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Unsedated Thin-Caliber Endoscopy Is Efficient and Cost Effective for Pre-Surgical Evaluation of Bariatric Patients
Wei-Chung Chen*1, Michael J. Bartel1, Horacio J. Asbun2, Maria Vazquez Roque1, Michele Lewis1
1Gastroenterology, Mayo Clinic Florida, Jacksonville, FL; 2Surgery, Mayo Clinic Florida, Jacksonville, FL
Background: Upper endoscopy (EGD) is routinely performed as preoperative evaluation for bariatric surgery. Abnormal findings are often seen EGD during the preoperative bariatric evaluation; however, recent data indicates that these findings rarely change the overall surgical management. Often, the dilemma of performing EGD in the bariatric patient is the risk of procedural sedation and the increased use of resources required to complete the procedure. Current policy at a single institution states that patients with body mass index (BMI) greater than 50 that require an EGD for bariatric surgery will have an anesthesia consult and often the procedure is performed in the operating room.
Aim: To evaluate the use of unsedated thin caliber endoscope in preoperative evaluation for bariatric surgery in terms of reducing patient risk, resource utilization and cost while maintaining quality.
Method: Initial retrospective review of bariatric patients that underwent sedated endoscopy using conventional endoscopy (sEGD) was reviewed. Afterwards, a new protocol was developed for unsedated endoscopy using thin caliber gastroscope (uEGD), and patients were enrolled prospectively for data collection. Specific variables collected include age, gender, BMI, endoscopic findings, immediate complications, length of procedure, and cost. After the procedure, uEGD patients completed an oral survey to assess tolerance using scale of 0 to 3 (0 = no discomfort, 1 = mild discomfort, 2 = moderate discomfort, 3 = severe discomfort) and preference regarding sedation for future procedures.
Result: Seven patients underwent uEGD and 3 patients underwent sEGD from September 2015 until November 2015. Please see table 1 for results. There were no differences in age, gender and BMI between the groups. Recovery room time in uEGD was significantly decreased compared to sEGD (p = 0.016). Estimated non-medicare/out of pocket cost for uEGD was significantly lower than sEGD (p = 0.008). Similar results can be noted for estimated medicare cost (p = 0.012). Successful biopsies of the stomach were taken from the stomach to rule out for Helicobacter pylori in all patients except for one patient due to the need for anticoagulation. One patient was found to have H. pylori on biopsy. No immediate complications were recorded for all patients. Survey results (Table 2) of patients that underwent uEGD using thin caliber scope demonstrate good tolerance and acceptance. Only one patient reported preference for future endoscopic procedures with sedation.
Limitation: Small sample size. Single center
Conclusion: Unsedated ultra-thin EGD was well tolerated by candidates for bariatric surgery. It resulted in significant shorter recovery room time and costs compared with conventional EGD with sedation.
Table 1. Comparison of demographics and clinical data between non-sedated vs sedated groups
| Variable | un-sedated ultra thin endoscopy group (n=7) | sedated conventional endoscopy group (n=3) | p value | | Age (y), mean ± SD | 52.7±10.0 | 47.3±4.2 | 0.407 | | Female sex, n(%) | 5 (71.4) | 2 (66.7) | 1.000 | | BMI, mean ± SD | 44.7±7.2 | 60.9±6.4 | 0.486 | | Height (cm), mean ± SD | 169.2±9.5 | 172.7±6.0 | 0.586 | | Weight (kg), mean ± SD | 128.4±23.9 | 181.7±24.9 | 0.452 | | Location of z-line (cm), mean ± SD | 39.1±3.2 | 38.7±1.2 | 0.816 | | Procedure time (min), mean ± SD | 4.2±1.3 | 8.9±8.0 | 0.42 | | Total procedure time (min), mean ± SD | 116.4±34.6 | 196.7±34.0 | 0.72 | | Recovery time (min), mean ± SD | 24.0±6.7 | 88.0±16.5 | 0.016 | | Estimated non-Medicare/out of pocket cost (dollar), mean ± SD | 3579±111.3 | 7533±100.0 | 0.008 | | Estimated Medicare cost (dollar), mean ± SD | 561±2.2 | 871±2.1 | 0.012 |
Table 2. Patient evaluation of tolerability of unsedated thin-caliber upper endoscopy | | Abdominal pain | Sore throat | Trouble swallowing | Willing to repeat unsedated upper endoscopy in the future | Previous sedated endoscopy in the past | Prefer unsedated or sedated endoscopy | | Patient #1 | 0 | 0 | 0 | Yes | Yes | unsedated | | Patient #2 | 0 | 0 | 0 | Yes | No | unsedated | | Patient #3 | 0 | 0 | 0 | Yes | Yes | unsedated | | Patient #4 | 0 | 0 | 0 | No | No | sedated | | Patient #5 | 0 | 1 | 1 | Yes | No | unsedated | | Patient #6 | 0 | 0 | 0 | Yes | No | unsedated | | Patient #7 | 0 | 1 | 0 | Yes | Yes | unsedated |
0 = No discomfort, 1 = Mild discomfort, 2 = Moderate discomfort, 3 = Severe discomfort
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