Place of upper endoscopy before and after bariatric surgery: A multicenter experience with 3219 patients

Table 1 Classification system for endoscopic findings

Group 0: No findings

Normal study

Group 1: Abnormal findings that do not change surgical approach/ postpone surgery

Mild esophagitis, gastritis, and/or duodenitis

Esophageal webs

Group 2: Findings that change the surgical approach/postpone surgery

Mass lesions (mucosal/submucosal)

Ulcers (any location)

Severe erosive esophagitis, gastritis, and/or duodenitis

Barrett’s esophagus

Bezoar

Hiatal hernia (any size)

Peptic stricture

Zenker’s diverticula

Esophageal diverticula

Arteriovenous malformations

Group 3: Absolute contraindications to surgery

Upper GI cancer

Varices

GI: Gastrointestinal.

Table 2 Patient characteristics

Variable	Summary = 3219
Age	37 ± 9 yr
Female:male	79%:21%
BMI	43 ± 13
Haemoglobin	13 ± 4 g/dL
Upper GI symptoms: 902 (28%)1
Heartburn	19.2%
Acid regurgitation	17.6%
Abdominal pain	7.3%
Nausea with or without vomiting	5.7%
Comorbedities: 1159 (36%)2
Obstructive sleep apnea	4.9%
Hypertension	57.8%
Arthritis	56.9%
Diabetes mellitus	40.5%
Hypothyroidism	36.6%
Asthma/COPD	15.1%
Coronary artery disease	9.9%
Type of endoscopy
Conscious sedation	354 (11%)
Local anesthesia spray	2865 (89%)
Type of bariatric procedure
Vertical sleeve gastrectomy	2415 (75%)
Roux-en-Y gastricbypass	322 (10%)
Laparoscopic minigastric bypass	482 (15%)

¹Some patients have more than one symptoms;

²Some patients have more than one comorbidity. GI: Gastrointestinal.

Table 3 Endoscopic findings during routine upper gastrointestinal endoscopy and their prevalence

EGD findings	Group A (n = 902)	Group B (n = 2317)	P value
Esophagus
Normal = 65%	19%	46%	0.001
Abnormal = 35%	25%	10%	0.001
Hiatal hernia	21.9%	7.9%
Esophagitis	19%	6%
Barrett’s esophagus	1.1%	0.1%
Stomach
Normal = 77%	24%	53%	0.001
Abnormal = 23%	17%	6%	0.001
Spotty gastropathy	4%	1.3%
Erythematous gastropathy	7%	2.5%%
Erosive gastropathy	8%	1.2%%
Atrophic gastropathy	1%	0.48%
Multiple polyps	0.1%	0.02%
Ulcer	2.4%	0.5%
Duodenum
Normal = 87%	23%	64%	0.001
Abnormal = 13%	9%	4%	0.001
Erythematous bulbopathy	6%	2.2%
Erosive bulbopathy	2.6%	1%
Ulcer	1.4%	0.8%
+ve biopsy for H. pylori, 407 (14.6%)	10.7%	3.9%	0.001

EGD: Esophagogastroduoudenoscopy; H. pylori: Helicobacter pylori.

Table 4 Lesions identified on upper endoscopy and impact on bariatric surgery, n = 219 (6.8%)

Lesion	Group A	Group B	Result
Hiatal hernia	25%	10%	Crural repair/reduction of hernia
Gastritis	17%	6%	Medical treatment, postpone surgery
Esophagitis	19%	6%	Medical treatment, postpone surgery
Gastric ulcer	2.4%	0.5%	Await biopsy results, medical treatment, repeat endoscopy
Barrett’s esophagus	1.1%	0.1%	Await biopsy results, medical treatment, repeat endoscopy
Duodenal ulcer	1.4%	0.8%	Await Helicobacter pylori results, medical treatment

Table 5 Univariate analysis of clinical predictors of abnormal upper endoscopy

Variables	Total population	Normal EGD (65%)	Abnormal EGD (35%)	P value
Age (yr)	37 ± 9	31 ± 9	43 ± 10	0.26
BMI	43 ± 13	43 ± 11	47 ± 16	0.09
Gender (F:M)	79%:21%	64%:36%	69%:31%	0.17
GIT symptoms	13.80%	72%	28%	0.001
Haemoglobin (g/dL)	13 ± 4	13 ± 3.4	11 ± 3.2	0.07
Comorbidities	36%	52%	48%	0.18

F: Female; M: Male; EGD: Esophagogastroduodenoscopy; BMI: Body mass index; GIT: Gatrointestinal tract.

Table 6 Multivariate regression analysis of clinical predictors of abnormal esophagogastroduodenoscopy

Variables	OR	95%CI	P value
Age	1.414	0.772-2.59	0.26
BMI	1.092	0.923-1.723	0.38
Gender	0.225	0.028-1.826	0.162
GIT symptoms	2.649	1.904-3.684	0.001
Comorbidities	0.68	0.335-1.381	0.286
Anaemia	0.945	1.241-2.093	0.274

OR: Odds ratio; GIT: Gastrointestinal tract symptoms; BMI: Body mass index

Table 7 Clinical and endoscopic characteristics of bleeding episodes

	1st episode n = 119	2nd episode n = 40	3rd episode n = 11
Presentation
Hematemesis	93	33	5
Melena	39	19	9
Hypotension	17	3	-
Management
EGD	28	7	-
Observation	91	33	11
Blood transfusion	43	19	3
Prominent findings on EGD
Active blood oozing	17/28	7/3
Bleeding vessel	28/6	7/4
Adherent clot	28/4	-
Other findings (visible vessel, red streaks, etc.)	28/4	-
Endoscopic therapy
Epinephrine injection	10	5
Heater probe	9	4
Clip	7	3

EGD: Esophagogastroduodenoscopy