients have undergone this surgery. Gastroscopy is an important and commonly used preoperative upper gastrointestinal examination. It enables physicians to visualize a variety of upper gastrointestinal lesions, particularly small lesions. Because LRYGB changes the patient’s upper gastrointestinal anatomy, postoperative examination of the distal stomach becomes extremely difficult. Standard gastroscopes are rendered useless and, although specially designed gastroscopes are available for examining the distal stomach after LRYGB or when the examination is performed via the abdominal wall, these instruments are very difficult to master. In addition, according to the World Health Organization (2002) East Asia (South Korea, Japan, and China) has the highest
http://dx.doi.org/10.1016/j.soard.2014.06.020 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
H.-M. Wong et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
2
incidence of gastric cancer (440 cases/100,000 males), which is considerably more than the incidence in Southeast Asia/South Asia (Philippines, Thailand, and India) and Western Asia (o10 cases/100,000 males) [4]. According to the data provided by China’s National Cancer Registry in 2007 and those reported in the 2010 China Health Statistics Yearbook, gastric cancer is the second most common cancer incidence-wise and has the third highest mortality rate, indicating that China remains a country with one of the highest gastric cancer prevalence in the world [5,6]. Therefore, preoperative gastroscopy is particularly important before LRYGB. It enables preoperative identification of various pathologic changes, particularly cancers and precancerous lesions, in the upper gastrointestinal tract, and thus facilitates the timely adjustment of surgical procedures. In this article, we summarize our experiences of preoperative gastroscopy of all LRYGB patients in our hospital and attempt to evaluate its role in this situation. Methods A total of 180 patients who had undergone LRYGB for morbid obesity and/or metabolic syndrome in the Department of Gastrointestinal Surgery of our hospital from January, 2009 to August, 2013 were retrospectively analyzed. Clinical data collected and assessed include sex, age, height, weight before surgery, preoperative body mass index (BMI), length of postsurgical hospital stay, postoperative complications, surgical records, and gastroscopy reports (including upper gastrointestinal inflammation, ulcers, polyps, hiatal hernia) (Table 1). The average follow-up period was 11 months (range: 1–28 mo). The same surgeon performed the procedures on all patients. Intraoperative exploration and hiatal hernia repair when this diagnosis was confirmed was performed in all patients in whom hiatal hernia was suspected on the basis of preoperative gastroscopy findings. In patients in whom preoperative gastroscopy had identified gastric or duodenal ulcers and gastric polyps, resection of the excluded stomach was performed simultaneously; resection included the distal Table 1 Pathologic changes identified on gastroscopy Pathologic change
n
Percentage (%)
Treatment
Chronic superficial gastritis Reflux esophagitis Erosion Hiatal hernia Gastric ulcer
159 88.3
Conservative
19 69 5 3
10.6 38.3 2.8 1.7
Duodenal ulcer
32
17.8
Gastric polyps
10
5.6
Conservative Conservative Intraoperative repair Resection of the excluded stomach Resection of the excluded stomach Resection of the excluded stomach
excluded stomach at 1-cm distal to the duodenal bulb. Patients with erosive gastritis were tested for Helicobacter pylori. Those who were positive for H. pylori, but without ulcers or polyps, received routine preoperative antibiotic treatment. Results A total of 180 patients who had undergone LRYGB for morbid obesity and/or metabolic syndrome in the Department of Gastrointestinal Surgery of our hospital from January 2009 to August 2013 were studied. All study patients had undergone gastroscopy before surgery. Findings are presented as mean ⫾ standard deviation (SD). The male to female ratio was 98 (54.4%):82 (45.6%); height: 170 ⫾ 9.2 cm (range 149–190 cm); weight: 114 ⫾ 37.5 kg (range: 53.5–216 kg); BMI: 38.97 ⫾ 11.47 (range: 32.0–90.0); mean postsurgical hospital stay: 7.0 ⫾ 10.84 days (range: 5.0–12.0 d). In all, 6/180 patients (3.3%) experienced complications (lung infection: 1 case; umbilical infection: 1 case; alopecia: 3 cases; and anemia: 1 case). No patient’s procedure required conversion to open surgery. No postoperative bleeding or gastric paralysis was observed. There was no anastomotic leakage or stenosis, no duodenal stump leakage, and no intraoperative or postoperative deaths. Gastroscopic examination identified 7 types of pathologic change (Table 1). Five patients had hiatal hernias, ranging in size from 3.5–4.5 cm. All 5 hernias were diagnosed and repaired during surgery. Final pathologic examination revealed 5 gastric ulcers, 32 duodenal ulcers, and 10 polyps. Histologic examination identified 3 patients with fundic gland polyps, 6 with hyperplastic polyps, and 1 with adenomatous polyps. Thirty-eight patients underwent resection of the excluded stomach. Forty-eight patients tested positive for H. pylori and 23 received routine preoperative antibiotic treatment. Discussion The role of gastroscopy has not been fully recognized LRYGB for the treatment of obesity is widely recognized, but whether a preoperative routine gastroscopy should be performed remains controversial. For example, Muñoz et al. [7] reports that all patients should undergo preoperative gastroscopy, whereas Azagury et al. [8] suggests that it should only be performed in patients with preoperative symptoms. Interestingly, both researchers reported the same rate of abnormalities in their respective studies (46%). Gastroscopy can visualize the various diseases of the upper gastrointestinal tract in a flexible manner and also facilitate biopsy. After decades of development, it has become a mature technology. However, it is a painful option for many patients who are planning to undergo surgical treatment for morbid obesity or metabolic syndrome, and a preoperative gastroscopy may appear to be
Routine gastroscopy before LRYGB / Surgery for Obesity and Related Diseases ] (2014) 00–00
unjustified to these “benign” patients. The additional cost may also be problematic. Finally, there are even some patients who are reluctant to have their underlying diseases visualized by gastroscopy. There are various explanations for the lack of standardized preoperative examinations in China. Apart from the above described patient-related factors, some physicians also want to avoid the difficulties associated with preoperative examinations and may therefore often omit the procedures defined in surgical guidelines/regulations. Some physicians assume that preoperative examinations have limited value and will not directly affect the surgical procedures and outcomes, particularly in patients with benign lesions. Consequently, too often, omission of preoperative examinations results in missed diagnoses and misdiagnoses, thus prejudicing some patient's health. Obesity is associated with gastritis As shown in our present study, preoperation gastroscopy showed that 159 of 180 patients (88.3%) had varying degrees of chronic superficial gastritis. About half of them (69 patients, 38.3%) also had erosions. Although chronic gastritis did not affect the subsequent procedure of LRYGB, its high incidence (88.3%) strongly supports an association between obesity and chronic gastritis. Dutta et al. [9] found that 23.7% of 101 morbidly obese patients had gastritis, which is a significantly greater proportion than the 11.8% reported for age- and sex-matched patients with BMIs within the normal range. Notably, the rate of infection with H. pylori, which is 1 of the most important causes of gastritis, does not differ significantly between these 2 groups. These data clearly demonstrate the association between obesity and gastritis. A recent study in Japan also indicated that morbid obesity is one of the causes of gastritis (particularly erosive gastritis) [10]. Along with increases in BMI, the proportion of patients with gastritis has also increased, which might be attributable to amounts of fat connexin. These findings are consistent with our results. Diagnosis and treatment of hiatal hernia Hiatal hernia was found in 5 patients (2.8%) during preoperative gastroscopy. During LRYGB, all of these patients underwent intraoperative exploration, all were confirmed to have hiatal hernia, and all hernias were repaired. A preoperative gastroscopy performed as part of the routine examination before LRYGB can help doctors understand the hiatal hernia in advance so they are better prepared before surgery. In addition, double checking both preoperatively and intraoperatively can reduce misdiagnosis, and can provide a better chance of successful treatment. LRYGB alone is effective management for gastroesophageal reflux disease (GERD) in patients with hiatal hernia. According to Frezza et al. [11], over a 3-year follow-up GERD symptoms
3
disappeared or improved in approximately 80% of morbidly obese patients who had undergone LRYGB for GERD. Despite LRYGB being so effective, hiatal hernia repair was still performed in our series because of the risks associated with GERD accompanying hiatal hernia. All 5 patients with preoperative gastroscopy were found to have reflux esophagitis, which was likely attributable to the presence of a hiatal hernia. All 19 reflux esophagitis patients had typical GERD symptoms, which resolved or improved postoperatively by the time of discharge. This improvement may have been attributable to the effectiveness of LRYGB itself. There were too few of these patients to warrant further follow up. To ensure that any abnormalities missed on gastroscopy were identified, intraoperative exploration for hiatal hernia was also performed in patients in whom hiatal hernia had not been suspected during preoperative gastroscopy. Interestingly, no hiatal hernias were detected among these patients, reflecting the high accuracy rate of preoperative gastroscopy. Again, no definite conclusions can be reached because there are too few cases. There are a number of studies that have reported more instances of hiatal hernia being found with a gastroscopy before LRYGB (8.6–90.2%) than that observed in our study (2.8%) [7,8,12–19]. But whether a hiatal hernia should be repaired remains controversial. A possible justification for repair of hiatal hernias is that it may decrease the risk of the proximal stomach entering the thoracic cavity after LRYGB, which changes the structure of the digestive tract and makes the proximal stomach very small. A small proximal stomach may more easily enter the thoracic cavity [15]. Ulcers, precancerous lesions, and cancers As indicated in a recent meta-analysis, increased BMI is associated with increased risk of some common and not so common malignancies, especially esophageal adenocarcinoma and colon cancer [20]. High BMIs are associated with some cancer types in both sexes. Chronic GERD is an important cause of esophageal adenocarcinoma. Therefore, in obese patients, in addition to assessing structures within the stomach, a preoperative gastroscopy should include careful examination of the esophagus to ensure that diagnosis of the highly prevalent esophageal adenocarcinoma is not missed. Beltran et al. [21] also reported on the accidental discovery of gastrointestinal tumors in bariatric operations, which perhaps suggests the importance of a preoperative examination before a bariatric operation. In our series, gastric ulcers (1.7%), duodenal ulcers (17.8%), and polyps (5.6%) were also found during preoperative gastroscopy. They are risk factors for cancer and are therefore important. After gastric bypass surgery, gastric acid continues to be secreted, but the operation changes the anatomic structure of the stomach. As there is no food to dilute the gastric acid, it directly stimulates ulcers and exacerbates the condition. Even if ulcers are treated with preoperative proton pump inhibitor treatment, the
4
H.-M. Wong et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
high-intensity acid stimulation is likely to result in the recurrence of ulcers. Gastric polyps may have a malignant tendency [22–25], and there is the possibility of relapse. Azagury et al. [8] performed prophylactic gastrectomies for 2 cases of fundic gastric gland polyps because of the risk of polyp residual and because there could be no examination after bariatric operation, despite there only being a small chance of the polyps becoming malignant. Zeni et al. [17] also reported on a case of a partial gastrectomy for benign polyps. The number of patients with LRYGB is currently relatively low in China. A search of the literature resulted in no articles being found that mentioned the recurrence rate of distal gastric ulcers/polyps after ulcers/polyps had been treated. It is extremely difficult to perform gastroscopy of the distal stomach after LRYGB. Sleeve gastrectomy (SG) is also associated with good weight loss effects, and has attracted increasing attention in recent years. SG is beneficial in obese patients with ulcers or polyps, given that it is a low-risk procedure that involves no conversion of the gastrointestinal tract and less resection of the stomach. However, the indications and long-term effects of SG remain to be verified in large case numbers [26]. LRYGB is still regarded as the “gold standard” treatment for obesity and metabolic disorders, and shows good and long-lasting effects in terms of weight loss [2]. Patients in the present study were given detailed information on the long-term safety, efficacy, and risks of the procedure, and all gave their informed consent for distal gastrectomy being performed by LRYGB. Furthermore, H. pylori can cause various gastric disorders, gastric cancer in particular. With recent technological developments, it is possible to detect H. pylori in gastric biopsies taken during gastroscopy. Thus, during preoperative gastroscopy both morphologic observation and tissue biopsy can be performed to screen for H. pylori infection and early gastric cancer. The prevalence of gastric cancer is high in China, these cancers being located in the distal stomach in most Chinese patients. Because LRYGB changes the anatomy of the digestive tract, only special forms of gastroscopy can visualize the excluded stomach, which makes thorough post-LRYGB examinations more challenging. Therefore, gastroscopy before LRYGB is particularly valuable. Polyps and deep ulcers identified during gastroscopy were removed during the subsequent surgery. Anti-H. pylori medical treatment should be initiated before surgery in patients with this infection. And for patients with gastric cancer, the surgical procedure should be changed. Unfortunately, tests for H. pylori infection were not performed routinely in all patients in our series. Necessity for preoperative gastroscopy Preoperative gastroscopy is highly effective and accurate in identifying lesions and the specific anatomic structures in individual patients. It is also helpful for visualizing the
volume and morphology of the stomach, thus providing particularly valuable information about individual anatomy for surgeons. This in turn can shorten the operative time and reduce surgery-associated risks and incidence of complications. It is optimal practice for the same surgeon to perform both the preoperative gastroscopy and the subsequent surgical procedure. However, this is an unrealistic goal in some clinical settings. Alternatively, the surgeon can be present during the gastroscopy, during which he/she may guide the endoscopist to find small lesions and obtain other relevant information that may not be noted in the written report. In this way, the surgeon can arrange more tailored treatment, which will benefit both the medical staff and the patient. Six studies have reported on the rate of preoperative abnormal gastroscopic findings, which ranged between 12 and 91% [7,12–15,27]. These studies suggest that routine gastroscopy should be performed before LRYGB. In recent years, many Chinese hospitals have introduced various novel gastroscopes with smaller blind areas, better camera quality, and clearer images. Because these gastroscopes provide many unique advantages that cannot be replaced by other imaging techniques, they have become an important means of examining for upper gastrointestinal lesions. As medical devices and technology continue to advance, gastroscopy will certainly become safer and more efficient in the future. Conclusion Gastroscopy is a useful examination before LRYGB. It can help physicians to develop tailored therapies and procedures and thus improve the prognosis considerably. Gastroscopy should be routinely performed on Chinese patients who are planning to undergo bariatric surgery. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] National Institutes of Health. Gastrointestinal surgery for severe obesity. National Institutes of Health Consensus Development Conference Statement Online. 1991:9:1–20. http://consensus.nih.gov/ 1991/1991 gisurgeryobesity084 html.htm. [2] Khwaja HA, Bonanomi G. Bariatric surgery: techniques, outcomes and complications. Curr Anaesth Crit Care 2010;21:31–8. [3] Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 1994;4: 353–7. [4] Ferlay J, Bray F, Pisani P, Parkin DM. GLOBOCAN 2002. Cancer incidence, mortality and prevalence worldwide. IARC Cancer Base No. 5, version 2.0. Lyon: IARC Press, 2004. [5] He J, Chen WQ. 2012 Chinese Cancer Registry Annual Report. Beijing, Military Medical Science Press, 2013.
Routine gastroscopy before LRYGB / Surgery for Obesity and Related Diseases ] (2014) 00–00 [6] National Health and Family Planning Commission of the People's Republic of China. 2010 Year Book of Health in China. http://www. moh.gov.cn/mohwsbwstjxxzx/s7967/201010/49253.shtml. [7] Muñoz R, Ibáñez L, Salinas J, et al. Importance of routine preoperative upper GI endoscopy: why all patients should be evaluated? Obes Surg 2009;19:427–31. [8] Azagury D, Dumonceau JM, Morel P, Chassot G, Huber O. Preoperative work-up in asymptomatic patients undergoing Roux-en-Y gastric bypass: is endoscopy mandatory? Obes Surg 2006;16:1304–11. [9] Dutta SK, Arora M, Kireet A, Bashandy H, Gandsas A. Upper gastrointestinal symptoms and associated disorders in morbidly obese patients: a prospective study. Dig Dis Sci 2009;54:1243–6. [10] Yamamoto S, Watabe K, Takehara T. Is obesity a new risk factor for gastritis? Digestion 2012;85:108–10. [11] Frezza EE, Ikramuddin S, Gourash W, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass. Surg Endosc 2002;16:1027–31. [12] Csendes A, Burgos AM, Smok G, Beltran M. Endoscopic and histologic findings of the foregut in 426 patients with morbid obesity. Obes Surg 2007;17:28–34. [13] de Moura Almeida A, Cotrim HP, Santos AS, et al. Preoperative upper gastrointestinal endoscopy in obese patients undergoing bariatric surgery: is it necessary? Surg Obes Relat Dis 2008;4:144–149; discussion 150–1. [14] Küper 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. [15] Madan AK, Speck KE, Hiler ML. Routine preoperative upper endoscopy for laparoscopic gastric bypass: is it necessary? Am Surg 2004;70:684–6. [16] Vanek VW, Catania M, Triveri K, Woodruff RW Jr.. Retrospective review of the preoperative biliary and gastrointestinal evaluation for gastric bypass surgery. Surg Obes Relat Dis 2006;2:17–22; discussion 22–3.
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[17] Zeni TM, Frantzides CT, Mahr C, et al. Value of preoperative upper endoscopy in patients undergoing laparoscopic gastric bypass. Obes Surg 2006;16:142–6. [18] Loewen M, Giovanni J, Barba C. Screening endoscopy before bariatric surgery: a series of 448 patients. Surg Obes Relat Dis 2008;4:709–12. [19] Sharaf RN, Weinshel EH, Bini EJ, Rosenberg J, Sherman A, Ren CJ. Endoscopy plays an important preoperative role in bariatric surgery. Obes Surg 2004;14:1367–72. [20] Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 2008;371:569–78. [21] Beltran MA, Pujado B, Méndez PE, et al. Gastric gastrointestinal stromal tumor (GIST) incidentally found and resected during laparoscopic sleeve gastrectomy. Obes Surg 2010;20:393–6. [22] Sebastian S, Qasim A, McLoughlin R, O’Morain CA, O’Connor HJ. Fundic gland polyps: not so trivial entity and worth evaluation. Gastroenterology 2004;126:1497–8. [23] Daibo M, Itabashi M, Hirota T. Malignant transformation of gastric hyperplastic polyps. Am J Gastroenterol 1987;82:1016–25. [24] Kelly PJ, Lauwers GY. Clinical guidelines: Consensus for the management of patients with gastric polyps. Nat Rev Gastroenterol Hepatol 2011;8:7–8. [25] Chai NL, Zhang WC, Wang YM, et al. Expression of Foxa2 and its early alarm value of cancerous in gastric polyps. Zhonghua Yi Xue Za Zhi 2013;93:2020–4. [26] Rosenthal RJ. International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8:8–19. [27] Mong C, Van Dam J, Morton J, Gerson L, Curet M, Banerjee S. Preoperative endoscopic screening for laparoscopic Roux-en-Y gastric bypass has a low yield for anatomic findings. Obes Surg 2008;18: 1067–73.
Original article
The value of routine gastroscopy before laparoscopic Roux-en-Y gastric bypass surgery in Chinese patients Hong-Meng Wong, M.D., Wah Yang, M.D., Jingge Yang, M.D., Cunchuan Wang, M.D., Ph.D.* Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, Guangdong Province, China Received September 16, 2013; accepted June 22, 2014
Abstract
Background: Obesity is closely related to upper gastrointestinal diseases. China has a high incidence of gastropathy. Postoperative examination of the distal stomach becomes extremely difficult after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB). Whether preoperative routine gastroscopy should be performed at all remains controversial. The objective of this study was to explore the value of routine gastroscopy before performing LRYGB in Chinese patients. Methods: The preoperative gastroscopy reports of 180 patients who had undergone LRYGB for morbid obesity and/or metabolic syndrome in the Department of Gastrointestinal Surgery of our hospital from January 2009 to August 2013 were retrospectively analyzed. Results: Gastroscopy showed chronic superficial gastritis (n ¼ 159, 88.3%), reflux esophagitis (n ¼ 19, 10.6%), erosion (n ¼ 69, 38.3%), hiatal hernia (n ¼ 5, 2.8%), gastric ulcer (n ¼ 3, 1.7%), duodenal ulcer (n ¼ 32, 17.8%), and gastric polyps (n ¼ 10, 5.6%). Conclusion: It is useful to perform gastroscopy before LRYGB. The findings of this investigation can help physicians to develop tailored therapies and procedures and thus improve the prognosis considerably. Gastroscopy should be routinely performed in Chinese patients who are planning to undergo bariatric surgery. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Gastroscopy; Gastric bypass; Morbid obesity; Metabolic syndrome; Bariatric surgery
Bariatric surgery has been widely recognized as the most effective treatment for morbid obesity [1]. Originating in the 1950s, it can effectively reduce patients’ weights in a sustainable and steady manner. Along with the rise of laparoscopic surgery, laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the treatment of choice for morbid obesity in the United States because of the relative balance of its weight-reducing effectiveness and surgeryassociated risks [2]. In 1994, Wittgrove et al. [3] introduced the procedure of LRYGB. In 2004, the first LRYGB was * Correspondence: Cunchuan Wang, Department of Gastrointestinal Surgery, First Affiliated Hospital of Jinan University, 613 Huangpu Avenue West, Guangzhou 510630, Guangdong Province, China. E-mail: [email protected]
performed in our hospital and so far 4300 patients have undergone this surgery. Gastroscopy is an important and commonly used preoperative upper gastrointestinal examination. It enables physicians to visualize a variety of upper gastrointestinal lesions, particularly small lesions. Because LRYGB changes the patient’s upper gastrointestinal anatomy, postoperative examination of the distal stomach becomes extremely difficult. Standard gastroscopes are rendered useless and, although specially designed gastroscopes are available for examining the distal stomach after LRYGB or when the examination is performed via the abdominal wall, these instruments are very difficult to master. In addition, according to the World Health Organization (2002) East Asia (South Korea, Japan, and China) has the highest
http://dx.doi.org/10.1016/j.soard.2014.06.020 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
H.-M. Wong et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
2
incidence of gastric cancer (440 cases/100,000 males), which is considerably more than the incidence in Southeast Asia/South Asia (Philippines, Thailand, and India) and Western Asia (o10 cases/100,000 males) [4]. According to the data provided by China’s National Cancer Registry in 2007 and those reported in the 2010 China Health Statistics Yearbook, gastric cancer is the second most common cancer incidence-wise and has the third highest mortality rate, indicating that China remains a country with one of the highest gastric cancer prevalence in the world [5,6]. Therefore, preoperative gastroscopy is particularly important before LRYGB. It enables preoperative identification of various pathologic changes, particularly cancers and precancerous lesions, in the upper gastrointestinal tract, and thus facilitates the timely adjustment of surgical procedures. In this article, we summarize our experiences of preoperative gastroscopy of all LRYGB patients in our hospital and attempt to evaluate its role in this situation. Methods A total of 180 patients who had undergone LRYGB for morbid obesity and/or metabolic syndrome in the Department of Gastrointestinal Surgery of our hospital from January, 2009 to August, 2013 were retrospectively analyzed. Clinical data collected and assessed include sex, age, height, weight before surgery, preoperative body mass index (BMI), length of postsurgical hospital stay, postoperative complications, surgical records, and gastroscopy reports (including upper gastrointestinal inflammation, ulcers, polyps, hiatal hernia) (Table 1). The average follow-up period was 11 months (range: 1–28 mo). The same surgeon performed the procedures on all patients. Intraoperative exploration and hiatal hernia repair when this diagnosis was confirmed was performed in all patients in whom hiatal hernia was suspected on the basis of preoperative gastroscopy findings. In patients in whom preoperative gastroscopy had identified gastric or duodenal ulcers and gastric polyps, resection of the excluded stomach was performed simultaneously; resection included the distal Table 1 Pathologic changes identified on gastroscopy Pathologic change
n
Percentage (%)
Treatment
Chronic superficial gastritis Reflux esophagitis Erosion Hiatal hernia Gastric ulcer
159 88.3
Conservative
19 69 5 3
10.6 38.3 2.8 1.7
Duodenal ulcer
32
17.8
Gastric polyps
10
5.6
Conservative Conservative Intraoperative repair Resection of the excluded stomach Resection of the excluded stomach Resection of the excluded stomach
excluded stomach at 1-cm distal to the duodenal bulb. Patients with erosive gastritis were tested for Helicobacter pylori. Those who were positive for H. pylori, but without ulcers or polyps, received routine preoperative antibiotic treatment. Results A total of 180 patients who had undergone LRYGB for morbid obesity and/or metabolic syndrome in the Department of Gastrointestinal Surgery of our hospital from January 2009 to August 2013 were studied. All study patients had undergone gastroscopy before surgery. Findings are presented as mean ⫾ standard deviation (SD). The male to female ratio was 98 (54.4%):82 (45.6%); height: 170 ⫾ 9.2 cm (range 149–190 cm); weight: 114 ⫾ 37.5 kg (range: 53.5–216 kg); BMI: 38.97 ⫾ 11.47 (range: 32.0–90.0); mean postsurgical hospital stay: 7.0 ⫾ 10.84 days (range: 5.0–12.0 d). In all, 6/180 patients (3.3%) experienced complications (lung infection: 1 case; umbilical infection: 1 case; alopecia: 3 cases; and anemia: 1 case). No patient’s procedure required conversion to open surgery. No postoperative bleeding or gastric paralysis was observed. There was no anastomotic leakage or stenosis, no duodenal stump leakage, and no intraoperative or postoperative deaths. Gastroscopic examination identified 7 types of pathologic change (Table 1). Five patients had hiatal hernias, ranging in size from 3.5–4.5 cm. All 5 hernias were diagnosed and repaired during surgery. Final pathologic examination revealed 5 gastric ulcers, 32 duodenal ulcers, and 10 polyps. Histologic examination identified 3 patients with fundic gland polyps, 6 with hyperplastic polyps, and 1 with adenomatous polyps. Thirty-eight patients underwent resection of the excluded stomach. Forty-eight patients tested positive for H. pylori and 23 received routine preoperative antibiotic treatment. Discussion The role of gastroscopy has not been fully recognized LRYGB for the treatment of obesity is widely recognized, but whether a preoperative routine gastroscopy should be performed remains controversial. For example, Muñoz et al. [7] reports that all patients should undergo preoperative gastroscopy, whereas Azagury et al. [8] suggests that it should only be performed in patients with preoperative symptoms. Interestingly, both researchers reported the same rate of abnormalities in their respective studies (46%). Gastroscopy can visualize the various diseases of the upper gastrointestinal tract in a flexible manner and also facilitate biopsy. After decades of development, it has become a mature technology. However, it is a painful option for many patients who are planning to undergo surgical treatment for morbid obesity or metabolic syndrome, and a preoperative gastroscopy may appear to be
Routine gastroscopy before LRYGB / Surgery for Obesity and Related Diseases ] (2014) 00–00
unjustified to these “benign” patients. The additional cost may also be problematic. Finally, there are even some patients who are reluctant to have their underlying diseases visualized by gastroscopy. There are various explanations for the lack of standardized preoperative examinations in China. Apart from the above described patient-related factors, some physicians also want to avoid the difficulties associated with preoperative examinations and may therefore often omit the procedures defined in surgical guidelines/regulations. Some physicians assume that preoperative examinations have limited value and will not directly affect the surgical procedures and outcomes, particularly in patients with benign lesions. Consequently, too often, omission of preoperative examinations results in missed diagnoses and misdiagnoses, thus prejudicing some patient's health. Obesity is associated with gastritis As shown in our present study, preoperation gastroscopy showed that 159 of 180 patients (88.3%) had varying degrees of chronic superficial gastritis. About half of them (69 patients, 38.3%) also had erosions. Although chronic gastritis did not affect the subsequent procedure of LRYGB, its high incidence (88.3%) strongly supports an association between obesity and chronic gastritis. Dutta et al. [9] found that 23.7% of 101 morbidly obese patients had gastritis, which is a significantly greater proportion than the 11.8% reported for age- and sex-matched patients with BMIs within the normal range. Notably, the rate of infection with H. pylori, which is 1 of the most important causes of gastritis, does not differ significantly between these 2 groups. These data clearly demonstrate the association between obesity and gastritis. A recent study in Japan also indicated that morbid obesity is one of the causes of gastritis (particularly erosive gastritis) [10]. Along with increases in BMI, the proportion of patients with gastritis has also increased, which might be attributable to amounts of fat connexin. These findings are consistent with our results. Diagnosis and treatment of hiatal hernia Hiatal hernia was found in 5 patients (2.8%) during preoperative gastroscopy. During LRYGB, all of these patients underwent intraoperative exploration, all were confirmed to have hiatal hernia, and all hernias were repaired. A preoperative gastroscopy performed as part of the routine examination before LRYGB can help doctors understand the hiatal hernia in advance so they are better prepared before surgery. In addition, double checking both preoperatively and intraoperatively can reduce misdiagnosis, and can provide a better chance of successful treatment. LRYGB alone is effective management for gastroesophageal reflux disease (GERD) in patients with hiatal hernia. According to Frezza et al. [11], over a 3-year follow-up GERD symptoms
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disappeared or improved in approximately 80% of morbidly obese patients who had undergone LRYGB for GERD. Despite LRYGB being so effective, hiatal hernia repair was still performed in our series because of the risks associated with GERD accompanying hiatal hernia. All 5 patients with preoperative gastroscopy were found to have reflux esophagitis, which was likely attributable to the presence of a hiatal hernia. All 19 reflux esophagitis patients had typical GERD symptoms, which resolved or improved postoperatively by the time of discharge. This improvement may have been attributable to the effectiveness of LRYGB itself. There were too few of these patients to warrant further follow up. To ensure that any abnormalities missed on gastroscopy were identified, intraoperative exploration for hiatal hernia was also performed in patients in whom hiatal hernia had not been suspected during preoperative gastroscopy. Interestingly, no hiatal hernias were detected among these patients, reflecting the high accuracy rate of preoperative gastroscopy. Again, no definite conclusions can be reached because there are too few cases. There are a number of studies that have reported more instances of hiatal hernia being found with a gastroscopy before LRYGB (8.6–90.2%) than that observed in our study (2.8%) [7,8,12–19]. But whether a hiatal hernia should be repaired remains controversial. A possible justification for repair of hiatal hernias is that it may decrease the risk of the proximal stomach entering the thoracic cavity after LRYGB, which changes the structure of the digestive tract and makes the proximal stomach very small. A small proximal stomach may more easily enter the thoracic cavity [15]. Ulcers, precancerous lesions, and cancers As indicated in a recent meta-analysis, increased BMI is associated with increased risk of some common and not so common malignancies, especially esophageal adenocarcinoma and colon cancer [20]. High BMIs are associated with some cancer types in both sexes. Chronic GERD is an important cause of esophageal adenocarcinoma. Therefore, in obese patients, in addition to assessing structures within the stomach, a preoperative gastroscopy should include careful examination of the esophagus to ensure that diagnosis of the highly prevalent esophageal adenocarcinoma is not missed. Beltran et al. [21] also reported on the accidental discovery of gastrointestinal tumors in bariatric operations, which perhaps suggests the importance of a preoperative examination before a bariatric operation. In our series, gastric ulcers (1.7%), duodenal ulcers (17.8%), and polyps (5.6%) were also found during preoperative gastroscopy. They are risk factors for cancer and are therefore important. After gastric bypass surgery, gastric acid continues to be secreted, but the operation changes the anatomic structure of the stomach. As there is no food to dilute the gastric acid, it directly stimulates ulcers and exacerbates the condition. Even if ulcers are treated with preoperative proton pump inhibitor treatment, the
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high-intensity acid stimulation is likely to result in the recurrence of ulcers. Gastric polyps may have a malignant tendency [22–25], and there is the possibility of relapse. Azagury et al. [8] performed prophylactic gastrectomies for 2 cases of fundic gastric gland polyps because of the risk of polyp residual and because there could be no examination after bariatric operation, despite there only being a small chance of the polyps becoming malignant. Zeni et al. [17] also reported on a case of a partial gastrectomy for benign polyps. The number of patients with LRYGB is currently relatively low in China. A search of the literature resulted in no articles being found that mentioned the recurrence rate of distal gastric ulcers/polyps after ulcers/polyps had been treated. It is extremely difficult to perform gastroscopy of the distal stomach after LRYGB. Sleeve gastrectomy (SG) is also associated with good weight loss effects, and has attracted increasing attention in recent years. SG is beneficial in obese patients with ulcers or polyps, given that it is a low-risk procedure that involves no conversion of the gastrointestinal tract and less resection of the stomach. However, the indications and long-term effects of SG remain to be verified in large case numbers [26]. LRYGB is still regarded as the “gold standard” treatment for obesity and metabolic disorders, and shows good and long-lasting effects in terms of weight loss [2]. Patients in the present study were given detailed information on the long-term safety, efficacy, and risks of the procedure, and all gave their informed consent for distal gastrectomy being performed by LRYGB. Furthermore, H. pylori can cause various gastric disorders, gastric cancer in particular. With recent technological developments, it is possible to detect H. pylori in gastric biopsies taken during gastroscopy. Thus, during preoperative gastroscopy both morphologic observation and tissue biopsy can be performed to screen for H. pylori infection and early gastric cancer. The prevalence of gastric cancer is high in China, these cancers being located in the distal stomach in most Chinese patients. Because LRYGB changes the anatomy of the digestive tract, only special forms of gastroscopy can visualize the excluded stomach, which makes thorough post-LRYGB examinations more challenging. Therefore, gastroscopy before LRYGB is particularly valuable. Polyps and deep ulcers identified during gastroscopy were removed during the subsequent surgery. Anti-H. pylori medical treatment should be initiated before surgery in patients with this infection. And for patients with gastric cancer, the surgical procedure should be changed. Unfortunately, tests for H. pylori infection were not performed routinely in all patients in our series. Necessity for preoperative gastroscopy Preoperative gastroscopy is highly effective and accurate in identifying lesions and the specific anatomic structures in individual patients. It is also helpful for visualizing the
volume and morphology of the stomach, thus providing particularly valuable information about individual anatomy for surgeons. This in turn can shorten the operative time and reduce surgery-associated risks and incidence of complications. It is optimal practice for the same surgeon to perform both the preoperative gastroscopy and the subsequent surgical procedure. However, this is an unrealistic goal in some clinical settings. Alternatively, the surgeon can be present during the gastroscopy, during which he/she may guide the endoscopist to find small lesions and obtain other relevant information that may not be noted in the written report. In this way, the surgeon can arrange more tailored treatment, which will benefit both the medical staff and the patient. Six studies have reported on the rate of preoperative abnormal gastroscopic findings, which ranged between 12 and 91% [7,12–15,27]. These studies suggest that routine gastroscopy should be performed before LRYGB. In recent years, many Chinese hospitals have introduced various novel gastroscopes with smaller blind areas, better camera quality, and clearer images. Because these gastroscopes provide many unique advantages that cannot be replaced by other imaging techniques, they have become an important means of examining for upper gastrointestinal lesions. As medical devices and technology continue to advance, gastroscopy will certainly become safer and more efficient in the future. Conclusion Gastroscopy is a useful examination before LRYGB. It can help physicians to develop tailored therapies and procedures and thus improve the prognosis considerably. Gastroscopy should be routinely performed on Chinese patients who are planning to undergo bariatric surgery. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] National Institutes of Health. Gastrointestinal surgery for severe obesity. National Institutes of Health Consensus Development Conference Statement Online. 1991:9:1–20. http://consensus.nih.gov/ 1991/1991 gisurgeryobesity084 html.htm. [2] Khwaja HA, Bonanomi G. Bariatric surgery: techniques, outcomes and complications. Curr Anaesth Crit Care 2010;21:31–8. [3] Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 1994;4: 353–7. [4] Ferlay J, Bray F, Pisani P, Parkin DM. GLOBOCAN 2002. Cancer incidence, mortality and prevalence worldwide. IARC Cancer Base No. 5, version 2.0. Lyon: IARC Press, 2004. [5] He J, Chen WQ. 2012 Chinese Cancer Registry Annual Report. Beijing, Military Medical Science Press, 2013.
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