CLINICAL REVIEWSHigh Cost for Low Yield A Systematic Review and Meta-Analysis to Assess Cost of Routine Preoperative Esophagogastroduodenoscopy Before Bariatric SurgeryEvans, Gretchen MD, MPH*; Barker, Abigail PhD†; Simon, Laura MLIS‡; Kushnir, Vladmir MD§Author Information *Department of Internal Medicine §Division of Gastroenterology, Washington University School of Medicine †Brown School of Social Work ‡Becker Medical Library, Washington University in St Louis, St Louis, MO Supported by mentors in Medicine research grant of Department of Medicine, Washington University School of Medicine. The authors declare that they have nothing to disclose. Address correspondence to: Gretchen Evans, MD, MPH, Department of Internal Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110 (e-mail: [email protected]). Journal of Clinical Gastroenterology: May/June 2020 - Volume 54 - Issue 5 - p 398-404 doi: 10.1097/MCG.0000000000001334 Buy SDC Metrics Abstract Routine esophagogastroduodenoscopy (EGD) is an area of continued controversy in the preoperative evaluation for bariatric surgery; more information is needed regarding its impact on surgical management and associated costs. This systematic review and meta-analysis reports rates of abnormalities detected on preoperative EGD that changed operative management or delayed bariatric surgery. Sensitivity analysis examined the impact of controversial findings of hiatal hernia, Helicobacter pylori, gastritis, peptic ulcer disease. Data were used to calculate the cost per surgical alteration made due to abnormalities detected by routine EGD, compactly termed “cost-of-routine-EGD.” Thirty-one retrospective observational studies were included. Meta-analysis found 3.9% of EGDs resulted in a change in operative management; this proportion decreased to 0.3% after sensitivity analysis, as detection of hiatal hernia comprised 85.7% of findings that changed operative management. Half of the 7.5% of cases that resulted in surgical delay involved endoscopic detection of H. pylori. Gastric pathology was detected in a significantly greater proportion of symptomatic patients (65.0%) than in asymptomatic patients (34.1%; P<0.001). Cost-of-routine-EGD to identify an abnormality that changed operative management was $601,060, after excluding controversial findings. The cost-of-routine-EGD to identify any abnormality that led to a change in type of bariatric operation was $281,230 and $766,352 when controversial findings were included versus excluded, respectively. Cost-of-routine-EGD to identify a malignancy was $2,554,506. Cost-of-routine-EGD is high relative to the low proportion of abnormalities that alter bariatric surgery. Our results highlight the need to develop alternative strategies to preoperative screening, in order to improve access and decrease cost associated with bariatric surgery. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.