1. RESULTS OF ROUTINE PREOPERATIVE ENDOSCOPY FOR BARIATRIC SURGERY IN GERMANY: A STUDY OF 158 PATIENTS Rheinwalt KP¹, Plamper A¹, Kolec S¹, Kleimann E¹, Ehresmann F¹, Rutledge R² Introduction Upper endoscopy is considered by many centres as compulsory prior to bariatric surgery (1). Some investigators found lesions on gastroscopy prior to bariatric surgery in up to 90%, although none of these findings contraindicated surgery (2). To re-evaluate the role of this investigation we performed this retrospective study on 200 consecutive bariatric patients in a single bariatric unit in Germany. ¹Department for Bariatric and Metabolic Surgery St. Franziskus-Hospital Cologne Schoensteinstrasse 63 50825 Cologne, Germany 1. Humphreys LM, Meredith H, Morgan J, Norton S. Detection of asymptomatic adenocarcinoma at endoscopy prior to gastric banding justifies routine endoscopy. Obes Surg 2012;22(4): 594-596 2. Sharaf RN, Weinshel EH, Bini EJ, Rosenberg J, Sherman A, Ren CJ. Endoscopy plays an important preoperative role in bariatric surgery. Obes Surg 2004; 14(10): 1367-1372 3. Verset D, Houben JJ, Gay F, Elcheroth J, Bourgeois V, Van Gossum A. The place of upper gastrointestinal tract endoscopy before and after vertical banded gastroplasty for morbid obesity. Dig Dis Sci 1997; 42(11): 2333-2337 4. Korenkov S, Sauerland S, Shah S, et al. Is routine preoperative upper endoscopy in gastric banding patients really necessary? Obes Surg 2006;16(1): 45-47 5. Levi F, Lucchini F, Gonzalez JR et al. Monitoring falls in gastric cancer mortality in Europe. Ann Oncol 2004(15): 338-345 6. Khitin L, Roses RE, Birkett DH. Cancer in the gastric remnant after gastric bypass: a case report. Curr Surg 2003 Sep-Oct; 60(5): 521-523 7. Vainio HBF. Weight control and physical activity. Lyon: IARC Press; 20029] Methods The patient folders of 200 consecutive bariatric patients (both digitalized and hard copy) where reviewed retrospectively concerning age, sex, BMI, type of operation, reflux symptoms, realization of preoperative gastroscopy, findings such as gastritis, status of helicobacter pylori, oesophagitis, hiatal hernias and other endoscopically detected pathology. Conclusions Results Diagramm 1 : Distribution of bariatric procedures (200 in total) ²Center for Laparoscopic Obesity Surgery 98E Lake Mead Parkway 302, Henderson, NV, USA 200 patients, 146 female (73,0 %), 54 male (27,0 %), mean age 42,6 years (range from 17 to 66), mean BMI 49,0 kg/m² (from 28,5 to 79,4) had bariatric surgery in the period from April 2006 to October 2011. 197 (98,5 %) operations were done laparoscopically, 3 (1,5 %) via open surgery. All of the 95 bypass patients (mainly Roux-en-Y Gastric Bypass and Mini-Gastric-Bypass, few Biliopancreatic Diversions with or without Duodenal Switch), 50 of 81 sleeve gastrectomies and 13 of 24 gastric bandings had preoperative upper endoscopy. 38 % (76) of the patients had preoperative reflux symptoms. Among these, with exception of 2 sleeve gastrectomy patients, all had gastroscopy done prior to the operation. 158 gastroscopies revealed the following pathology: gastritis (87), hiatal hernia (38, among those 34 axial and 4 paraesophageal), H. pylori infection (19), esophagitis (38, among those 6 Barrett’s), benign gastric ulcers (2), benign gastric polyps (2), diffuse non-adenomatous gastric polyposis (1), neuroendocrine neoplasia of the stomach (1, diameter < 1 cm), gastric diverticulum (1). The gastric polyps were eliminated by endoscopy prior to surgery. As endoscopic ablation of the neuroendocrine tumour was not considered to be adequately safe for complete resection, this patient had distal gastrectomy combined with the planned gastric bypass (the specimen indeed revealed a second neuroendocrine lesion). The patient with hyperplastic polyposis had the planned sleeve gastrectomy and stays under long-term endoscopic survey. 158 preoperative gastroscopies in 200 consecutive bariatric patients revealed only two (1,3 %) relevant pathological findings (early stage neuroendocrine tumour, hyperplastic polyposis of the stomach) of which at least one (hyperplastic polyposis) would have been detected by routine postoperative histopathological examination of the specimen. Remarkable were however 6 Barrett’s lesions (3,8 %). This did not contraindicate bariatric surgery but might justify the demand for routine upper endoscopy in the total obese population to detect and treat rising numbers of esophageal adonocarcinomas in earlier stages. In summary the question whether bariatric patients should have routine preoperative gastroscopy seems to depend much more on the given medico-legal and socio-economic scenario than on evidence-based medical and scientific considerations. The authors of this study recommend that all candidates for bypass procedures should be routinely examined by upper endoscopy preoperatively whereas this is not clearly evident for sleeve and gastric banding patients. The results of preoperative upper endoscopy in this series were comparable to those in the literature and did not change the planned bariatric therapy in any case (1, 3). Many centres of obesity surgery recommend gastroscopic evaluation preoperatively (1). Other authors advice to examine only preoperatively symptomatic patients (4). Especially all the bariatric bypass procedures (with exception of BPD in Scopinaro’s original technique with distal gastrectomy) leave in place the blind-closed distal stomach which cannot be studied easily by endoscopy further on. Even though the incidence for gastric cancer continues to decline during the past decades (5) and gastric bypass procedures should be considered as rather cancer- protective measurements (with the distal stomach postoperatively not anymore exposed to potentially cancerogenic alimentary agents, (6)) the authors do not doubt the necessity and value of gastroscopy prior to any gastric bypass procedure. Considering the low percentage of (so far) benign pathological findings in the analysed bariatric patient group, it could be discussed whether occidental candidates for sleeve and gastric banding without any “gastric symptoms” need gastroscopic screening in any case. Sleeve and banding do not intervene with the possibility of postoperative endoscopy. On the other hand the fact of the rising incidence of esophageal adenocarcinoma with possibly 39 % of cases due to overweight (7), some findings in the literature (1) and the high percentage of Barrett’s lesions in our own study could support the demand for preoperative routine endoscopy. In this case consequently the complete obese population (this means around 30% of the general population) should routinely be examined endoscopically to detect Barrett’s and early forms of esophageal adenocarcinoma. Anyway it should be taken into account that the group of bariatrically operated patients will be examined by gastroscopy more frequently in their further live than the average population. Thus the question should be: Why should bariatric patients be screened more thoroughly for upper GI-pathologies than the average population? This question in our opinion might be answered not only under pure medical and scientific considerations but taking into account the medical-legal and forensic point of view in which the very rare post-operative detection of a possibly pre- existing neoplastic gastric condition might trouble the bariatric surgeon. Discussion References LesionsFrequency in 158 upper endoscopies Esophagitis (without Barrett’s) 32 Barrett’s6 Axial hiatal hernia34 Paraesophageal hernia 4 Gastritis87 H. pylori infection19 Peptic gastroduodenal ulcer 2 Single gastric polype2 Gastric diverticulum1 Hyperplastic gastric polyposis 1 Neuroendocrine tumor < 1 cm 1 Table 1: Endoscopic findings P 111