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Endoscopic Evaluation of the Bariatric Surgery Patient

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The SAGES Manual of Physiologic Evaluation of Foregut Diseases

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Abstract

With the continued rise of obesity worldwide, the number of metabolic and bariatric surgeries performed annually continues to grow. The standard of practice of obesity surgery keeps evolving and so has the surgical techniques and the standardized guidelines. As witnessed in other gastrointestinal surgical disciplines, the use of endoscopy has become an essential adjunct in the evaluation and management of the patient. Upper endoscopy is frequently used during various phases of care, including preoperatively, intraoperatively, and postoperatively. Many factors must be taken into account when performing an endoscopic evaluation, including medical and surgical history, in-office or hospital-based setup, postoperative imaging, the sedation matter, and the indication for endoscopy.

This chapter aims to provide an overview discussion on the application and usefulness of upper gastrointestinal endoscopy and its technical aspects in the preoperative, intraoperative, and postoperative care of the bariatric patient.

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Author information

Authors and Affiliations

  1. Barijuve Surgical, Darien, IL, USA

    Sofiane El Djouzi

Authors
  1. Sofiane El Djouzi
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Correspondence to Sofiane El Djouzi .

Editor information

Editors and Affiliations

  1. Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA

    Ankit D. Patel

  2. BMI Surgical Institute, Atlanta, GA, USA

    Amir Aryaie

  3. Department of Surgery, University of Alabama at Birmingham and Birmingham VA Health Care System, Birmingham, AL, USA

    Jayleen Grams

  4. Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA

    Leena Khaitan

Editors’ Note

Editors’ Note

See Figs. 16.1, 16.2, 16.3, and 16.4.

Fig. 16.1
7 post gastric bypass endoscopic views of a patient. They demonstrate the pouch length, outlet size, presence or absence of a hiatal hernia, esophagus, gastric cardia, Roux-en-Y, and gastrojejunostomy.

Endoscopic views in a patient after Roux-en-Y gastric bypass. Important factors to note include the length of the pouch, the size of the outlet of the pouch (in scope diameters), and the presence/absence of a hiatal hernia. The LES can also be examined to subjectively determine whether it is patulous. Finally, the scope should be passed as distally as possible in the roux limb to determine length (if the jejunojejunostomy can be reached) and there should be no bile in the roux limb

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Fig. 16.2
26 post gastric bypass endoscopic views of a patient, arranged in 7 rows. They feature a normal outlet size of the pouch, esophagus, J J anastomosis, Roux-en-Y, gastrojejunostomy pouch, G J pouch with hiatal hernia, and gastric cardia, among others.

Another patient’s upper endoscopy after a gastric bypass. This patient had a hiatal hernia, a normal outlet size at the gastrojejunostomy. However, the roux limb was noted to be short at 50 cm and bile seen at the jejunojejunostomy as expected

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Fig. 16.3
11 endoscopic views of a patient post gastric banding. A, 2 retroflexed views present gastric body with the evidence of previous surgery. B, 5 views demonstrate the food in the esophagus after the band placement. Another 4 views present in situ band with no erosion.

Endoscopy after a gastric banding. The size of the pouch is very important from the gastroesophageal junction to the band. An excessive amount of stomach above the band is considered a slip. Also, a retroflexed view beyond the band can be helpful to identify erosions. (a) Retroflexed view showing band in place with no erosion. (b) Food in esophagus after band placed suggesting band to tight. Band in place with no erosion

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Fig. 16.4
17 endoscopic views of post-vertical sleeve gastrectomy. A, 9 views feature the different orientations of the gastric sleeve and a staple line. B, 8 views feature jejunum, tightly held incisura to the scope, presence, or absence of hiatal hernia.

Endoscopy after vertical sleeve gastrectomy. (a) The sleeve should be tubular proximally and have a reasonable view through the incisura into the distal stomach where the staple line ends 5–7 cm proximal to the pylorus. Retroflexion in the distal stomach shows an open incisura as in panel 12. Retroflexion in the proximal stomach can be difficult in tighter sleeves. (b). In panel 7, the incisura tightly holds the scope on retroflexion. This is an undesirable finding on endoscopy in a sleeve. In panels 14 and 15, one can see a hiatal hernia and patulous LES, which can contribute to reflux after a sleeve

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El Djouzi, S. (2023). Endoscopic Evaluation of the Bariatric Surgery Patient. In: Patel, A.D., Aryaie, A., Grams, J., Khaitan, L. (eds) The SAGES Manual of Physiologic Evaluation of Foregut Diseases. Springer, Cham. https://doi.org/10.1007/978-3-031-39199-6_16

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