Role of endoscopy in the bariatric surgery of patients

Abstract

Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett's esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett's esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.

Keywords: Complications; Endoscopic therapy; Endoscopy; Morbid obesity; Obesity surgery.

Figure 1

Patient with late hemorrhage after Roux-en-Y gastric bypass: endoscopic view shows a marginal ulceration with a visible vessel at the base of the lesion.

Figure 2

Multiple erosions in the anastomosed jejunum.

Figure 3

Patient with fistula after sleeve gastrectomy. A: Endoscopic view of fistula at the upper portion of staple line in a patient after laparoscopic sleeve gastrectomy; a clip is visible on the boundary of the fistulous orifice as a result of a unsuccessful previous attempt at treatment; B: Fully covered removable stent (Taewoong Niti-S™ esophageal Mega stent) was implanted, promoting healing of the fistula.

Figure 4

Different steps of endoscopic Lap-Band extraction. A: Endoscopic view of an almost penetrated band, with only a small tissue bridge holding the device to the gastric wall; B: Endoscopic view of the AMI gastric band cutter (CJ Medical, Haddenham, United Kingdom) passed around the band after endoscopic resection of the tissue bridge; C: After the section, the band is grasped at the connection with the port-site, and extracted through the mouth; D: Gastric pouch outlet aspect after ring extraction (retrovision from the stomach).

Figure 5

Laparoscopic assisted endoscopic retrograde cholangiopancreatography after Roux-en-Y gastric bypass. A side-viewing endoscope is inserted through a 15-mm trocar that was previously placed into the excluded stomach. Subsequently, endoscopic retrograde cholangiopancreatography is performed in the usual fashion.