Researchers from South Tyneside & Sunderland NHS Foundation Trusts, Sunderland, UK, have reported that the majority of bariatric surgeons worldwide offer routine pre-operative esophago-gastro-duodenoscopy (EGD), with a smaller proportion offering routine post-operative EGD. The findings were reported in the paper, ‘Routine Use of Esophago-gastro-duodenoscopy (EGD) in Bariatric Surgery—an International Survey of Our Current Practice’, published in Obesity Surgery.
In 2020, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued recommendations on the routine use of EGD before and after bariatric surgery (Brown WA et al IFSO Position Statement on the Role of Esophago-Gastro-Duodenal Endoscopy Prior to and after Bariatric and Metabolic Surgery Procedures. Obes Surg. 2020 Aug;30(8):3135-3153).
Nevertheless, the authors noted that the role of unselected EGD in asymptomatic patients remains a contentious issue with variations in practice. Advocates against routine pre-operative EGD state resource allocation, false positives and low yield of pathology especially in the Caucasian population, as well as the risks of bleeding, perforation and aspiration, as reason against carrying out the procedure. Therefore, the researchers undertook an international study to establish bariatric surgeon’s practice on the routine use of EGD with regard to IFSO recommendations, via an online survey, assessing their practice on the use of EGD.
The survey included questions asking surgeons if they offer EGD for asymptomatic patients in the following settings: pre-operative, post-operative at one year, every two-three-years following longitudinal sleeve gastrectomy (LSG) or one-anastomosis gastric bypass (OAGB). Follow-up questions were asked to determine which factors contributed to their selective practice, including but not limited to patient and surgical factors.
In total, there were 121 responses from consultants (80.2%), specialists (4.1%) and higher surgical trainees (15.7%). The commonly performed procedures were LSG (99%), RYGB (94%) and OAGB (55%). The survey revealed that 53.7% (n=65) of surgeons routinely offer pre-operative EGD for patients before a bariatric procedure and 14.3% (n=17) of surgeons routinely offer post-operative EGD for bariatric patients at one year after their procedure (Figure 1). Most respondents did not routinely offer EGD after LSG (74.6%) or OAGB (79.7%) every two-three years as proposed by IFSO.
The researchers noted that for pre-operative EGD, there was a statistically significant association between volume of bariatric surgery cases per institution and surgeon’s practice on the use of EGD (p=0.0214), for surgeons practicing in low-volume centres, a greater proportion offered pre-operative EGD, compared to those in high-volume centres.
“Our survey is the first international study to examine bariatric surgeons’ practice on the use of EGD since the publication of the IFSO position statements...” the authors explained. “Several factors could account for surgeons deciding not to offer EGD, such as low suspicion of abnormal pathology, availability of EGD, financial implications on patient and/or institution, cost-effectiveness, and lack of awareness of current recommendations.”
Interesting, the researchers noted that it is possible that the COVID-19 pandemic might have impacted surgeons’ practice and they called for further research by means of a registry study to accurately determine the scope of endoscopic investigations, especially in the post-operative setting.
The authors added that further research is necessary to develop robust evidence-base for the role of endoscopy after bariatric surgery with the inclusion of patient and public involvement.
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