Video-endoscopic capsule could be alternative to EGD prior to bariatric surgery

Updated: Mar 24

Upper gastrointestinal video-endoscopic capsule (VEC) could be valid alternative to routine esophagogastroduodenoscopy (EGD) prior bariatric surgery, according to researchers from the University of Naples Federico II, Naples, Italy. The findings were featured in the paper, 'New endoscopic capsule vs upper gastrointestinal endoscopy in preoperative work-up of obese candidate for bariatric surgery: Relevance of a pilot study in the COVID-19 era', published in the journal, Endoscopy International Open.

Figure 1: Comparison of upper gastrointestinal VEC images with those for EGD.|

The current rationale for performing EGD is to detect and treat lesions that could potentially impact the choice of the procedure being performed and the endoscopic findings may result in postoperative complications or symptoms. However, EGD may carry higher risks in patients with high rates of respiratory problems, such as sleep apnoea, respiratory decompensation and oxygen desaturation during sedation.


An alternative to ERDG is a model of video-endoscopic capsule (VEC) has been introduced for the study of the upper gastrointestinal tract (Ching HL, Healy A, Thurston V. et al. Upper gastrointestinal tract capsule endoscopy using a nurse-led protocol: first reported experience. World J Gastroenterol 2018; 14: 2893-2901), presented as a comfortable, noninvasive, well-tolerated, and well-performing alternative to an upper endoscopy, which allows EGD to be performed on a select minority of patients who really need it for biopsies or treatment.


The aim of this study was to determine if a kind of new upper gastrointestinal VEC is an adequate diagnostic alternative to EGD in preoperative work-up of obese patients selected for bariatric surgery, particularly in the setting of COVID-19.


For the study, all patients selected for bariatric surgery were asked to undergo an upper gastrointestinal VEC evaluation and an EGD the next day. This sequence was chosen to avoid misinterpretation during VEC of mucosal traumas from an endoscope touching or sucking possible vascular lesions.


Images from each upper gastrointestinal VEC procedure (PillCam upper gastrointestinal, Medtronic) were interpreted by two medical experts, separately and blinded to each other, to reach a higher level of agreement. For the same reason, the data from each EGD ware analysed by two expert endoscopists, separately and blinded to each other: the first during the endoscopic of the procedure; the second one subsequently, by viewing the recorded file of the procedure. Primary endpoint of the study was to define a noninferiority of upper gastrointestinal VEC compared to EGD in detecting upper gastrointestinal diseases or focal lesions in obese patients prior to bariatric surgery. To evaluate the general discomfort evoked during upper gastrointestinal VEC and EGD, a questionnaire was administered after each procedure.


In total, 26 patients were enrolled in the study; eight men (30.8 %) and 18 women (69.2 %); mean age was 37 ± 8.7 years, with a mean BMI of 46.88 ± 6.56 kg/m2. Nine patients (34.6 %) had type 2 diabetes mellitus (T2DM).


Upper gastrointestinal VEC

Complete examination of the second duodenum (D2) was achieved in all patients. The mean (± SD) time of capsule transit in the oesophagus, stomach, and duodenum was 29 seconds (± 98), 65 minutes (± 21), and 12 minutes (± 16), respectively. The transit time of the capsule through the oesophagus, stomach, and duodenum was irrelevant to the aims of the study, as transit occurred while the patient was discharge, therefore the transit time was not calculated. Mean residence time in the endoscopic room was 7.27 minutes (± 1,43) for activation of capsule endoscopy.


The mean reading time for capsule video was 46 minutes (± 15) with standard mode. The long average reading time was due to the use of a new device, specific for upper gastrointestinal assessment, and the readers had experience with the ileum and colon capsule. This was the first study that evaluated bariatric patients with a new, specific device, and for this reason, the reading time was longer. No specific challenges were reported.


Pathologies detected by upper gastrointestinal VEC included 16 hiatal hernias, nine esophagitis, eight gastric erythemas, six gastric erosions, five vascular alterations, and two duodenitis; four examinations were normal. The degree of satisfaction of the readers was complete.

In our experience, there was a significant interoperator agreement in terms of visibility score both at all sites of the stomach (fundus, body, antrum) (p<0.001) and in all explored tracts (p<0.001).


EGD

There were no adverse events during any examinations; in one case orotracheal intubation was required. In nine patients, the endoscopic intubation was regular, in six patients it was difficult, and eight patients were agitated during the examination despite premedication. In three other patients, aesthetic assistance was requested.


Mean residence time in the endoscopic room was 38.8 minutes (±5.7), of which, 13.4 minutes (±1.33) was for endoscopy. Pathologies detected by EGD included 18 hiatal hernias, nine esophagitis, eight gastric erythemas, four gastric erosions, four vascular alterations, one hyperplastic polyp, and two duodenitis; five examinations were normal.


There was significant inter-operator agreement in terms of visibility score at all sites in the stomach (p<0.001). Considering the global evaluation of all explored tracts, the correlations between the two endoscopists were even higher (p<0.001).


Considering the primary endpoint, upper gastrointestinal VEC detected 47 upper gastrointestinal pathologies and EGD detected 47. There was no difference in detection of significant lesions. EGD and VEC concomitantly identified hiatal hernia (n=16), esophagitis (n=9), gastric erythema (n=8) and erosive duodenitis (n=4). VEC alone additionally identified two cases of gastric erosions and one of angioectasia. However, EGD alone identified two additional hiatal hernias and one hyperplastic polyp.


In detail, for the gastric evaluation, fundus, body, and antrum were separately assessed. No gastric fundal lesions were revealed by VEC or EGD; EGD missed erosions in two patients and one vascular lesion detected by VEC in the body. Moreover, EGD revealed one hyperplastic polyp of the body missed by VEC. No differences were noted for antrum evaluation with two techniques.

Based on the findings from VEC, all 26 patients were identified as potentially being safe to undergo surgery, as well as EGD.


No complications were seen with VEC or EGD. Mean residence time in the endoscopic room was 7.27 minutes (± 1,43) and 38.8 minutes (± 5,7) for upper gastrointestinal VEC and EGD, respectively (p<0.05). All upper gastrointestinal VEC procedures were conducted with only one experienced nurse while EGDs required a mean of 3.2 staff members (one nurse, one endoscopist and one anaesthetist in some described cases).


Furthermore, considering patient-reported discomfort, VAS for VEC was significantly lower compared to that of EGD (0.27 ± 0.7 vs 5 ± 1.98, respectively p<0.001).


“In conclusion, our report seems to confirm that upper gastrointestinal VEC, compared with EGD, shows diagnostic noninferiority in detecting significative lesions in preoperative work-up of obese patients prior to bariatric surgery,” the authors concluded. “These results lead us to propose that upper gastrointestinal VEC could be the real first-line endoscopic diagnostic test in obese asymptomatic patients selected for bariatric surgery…A multicenter experience, in a larger sample of patients, is required to confirm our preliminary results.”


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