Surg Endosc DOI 10.1007/s00464-010-0893-5
Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery M. A. Ku¨per • T. Kratt • K. M. Kramer • M. Zdichavsky • J. H. Schneider • J. Glatzle • D. Stu¨ker • A. Ko¨nigsrainer • B. L. D. M. Bru¨cher
Received: 10 August 2009 / Accepted: 7 January 2010 Springer Science+Business Media, LLC 2010
Abstract Background Obesity is becoming an epidemic health problem and is associated with concomitant diseases, such as sleep apnea syndrome and gastroesophageal reflux disease (GERD). There is no standardized diagnostic workup for the upper gastrointestinal tract in obese patients; many patients have no upper gastrointestinal symptoms, and few data are available on safety of endoscopy in morbidly obese patients. Methods Sixty-nine consecutive diagnostic upper gastrointestinal endoscopies in morbidly obese patients (26 men, 43 women; mean age 43.4 ± 10.9 years) were prospectively evaluated from January to December 2008 in an outpatient setting before bariatric procedures. Sedation was administered with propofol. Data on sedation, critical events, and examination times were recorded, as well as pathological findings. Results The patients’ mean body mass index was 47.6 ± 7.9 (range, 35.1–73.3) kg/m2; 17.4% reported GERD symptoms. The mean duration of the endoscopy procedure (including sedation) was 20.3 ± 9.3 (range, 5–50) min, and the whole procedure (including preparation and postprocessing) took 58.2 ± 19 (range, 20–120) min. The mean propofol dosage was 380 ± 150 (range, 80–900) mg. Two patients had critical events that required bronchoscopic intratracheal O2 insufflation due to severe hypoxemia (\60% M. A. Ku¨per and T. Kratt contributed equally to this manuscript. M. A. Ku¨per (&) T. Kratt K. M. Kramer M. Zdichavsky J. H. Schneider J. Glatzle D. Stu¨ker A. Ko¨nigsrainer B. L. D. M. Bru¨cher Department of General, Visceral and Transplant Surgery, Tu¨bingen University Hospital, Hoppe-Seyler-Strasse 3, 72076 Tu¨bingen, Germany e-mail:
[email protected]
SaO2). Nearly 80% of patients had pathological findings in the upper gastrointestinal tract. Only 20% reported upper gastrointestinal symptoms. Pathologic conditions were found in the esophagus in 23.2% of the patients, in the stomach in 78.2%, and in the duodenum in 11.6%. The prevalence of Helicobacter pylori infection was 8.7%. Conclusions Upper gastrointestinal endoscopy can be performed safely. However, careful monitoring and anesthesiological support are required for patients with concomitant diseases and those receiving sedation. Because 80% of the patients with pathological findings were asymptomatic, every morbidly obese patient should undergo endoscopy before bariatric surgery because there may be findings that might change the surgical strategy. Keywords Morbid obesity Upper gastrointestinal endoscopy Upper gastrointestinal pathologies Esophagus Stomach Duodenum Sedation
Morbid obesity is associated with different concomitant diseases, such as arterial hypertension, diabetes mellitus, coronary heart disease, or sleep apnea syndrome. Other obesity-associated diseases include pathological conditions in the upper gastrointestinal tract, such as gastroesophageal reflux disease (GERD) [1, 2] and an increased incidence of esophageal and gastric cancer [3]. Obesity has been identified as an independent risk factor for the development of GERD [2], and the association between morbid obesity and GERD might be a possible explanation for the increased incidence of esophageal cancer in morbidly obese patients [3], because GERD is a well-known risk factor for the development of esophageal adenocarcinoma [4, 5]. However, classic symptoms of GERD, such as heartburn, noncardiac chest pain, and recurrent posterior laryngitis often
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are absent in obese individuals, leading to difficulties in diagnosing GERD in these patients. In patients with morbid obesity, surgery is a treatment option associated with good medium-term and long-term results [6, 7], with procedures such as gastric banding, sleeve gastrectomy, gastric bypass, and biliopancreatic diversion. These operations can now be performed laparoscopically in most obesity centers throughout the world [8–10]. However, there is evidence that the chosen procedure might be changed, if specific pathological upper GI findings are known preoperatively. For example, gastric banding should be avoided in cases of known hiatal or paraesophageal hernia [11–14] or gastric bypass is recommended in cases of Barrett’s esophagus caused by GERD [14, 15]. Because morbidly obese patients per se are at high perioperative risk, the chosen procedure should be as safe as possible. Therefore, endoscopic evaluation of the upper GI tract may be useful for detecting pathological findings that might negatively influence the postoperative outcome. Few studies have focused on preoperative upper gastrointestinal endoscopy in patients with morbid obesity in whom bariatric procedures are planned [16–23]. In the guidelines on the diagnostic workup and preoperative preparation for bariatric surgery patients, upper gastrointestinal endoscopy is not currently recommended, because most of the patients have no upper gastrointestinal symptoms [24] and there is a lack of data on the safety of endoscopy in these critical patients. Due to the concomitant diseases present in morbidly obese patients, especially diabetes mellitus because patients have to fast overnight before endoscopy or sleep apnea syndrome, which may lead to severe hypoxemia during sedation, upper gastrointestinal endoscopy has to be conducted with special monitoring, leading to considerable technical and personnel expenses. Because data on upper gastrointestinal endoscopy and the prevalence of pathological upper gastrointestinal conditions are still scarce for morbidly obese patients, the present study was conducted to evaluate the effort and safety associated with upper gastrointestinal endoscopy in these critical patients and the prevalence of pathological upper gastrointestinal conditions in morbidly obese patients.
Patients and methods Study population The authors’ department participates in an interdisciplinary obesity working group that includes bariatric surgeons, endocrinologists, sports medicine specialists, psychosomatic physicians, and dietitians. Thorough diagnostic workup is performed for every patient who is referred to
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the unit for obesity therapy. When conservative treatment for morbid obesity (e.g., low-calorie diet, physical activity program, behavioral training, and pharmacological treatment) is unsuccessful, the indication for bariatric surgery is assessed by the members of the working group in an interdisciplinary conference. Before any planned bariatric procedure, patients undergo upper gastrointestinal endoscopy routinely in our department. From January to December 2008, 69 consecutive morbidly obese patients in whom bariatric surgery was indicated and upper gastrointestinal endoscopy was performed in an outpatient setting were enrolled in this prospective evaluation.
Upper gastrointestinal endoscopy Upper gastrointestinal endoscopy was performed by one of three experienced investigators before the bariatric operation. After providing written, informed consent to undergo endoscopy, patients were asked about upper gastrointestinal symptoms before the endoscopic examination. Endoscopy was performed with the patients asked to fast overnight. Endoscopy was performed with sedation if requested by the patient; standard sedation was with propofol, which was extended to midazolam (plus ketamine) if necessary. Endoscopy was performed with the patient in the left-lateral position when possible. During examination, patients received a supply of 5 l of O2 via a nasal tube. The following parameters were recorded during the procedures: • •
Duration of the endoscopy itself (including sedation). Duration of the whole procedure (including preparation and postprocessing). • Heart rate, blood pressure, and oxygen saturation during endoscopy. • Amount of sedation. • Critical events: aspiration, severe hypotension (BPsyst \ 80 mmHg) and severe hypoxemia (SaO2 \ 60%) with emergency intubation. Pathological findings Upper gastrointestinal endoscopy was performed in the standard setting as described earlier. If pathological findings were seen, a biopsy was taken from the suspicious area for histological examination. The endoscopic findings were only recorded as pathological if the histological examination showed corresponding findings. All patients were examined for Helicobacter pylori colonization of the gastric body and antrum, using a commercial urease test for H. pylori (Heipha, Dr. Mu¨ller Ltd., Eppelheim, Germany).
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Statistics
Table 2 Endoscopic procedure and sedation (n = 69)
All data were analyzed using the SPSS for Windows 13.0 program (SPSS Inc., Chicago, IL, USA). Data are expressed as means ± standard deviation unless otherwise stated.
Results
58 ± 19 (20–120) 20 ± 9 (5–50)
Critical events
2 (2.9%)
Hypoxemia (SaO2 \ 60%)
2 (2.9%)
Hypotension (BPsyst \ 80 mmHg)
0
Aspiration
0
Emergency bronchoscopy
2 (2.9%)
Sedative medication
Demographics and anthropometry Twenty-six men and 43 women were enrolled in the study (Table 1). The patients’ mean age was 43.4 ± 10.9 years, and mean body mass index (BMI) was 47.6 ± 7.9 (range, 35.1–73.3) kg/m2. Diabetes mellitus was present in 50.7% (35/69) and 21.7% (15/69) were known to have sleep apnea syndrome and were receiving nocturnal continuous positive airway pressure ventilation. Only 12 of 69 patients (17.4%) had reported occasional upper gastrointestinal symptoms before the endoscopy. Endoscopic procedure and sedation Five patients (7.2%) were investigated in supine position instead of left-lateral position due to their body weight (Table 2). The mean duration of the whole procedure, including preparation and postprocessing, was 58 ± 19 (range, 20–120) min. Including sedation time, the endoscopy took 20 ± 9 (range, 5–50) min. Critical events occurred in two patients (2.9%), in both cases involving severe hypoxemia (SaO2 \ 60%). Both patients were known to have sleep apnea syndrome. They received emergency bronchoscopic intratracheal O2 insufflation; intubation was not necessary in either patient. No other critical events, such as aspiration or severe hypotension, occurred. Three patients declined sedation. In these patients, endoscopy was performed after administration of local anesthesia in the posterior pharyngeal wall. One male patient (181 cm, 240 kg, BMI 73.3 kg/m2, with sleep apnea syndrome) was examined under primary general Table 1 Demographic and anthropometric characteristics of the patients (n = 69) Age, yr (range)
Duration of whole procedure, min (range) Duration of the endoscopy, min (range)
43.4 ± 10.9 (22–70)
Gender Male
26 (37%)
Female
43 (63%)
BMI, kg/m2 (range)
47.6 ± 7.9 (35.1–73.3)
Diabetes mellitus
35 (51%)
Sleep apnea syndrome GERD symptoms
15 (22%) 12 (17%)
BMI body mass index, GERD gastroesophageal reflux disease
None
3 (4.3%)
Propofol alone
59 (85.5%)
Propofol ? midazolam
5 (7.2%)
Propofol ? midazolam ? ketamine
1 (1.4%)
General anesthesia
1 (1.4%)
Medication dosages, mg (range) Propofol Midazolam
380 ± 150 (80–900) 3.6 ± 0.9 (3–5)
Ketamine
60
anesthesia. Sixty-five patients underwent endoscopy with propofol sedation. The mean dosage was 380 ± 150 (range, 80–900) mg. Five patients also received midazolam (3.6 ± 0.9 mg), and one patient also received midazolam plus ketamine (3 mg ? 60 mg). Pathological findings Fifty-five of 69 patients (79.7%) had at least one pathological finding in the upper gastrointestinal tract (Table 3). However, only 11 of these 55 patients (20%) had reported upper gastrointestinal symptoms before endoscopy, whereas 80% were asymptomatic. Six patients (8.7%) were positive for H. pylori. Pathological conditions in the esophagus were found in 23.2% of the patients (16/69; 8 cases of reflux esophagitis, 1 of Barrett’s esophagus, and 7 other conditions). At least one abnormality in the stomach was observed in 78.2% (54/69; 19 hiatal hernias, 25 cases of gastritis, 16 peptic ulcers, 1 paraesophageal hernia, and 11 other conditions). A further 11.6% (8/69) had disorders in the duodenum (2 ulcers and 6 other conditions).
Discussion In this study, upper gastrointestinal endoscopy in morbidly obese patients was evaluated regarding effort as well as safety in an outpatient setting, and it was used to investigate the prevalence of upper gastrointestinal tract diseases in patients with morbid obesity. Patients with morbid obesity often have concomitant diseases that are relevant in connection with upper gastrointestinal endoscopy—e.g.,
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Surg Endosc Table 3 Pathological findings and correlating preEGD symptoms in the upper gastrointestinal tract Lesion
Prevalence
PreEGD symptoms
Esophagus
16 (23.2%)
4 (25%)
Reflux esophagitis
8 (11.6%)
4 (50%)
Barrett’s esophagus
1 (1.4%)
0
Polyps
2 (2.9%)
0
Other
5 (7.2%)
0
Stomach Hiatal hernia
54 (78.2%) 19 (27.5%)
10 (18.5%) 3 (15.8%)
Gastritis
25 (36.2%)
3 (12%)
Peptic ulcer
16 (23.2%)
Polyps
4 (25%)
6 (8.7%)
0
Submucous tumor
2 (2.9%)
0
Other
3 (4.3%)
0
Helicobacter pylori
6 (8.7%)
Duodenum
8 (11.6%)
2 (25%)
Ulcer
2 (2.9%)
1 (50%)
Bulbitis
3 (4.3%)
1 (33.3%)
Submucous tumor
1 (1.4%)
0
Other
2 (2.9%)
0
diabetes mellitus (patients have to fast overnight before the examination) and sleep apnea syndrome (which can lead to problems during sedation). The data show that endoscopy can be performed safely, but anesthesiological support is strongly recommended in patients with critical conditions. Approximately two-thirds of patients with morbid obesity have pathological conditions in the upper gastrointestinal tract, without experiencing any symptoms. The prevalence of morbid obesity has been steadily increasing during the last 10 years. Obesity is associated with many concomitant diseases, such as diabetes mellitus, sleep apnea syndrome, and GERD. However, typical upper gastrointestinal symptoms of GERD, such as heartburn and chest pain, often are absent in these patients. Manometry and pH-metry studies have shown that both symptomatic and asymptomatic morbidly obese individuals have a reduced resting pressure in the lower esophageal sphincter, as well as disturbed esophageal motility, which can lead to an increased incidence of GERD in these patients [25–29]. However, data for macroscopic findings in the upper gastrointestinal tract in morbidly obese patients are still scarce and contradictory regarding both peri-procedure morbidity and rates of pathological findings [16–19]. The data in the present study show that approximately 80% of morbidly obese patients have at least one pathological condition in the upper gastrointestinal tract. In addition, approximately 80% of patients in whom endoscopic or histological findings are identified have no upper gastrointestinal tract
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symptoms. Nearly two-thirds of morbidly obese patients have no symptoms despite pathological conditions in the upper gastrointestinal tract. In addition to conservative options, such as special dietary programs, behavioral therapy, and various exercise programs, treatments for obesity include bariatric surgical procedures, such as adjustable gastric banding (AGB), sleeve gastrectomy (SG), or Roux-en-Y gastric bypass (RYGBP). In the present study, nearly 80% of the patients had pathological findings in the stomach, which is affected by any bariatric procedure. There were, of course, many findings (such as gastritis) that are of no relevance to the choice of bariatric procedure. On the other hand, there were findings, such as hiatal or paraesophageal hernia, which may be exacerbated after AGB [11–14]: peptic ulcers may be problematic in SG if the resection line runs through the ulcer or in RYGBP if the ulcer is located in the gastric remnant and ulcer bleeding occurs during the postoperative course [30]; submucous tumors or polyps should be extendedly diagnosed by endoscopic ultrasound and (endoscopically) resected before any bariatric procedure when indicated, because morbid obesity is an independent risk factor for the development of upper gastrointestinal malignancies and because there are reports of incidental intraoperative findings of gastric tumors during bariatric surgery [31]. The endoscopic workup in the upper gastrointestinal tract before bariatric procedures is not yet standardized, because most patients do not report any upper gastrointestinal symptoms [24]. Due to concomitant diseases, morbidly obese patients are likely to be exposed to significant risks during upper gastrointestinal endoscopy. Because an overnight fasting period is necessary for adequate upper gastrointestinal endoscopy, obese patients with diabetes mellitus may experience problems with their metabolic status. In addition, patients with sleep apnea syndrome need intensive surveillance during sedation, and assistance (e.g., Esmarch’s maneuver) is usually required to avoid hypoxemia. The resources required for outpatient endoscopy are consequently more extensive in obese patients than in normal-weight individuals. However, there are few data about the safety of upper gastrointestinal endoscopy in morbidly obese patients. Most studies report pathological findings or present a cost analysis. The present study shows that these critical patients can be examined safely despite relevant concomitant diseases and high dosages of sedative medication. However, critical events still occurred in two patients during endoscopy, both involving severe hypoxemia despite Esmarch’s maneuver and O2 insufflation. Both patients had sleep apnea syndrome and required emergency bronchoscopic intubation and intratracheal O2 insufflation via the bronchoscope. Orotracheal intubation was not necessary in either patient;
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the bronchoscope could be removed at the end of the endoscopic procedure and they were discharged from the hospital on the same day. The rate of 2.9% for critical events in upper gastrointestinal endoscopy means an approximately 10-fold increase in morbidly obese patients compared with the rates in large endoscopic series with unselected patients [32]. With one patient undergoing the endoscopic examination under primary general anesthesia, the results show that approximately 5% of the patients need anesthesiological support. In addition, due to the need for special surveillance, the procedure requires substantial time and personnel resources. In conclusion, the present study found that a high proportion of morbidly obese patients who were asymptomatic had histopathological findings in the upper gastrointestinal tract. Because there also were incidental findings, such as submucous tumors in the stomach and duodenum, which need to be diagnosed and potentially be resected before a Roux-en-Y gastric bypass because they cannot be reached endoscopically afterwards, as well as findings, such as reflux esophagitis and Barrett’s esophagus in which the patient needs special endoscopic surveillance, we would recommend that upper gastrointestinal endoscopy should be performed in all patients in whom bariatric procedures of any sort are planned. These examinations should be performed by experienced investigators (in case emergency bronchoscopy is needed), and anesthesiological support should be available due to the significant amount of sedation required and the concomitant diseases present in these patients (particularly sleep apnea syndrome). Disclosures M. A. Ku¨per, T. Kratt, K. M. Kramer, M. Zdichavsky, J. H. Schneider, J. Glatzle, D. Stu¨ker, A. Ko¨nigsrainer, and B. L. D. M. Bru¨cher have no conflicts of interest or financial ties to disclose.
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