Morbid obesity is an epidemic health problem responsible for more than 300 000 deaths annually in the US [1,2•]. Weight loss surgery remains the only therapy that reliably achieves sustained weight loss and significant reduction in obesity-related comorbidities such as diabetes mellitus, hypertension, and congestive heart failure [1,3]. An estimated 220 000 bariatric surgeries were performed in the US and Canada during 2009 [4,5]. The role of the gastroenterologist has been gradually increasing in the management of bariatric surgical patients in recent years. This involves preoperative and intraoperative evaluations, the postoperative recognition and management of complications, as well as the long-term downstream care of these patients. It is therefore essential for the gastroenterologist to be knowledgeable in all areas of their care.
The article will start by discussing the gastroenterologist's role preoperatively, intraoperatively, and postoperatively emphasizing the early recognition and management of bariatric surgical complications. Subsequently, we will review issues of long-term care relevant to the gastroenterologist. Finally, we will conclude by raising the concept of bariatric endoscopy which may provide alternatives to bariatric surgery in the future.
Preoperative esophagogastroduodenoscopy (EGD) should be performed for all patients prior to Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric band (LAGB) [6•,7••]. EGD prior to RYGB is crucial to look for potential disease processes in the distal stomach and proximal small bowel which will be difficult to access postoperatively [8••]. Endoscopy prior to LAGB is needed to look for large hiatal hernias since they are associated with higher rates of band slippage and may warrant alternative bariatric intervention [8••]. In patients who are to undergo bariatric procedures other than RYGB or LAGB, preoperative EGD is warranted if they are symptomatic since endoscopy may alter the planned surgical procedure or timing of surgery in 4–12% of patients [7••]. If patients are asymptomatic, the need for EGD is somewhat controversial as data in this population remain limited [6•,7••]. In light of this, radiographic studies and evaluation for Helicobacter pylori by serology should be considered since they provide an alternative means for preoperative risk stratification. These recommendations are further elaborated in a position statement by the American Society for Gastrointestinal Endoscopy .
Gastroenterologists may be asked by their surgical colleagues to perform intraoperative endoscopy during RYGB. EGD in this setting helps the surgeon immediately assess staple lines for hemorrhage, evaluate pouch size, measure stomal diameter, and test for integrity of the gastrojejunal anastomosis and pouch to help prevent early postoperative leaks [7••]. During leak testing, the surgeon clamps the Roux limb and submerges the gastrojejunal anastomosis and pouch in saline while the endoscopist pneumatically insufflates the lumen. Leaks may be identified as bubbles emanating from a staple line and promptly repaired by the surgeon. Pooled data from 1930 patients undergoing intraoperative pneumatic testing successfully identified leaks in 7.3% of patients, with a subsequent postoperative leak rate of 0.7% [7••]. This postoperative leak rate is notably lower than the estimated leak rate of 1.4% to 2% for all RYGB procedures that were not evaluated intraoperatively .
Bariatric surgical complications may occur early or late in the postoperative course in up to 40% of patients [11,12]. Early complications such as bleeding, infection, and anastomotic leaks are traditionally managed surgically . Some late complications such as anastomotic strictures and marginal ulcers can be managed endoscopically. This section will review the postsurgical anatomy of the gastrointestinal tract following LAGB and RYGB, outline common symptoms which may herald a postoperative complication, and then discuss the recommended endoscopic approach to these complications.
It is essential for the gastroenterologist to fully understand postoperative gastrointestinal tract anatomy in order to recognize potential symptoms and complications that may arise. The RYGB is formed by partitioning the stomach into a proximal gastric pouch and distal gastric remnant by means of a laparoscopic stapling device (Fig. 1). The jejunum is incised 10–30 cm distal to the ligament of Treitz and the distal jejunal ‘Roux’ limb is anastomosed to the gastric pouch. The proximal ‘biliopancreatic’ limb is attached downstream, creating a separate jejunojejunal anastomosis.
LAGB consists of an adjustable gastric band, a subcutaneous port, and tubing connecting the band and port (Fig. 2). The band is secured laparoscopically around the proximal stomach just distal to the gastroesophageal junction. The anterior aspect of the band is sutured in the region of the cardia to reduce band slippage [8••]. When saline is infused into the port, it passes through the tubing and expands the band's reservoir, thereby increasing gastric restriction.
Common postoperative symptoms include inadequate weight loss, nausea and vomiting, and abdominal or retrosternal pain [8••,14].
Inadequate weight loss
Up to 25% of patients undergoing bariatric surgery experience inadequate weight loss, thus extensive preoperative counseling is mandatory to help establish realistic weight loss goals. It can be a diagnostic challenge to determine if inadequate weight loss is due to operative failure or dietary noncompliance. Endoscopy remains the best way to assess the integrity of the postoperative anatomy and is indicated when weight loss is less than anticipated despite appropriate dietary habits [8••]. Anatomic disturbances that may cause inadequate weight loss include pouch dilation, dilation of the gastrojejunal anastomotic aperture, and gastrogastric fistula formation.
Nausea and vomiting
Nausea and vomiting are common postoperative symptoms and are often due to dietary indiscretion, which may include rapid or large-volume food intake or inadequate mastication [8••]. An initial management strategy should include dietary counseling and modification if dietary indiscretions are identified. However, nausea and vomiting may also be hallmark symptoms of an anatomic problem such as an anastomotic stricture, reflux esophagitis, marginal ulcer, band erosion or slippage, or gastrogastric fistula [15••]. When nausea and vomiting are particularly relentless, endoscopy is warranted . Endoscopy is also indicated in patients who experience a dramatic change in their ability to tolerate food and in patients who experience ongoing nausea despite appropriate dietary habits [15••].
Abdominal pain and retrosternal pain
Epigastric abdominal pain and retrosternal pain are abnormal postoperative complaints which may indicate a wide variety of pathologic causes including band erosion, bile or acid reflux, development of an abscess or seroma, or mucosal ulceration. If a patient's history suggests that dietary factors are playing a role, dietary counseling is a reasonable first step. Endoscopy is warranted for moderate-to-severe pain or when dietary changes fail to alleviate pain in order to evaluate for stomal stenosis, marginal ulceration, and other structural abnormalities. If abscess or seroma formation is of concern, prompt abdominal CT scan is indicated [15••].
Endoscopic management of complications common to Roux-en-Y gastric bypass and laparoscopic adjustable gastric band
Luminal stenosis and gastrointestinal bleeding are postoperative complications that are common to RYGB and LAGB.
The gastrojejunal anastomosis is the most common site of stenosis following bariatric surgery. Stenosis may also occur at the region of a gastric band, at sites of adhesions, or at the jejunojejunal anastomosis.
Gastrojejunal anastomotic strictures occur in 5.1–6.8% of patients following RYGB and typically present within the first year following surgery [8••]. The incidence of anastomotic stenosis is technique-dependent, with stapled anastomoses yielding a higher stricture rate than those which are hand sewn . The mainstay of treatment for gastrojejunal anastomotic strictures is endoscopic balloon dilation, although the use of Savary-Gilliard dilators (Cook Medical, Indiana, USA) has also been described [8••]. Repeat dilation with progressively larger balloons may be required to achieve durable results. Studies demonstrate that 17–67% of patients respond to the first dilation, whereas 3–8% of patients require three or more dilations . The selection of an appropriate initial balloon depends on a number of factors including the caliber of the stricture and the presence of suture or staple material that may inhibit full balloon expansion [16,17]. Some apprehension exists that excessive balloon dilation of the anastomosis may lead to subsequent weight gain due to loss of physiologic restriction at the anastomosis. However, data suggest that initial gastrojejunal stricture dilation to 15 mm can be done safely in the majority of cases without resultant weight gain, thereby reducing the need for repeat dilation [8••,18]. When standard dilation is unsuccessful, additional strategies may be required such as removal of exposed sutures with endoscopic scissors, injection of the anastomosis with saline or steroids after dilation, or needle-knife electocautery of scar tissue [8••,15••].
Luminal stenosis following LAGB may be due to fibrosis of gastric tissue in the region of the band, band angulation or slippage, or formation of adhesions. Whereas fibrotic-related stenosis may be effectively treated with dilation, stenosis due to band angulation or slippage is rarely able to be managed endoscopically [15••]. Surgical options in this scenario include band replacement or conversion to RYGB.
Significant upper gastrointestinal bleeding occurs in approximately 1–4% of patients after RYGB and may be acute or chronic [7••]. It commonly occurs at the staple line of the gastrojejunal anastomosis and may be associated with marginal ulceration. Hemorrhage may also occur at staple lines of the gastric remnant, pouch, or jejunojejunal anastomosis. Thorough examination of the Roux and biliopancreatic limbs is technically challenging and may require the use of an enteroscope, colonoscope, balloon enteroscope, or shape-locking overtube [15••]. The endoscopic management of early postoperative bleeding after RYGB is complicated by the risk of perforation at immature surgical anastomotic sites. Some experts advocate early operative intervention with or without laparoscopically assisted endoscopy in this setting [7••]. If early postoperative endoscopy is considered, it must be conducted in the operating room setting under general anesthesia to permit immediate operative intervention should perforation occur or endoscopic intervention fail [7••,19].
Early postoperative gastrointestinal bleeding is less common following LAGB, and standard upper endoscopy is usually sufficient for management of hemorrhage in this situation.
Endoscopic management of complications following Roux-en-Y gastric bypass
Gastrojejunal anastomotic dilation, staple-line disruption, and marginal ulceration may all complicate RYGB.
Dilation of the gastrojejunal anastomosis
Widening of the gastrojejunal anastomosis may present as weight regain due to failure of the anastomosis to restrict food intake. Multiple endoscopic techniques to address this complication have been described. Endoscopic sclerotherapy with circumferential injection of sodium morrhuate at the anastomosis has been used successfully for stomal contraction and offers a nonsurgical treatment modality . Endoscopic suturing provides an alternative means for stomal reduction. The EndoCinch system (C.R. Bard Inc., New Jersey, USA) has been used to position sutures at the rim of dilated gastrojejunal anastomoses . When tightened, the sutures form tissue plications that effectively reduce aperture diameter and result in variable but significant weight loss. The Incisionless Operating Platform (USGI Medical, Inc., California, USA) is a modality that allows for endoluminal cutting, sewing, tissue manipulation, and creation of tissue plications. Multicenter experience with this platform for gastrojejunal stomal dilation demonstrated a 50% mean reduction in stomal diameter with mild-to-moderate weight loss observed over a 1-year follow-up period . Other promising techniques using clips, endoscopic suturing devices, fibrin glue, and argon plasma coagulation are evolving and may provide innovative strategies for reduction of anastomotic aperture. More confirmatory data are needed before these techniques can be routinely recommended.
Staple-line disruption, fistulas, and leaks
Staple-line disruption may result in extraluminal leaks or gastrogastric fistulas. Extraluminal leaks are particularly dreaded complications that occur in up to 5.6% of patients after RYGB and may result in peritonitis, abscess formation, sepsis, and death [8••]. One series of 63 patients with leaks after RYGB reported a mortality rate of 10% . The management of early postoperative leaks remains primarily surgical and there is little role for endoscopy in this setting [7••]. Endoscopic evaluation of suspected leaks should only be considered in a stable patient whose diagnosis remains uncertain or in the rare case in which an endoscopic intervention is planned. Endoscopic management of leaks has been described in small series using partially covered self-expanding metal stents, Polyflex stents, argon plasma coagulation, endoscopic clips, and fibrin glue [24,25]. Such methods remain investigational at this time and are solely to be considered as an adjunct to surgical therapy.
Techniques for the endoscopic management of chronic gastrogastric fistulas are being actively investigated . In one series of 95 patients with small, symptomatic gastrogastric fistulas, endoscopic repair was attempted with the EndoCinch suturing system or endoscopic clips using a mean of 2.2 sutures or 3 clips [27•]. Whereas fistula closure was achieved in 95% of patients, reopening occurred 65% of the time at a mean of 177 days. Fistula size predicted long-term outcomes, with the best results observed in fistulas 10 mm or less in diameter. Other investigators used the technique of endoscopic peristomal mucosectomy followed by the use of an endoscopic tissue opposition device to achieve temporary gastrogastric fistula closure . Whereas temporary fistula repair may be feasible endoscopically, long-term durability remains an ongoing challenge. Additional long-term data will be needed before these methods can be routinely recommended [7••].
Marginal ulcers develop in 0.6–16% of patients following RYGB [15••]. They occur most commonly in the first several months following surgery with a progressively decreased incidence thereafter. In one series, marginal ulcers were found endoscopically at 1 month following surgery in 4.1% of patients after open RYGB and 12.3% after laparoscopic RYGB, with 28% of all ulcers occurring in the absence of symptoms [29•]. Contributing factors to ulcer formation include local tissue ischemia, use of nonsteroidal anti-inflammatory drugs, foreign body reactions to staples or sutures, gastrogastric fistula, H. pylori infection, and surgical factors including pouch orientation and size.
The role of endoscopy in the management of marginal ulcers is primarily diagnostic; however, as ulcers may represent foreign body reactions to sutures or staples, judicious removal of foreign material with endoscopic scissors may lead to ulcer resolution [8••]. The endoscopic approach to marginal ulceration begins with a careful inspection of the gastric pouch and gastrojejunal anastomosis. Gastrogastric fistulas result in increased exposure of the pouch and stoma to gastric acid, making the mucosa more vulnerable to damage [15••]. In the absence of staple-line dehiscence, management of stomal ulcers includes a test-and-treat approach to H. pylori, smoking cessation, initiation of a proton pump inhibitor, and avoidance of ulcerogenic medications . If a marginal ulcer is exceptionally large and unresponsive to conservative therapy, surgical revision may be required.
Endoscopic management of complications following laparoscopic adjustable gastric band
Complications that pertain solely to LAGB include gastric band erosion and band slippage. These complications may present with a myriad of symptoms including gastroesophageal reflux, peptic ulcer disease, and luminal stenosis [8••].
Band erosion occurs in 1.6–3% of patients following LAGB [8••]. Diagnosis is best accomplished endoscopically with direct visualization of the band eroding through gastric mucosa. Adjustable gastric band extraction cannot be performed solely by means of endoscopy due to the presence of tubing that connects the band to the subcutaneous port. Adjustable band removal is best handled surgically with either band excision and replacement or conversion to RYGB [15••].
Band slippage, as shown radiographically in Fig. 3, is another complication that may occur after LAGB and is best diagnosed by upper gastrointestinal series . The endoscopic appearance of band slippage is variable and dependent on the degree of slippage encountered. Findings may include an enlarged pouch size with or without associated gastritis or distal esophagitis. Severe cases are potentially life-threatening and may present endoscopically as mucosal ulceration or tissue necrosis [8••].
Long-term management of patients following bariatric surgery
Morbid obesity and rapid weight loss are independent risk factors for gallstone formation. The challenges presented by postoperative choledocholithiasis are therefore issues of long term relevance to the gastroenterologist.
Choledocholithiasis after Roux-en-Y gastric bypass
Bariatric surgical patients have a high rate of both preoperative and postoperative choledocholithiasis for which stone extraction may be required . A standard approach to endoscopic retrograde cholangiopancreatography (ERCP) is quite feasible after LAGB. In contrast, RYGB anatomy poses a technical challenge for the endoscopist when biliary access is required [31••]. Successful biliary cannulation after RYGB depends on a variety of factors including operator skill and the lengths of the biliopancreatic and Roux limbs. The largest series to date in this population reported successful papillary cannulation in 10 out of 15 patients .
In cases when biliary access following RYGB is unattainable, a variety of techniques may permit successful biliary cannulation. ERCP using single or double balloon-assisted enteroscopes can help the endoscopist more effectively pleat the small bowel, thereby improving rates of advancement of the endoscope to the papilla . Pooled data from centers with experience in balloon-assisted enteroscopy demonstrate an 80% success rate in papillary cannulation in RYGB anatomy [31••]. Another well described approach is laparoscopic-assisted ERCP. In this technique, transgastric ERCP is performed through a trocar placed surgically into the excluded portion of the stomach. Once the trocar is in place, the endoscopist is able to advance a duodenoscope to the papilla for biliary access [31••]. Other researchers have described the use of percutaneous gastroenterostomy tubes placed into the excluded stomach as conduits for successful ERCP. All of these approaches are reasonable means to address the difficult quandary of ERCP after RYGB. Selection of an individual technique is dependent on the resources available to the endoscopist and the skill set of the operator.
Potential future applications of bariatric endoscopy
There is considerable interest in the development of well tolerated and effective endoscopic alternatives to surgery for primary weight loss. To date, no such method has been perfected. This section will discuss investigational applications of endoscopy to achieve weight reduction.
Endoscopic gastroplasty has been performed using both endoscopic stapling and suturing devices. Initial studies on a system for transoral gastroplasty (TOGa; Satiety Inc., California, USA) reported encouraging results for the endoscopic creation of a stapled-restrictive pouch along the lesser curvature of the stomach . Figure 4 demonstrates the steps used by TOGa for pouch creation. A randomized, sham-controlled trial to assess the safety and efficacy of TOGa is currently underway.
Endoluminal vertical gastroplasty using the EndoCinch system utilizes endoscopic suturing to restrict the volume of the gastric lumen (Fig. 5) . In a trial of 64 patients, endoluminal vertical gastroplasty resulted in a decrease in the mean body mass index from 39.9 to 30.6 without serious adverse events reported . Similar short-term efficacy of endoluminal vertical gastroplasty was reported in 16 patients within the US and a randomized, multicenter trial is ongoing at this time . Well designed trials with long-term follow-up will be necessary to determine the durability of weight loss, particularly since long-term stability of the gastric plications remains unproven [37••].
The BioEnterics Intragastric Balloon (Allergan Inc., California, USA) (Fig. 6) is an endoscopically placed balloon that occupies the gastric lumen, thereby limiting functional intragastric volume . Studies on the use of this balloon over 3-month and 1-year intervals have resulted in significant weight loss, although concern for potential gastrointestinal obstruction has been raised [8••,37••]. It may have value in specific patients by providing a bridge to surgery in high-risk, severely obese individuals who may otherwise be nonoperative candidates [8••,39]. Firm evidence of the long-term safety and efficacy of the intragastric balloon is lacking, and it remains unapproved by the Food and Drug Administration for use in the US.
Duodenojejunal bypass sleeve
Endoluminal appliances used to induce gastrointestinal malabsorption remain in an early stage of development but may offer great potential for long-term weight loss [37••]. The EndoBarrier duodenojejunal bypass sleeve (GI Dynamics, Massachusetts, USA) is an endoscopically deployed prosthesis comprised of a self-expanding implant which lodges in the duodenum and is attached to a 60-cm plastic sleeve that extends to the proximal jejunum (Fig. 7). In a trial of 25 patients, the sleeve stayed in place over a 3-month period in 80% of patients and achieved noninvasive duodenal exclusion and short-term weight loss . However, major adverse events occurred in 20% of patients and included anchor migration, stent obstruction, and upper gastrointestinal bleeding. Further studies will be needed to clarify the safety and efficacy of this device and it remains unapproved for use within the US.
As the prevalence of morbid obesity continues to rise, gastroenterologists will care for bariatric surgical patients with increasing frequency. It is imperative that gastroenterologists be knowledgeable about their role in the management of bariatric patients preoperatively, intraoperatively, and postoperatively in the early recognition of complications and their endoscopic management. As technology continues to evolve, we can anticipate new endoscopic platforms which will broaden the application of endoscopy for the morbidly obese patient leading to bariatric endoscopy. This is a term we are using here to refer to primary endoluminal weight loss procedures that provide a well tolerated and effective alternative to surgery. These techniques are on the horizon and offer the promise of less invasive weight loss strategies for the morbidly obese patient. However, to date the use of such techniques cannot be routinely recommended outside the realm of a clinical trial. Until then, the role of endoscopy in this burgeoning field, which was very limited in the recent past and seems to be expanding at an exponential rate, is curtailed only by our imagination.
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 668–669).
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