Back to Annual Meeting Program

Background: Evaluation of upper GI mucosa and anatomy is important prior to bariatric surgery. Esophagogastroduodenoscopy (EGD) can diagnose H.pylori infection (HP), mucosal inflammation and hiatal hernia (HH). HP can be treated preoperatively and the degree of GERD and HH may influence the choice of bariatric procedure. Mucosal biopsy adds to the cost of EGD and some endoscopists do not "routinely" biopsy for HP if the gastric mucosa appears normal. The goal of this study was to determine the relationship between gross visual findings on EGD and histopathology. We also examined the ability of EGD to accurately diagnose hiatal hernia.

Method: A retrospective review of prospectively collected data of a single surgeon (TSK) series of laparoscopic non revisional bariatric procedures at a center of excellence between 2010-2012. Preoperative EGD was performed on all patients. Patients without a gastric biopsy were excluded from analysis. Endoscopic appearance (gross) was considered positive if there were any signs of inflammation or hiatal hernia. The gross and histological appearances were compared. Biopsy results (histology) and laparoscopic evaluation of the hiatus were considered the gold standard Sensitivity (SS) and specificity (SP) of the gross EGD appearance were calculated.

Results: There were 274 patients in the study group. Mean age and BMI were 42.8 and 43.3 respectively. The majority of the patients were female (88%). Procedures included: 189 laparoscopic gastric bypass, 69 laparoscopic sleeve gastrectomy and 16 laparoscopic adjustable gastric bands. There were 57 HH confirmed at the time of surgery (20%). Preoperative EGD identified 21 of these (SS=.37, SP=.86). H. pylori was identified in 34 patients (12.5%); 19 of these patients had gross inflammatory changes on EGD (SS=.56, SP = .58). Gross gastric inflammatory changes were identified in 63/125 patients that had histological gastritis (SS=.50, SP=.64). There were 12 patients with histological GERD, 8 of these patients had grossly inflamed esophageal mucosa (SS=.67, SP=.24).

Conclusion: EGD prior to bariatric surgery can provide important information that may alter preoperative interventions and influence the choice of bariatric procedure. Our findings suggest that the gross appearance during EGD is unreliable for detecting histological inflammation, infection (HP) and HH. Thus, we recommend routine gastric biopsies to maximize H. pylori detection during EGD. Furthermore, if the presence of a hiatal hernia could change a procedural recommendation, a complimentary upper GI evaluation should be considered.