Comparison of transnasal esophagoscopy and sedated esophagogastroduodenoscopy in the assessment of laryngopharyngeal reflux.

OBJECTIVE: Transnasal esophagoscopy (TNE) in the awake patient and esophagogastroduodenoscopy (EGD) in sedation are both used in the assessment of laryngopharyngeal reflux (LPR). The objective of this study was to compare these two endoscopic methods in contributing to the diagnosis of LPR. METHODS: This study included 54 patients presenting with signs and symptoms suspicious for LPR, which were examined both by TNE and EGD. The contribution of each method to the diagnosis of LPR was evaluated separately and then compared with each other. RESULTS: In detecting LPR, TNE showed a significant higher sensitivity (94% vs. 60%) and accuracy (93% vs. 59%) than EGD, but their specificity was equal (50% each). The most common pathologic findings in both methods were a hiatal hernia (70% vs. 48%) and gaping cardia (69% vs. 24%), followed by peptic esophagitis (41% vs. 24%). CONCLUSION: The value of EGD is limited in the workup of LPR, as sedation tends to mask the subtle findings in this kind of reflux disease.

High Cost for Low Yield: A Systematic Review and Meta-Analysis to Assess Cost of Routine Preoperative Esophagogastroduodenoscopy Before Bariatric Surgery.

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.

Preoperative versus intraoperative diagnosis of hiatal hernia in bariatric population.

BACKGROUND: Hiatal hernia is frequently encountered intraoperatively during bariatric surgery. There is scarce research pertaining to the diagnostic accuracy of a preoperative diagnostic modality in comparison to intraoperative diagnosis, along with patient characteristics and related factors contributing to hiatal hernia. OBJECTIVE: To identify the prevalence and associations of hiatal hernia in the bariatric patient population, we compared the diagnostic accuracy of upper gastrointestinal series and esophagogastroduodenoscopy with the intraoperative findings across various patient characteristics. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, Teaching Hospital, New York, USA. METHODS: Retrospective study of patients from 2015 to 2018 who met National Institutes of Health criteria for bariatric surgery. RESULTS: There were 1094 patients included (135 males, 959 females), with an age range of 18 to 74 years. The diagnostic accuracy was determined by a sensitivity of 64.71% (95% confidence interval [CI] .55-.70), specificity of 74.38% (95% CI .71-.70), positive predictive value of 29.86% (95% CI .24-.30), negative predictive value of 92.59% (95%CI .89-90), likelihood ratio of 2.526, and P value < .0001 for esophagogastroduodenoscopy; a sensitivity of 14.02% (95% CI .08-0), specificity of 98.23% (95% CI .96-.90), positive predictive value of 71.43% (95% CI .50-.80), negative predictive value of 78.35% (95% CI .74-.80), likelihood ratio 7.921, and P value < .0001 were used for upper gastrointestinal series. Hiatal hernia with age <60 years was 17.09% versus 48.44% at >60 years (P < .0001). Hiatal hernia incidence was 17% in Hispanics, 22.5% in Caucasians, and 23.10% in blacks. CONCLUSION: The prevalence of hiatal hernia is 18.92%. There is strong association between hiatal hernia and age and ethnicity and no association based on sex and body mass index. The diagnostic accuracy of upper gastrointestinal series is very low compared with that of esophagogastroduodenoscopy for hiatal hernia. Preoperative diagnosis of hiatal hernia in the bariatric population is not required based on our study. Not only does it lessen the economic burden, patient wait time, and discomfort of an additional study, but preoperative diagnosis does not change, alter, or aid in the intraoperative management of hiatal hernia considering the suboptimal accuracy of preoperative diagnostics, thus deeming them unwarranted.

Watchful waiting versus elective repair for asymptomatic and minimally symptomatic paraesophageal hernias: A cost-effectiveness analysis.

OBJECTIVE: To evaluate the decision of watchful waiting (WW) versus elective laparoscopic hernia repair (ELHR) for minimally symptomatic paraesophageal hernias (PEH) with respect to cost-effectiveness. BACKGROUND: The current recommendation for minimally symptomatic PEHs is watchful waiting. This standard is based on a decision analysis from 2002 that compared the two strategies on quality-adjusted life-years (QALYs). Since that time, the safety of ELHR has improved. A cost-effectiveness study for PEH repair has not been reported. METHODS: A Markov decision model was developed to compare the strategies of WW and ELHR for minimally symptomatic PEH. Input variables were estimated from published studies. Cost data was obtained from Medicare. Outcomes for the two strategies were cost and QALY's. RESULTS: ELHR was superior to the WW strategy in terms of quality of life, but it was more costly. The average cost for a patient in the ELHR arm was 11,771 dollars while for the WW arm it was 2207. CONCLUSION: This study shows that WW and ELHR both have benefits in the management of minimally symptomatic paraesophageal hernias.

Does digestive symptoms require esophago gastroscopy prior to bariatric procedure? Assessment of 6 years' experience.

AIM: Performance of routine preoperative esophagogastroduodenal endoscopy (EGE) in patients undergoing bariatric surgery is still a controversial subject. The purpose of our study was to evaluate the benefits of performing preoperative EGE in a cohort of bariatric patients. MATERIAL AND METHODS: The present retrospective study was performed between March 2010 and June 2016. We divided the study participants into two groups: group A comprised subjects without disturbing upper digestive signs, while group B comprised patients with disturbing upper digestive signs. Logistic regression analysis was used to identify the predictors that might be associated with abnormal outcomes. RESULTS: Our study included 232 patients (who had undergone sleeve gastrectomy, gastric bypass, ileal interposition, or transit bipartition). The average age was 41.4 ± 10.3 years, and the average body mass index (BMI) was 43.6 ± 5.1 kg/m2. Of all the observed gastroscopic abnormalities, the prevalence for gastritis (17.3%), followed by esophagitis (10.2%), hiatus hernia (9.4%), and bulbitis (8.7%). In multivariate regression analysis, the Gastrointestinal Symptom Rating Scale (GSRS) score and upper gastric symptoms were found to be the only independent predictive markers (OR = 2.822, 95% CI: 1.674-3.456 and OR =2.735, 95% CI: 1.827-3.946, respectively). We identified a positive correlation between abnormal EGE findings and postoperative complications. CONCLUSION: Preoperative EGE had a high rate of detection for the possible abnormalities prior to bariatric surgery. Upper gastric symptoms are significant predictive factors of postoperative complications. Performing preoperative EGE for symptomatic patients could help reduce the morbidity and mortality rates in these patients. KEY WORDS: Bariatric surgery, Preoperative endoscopy, Upper digestive symptoms.

Esophagogastric junction morphology assessment by high resolution manometry in obese patients candidate to bariatric surgery.

INTRODUCTION: Obesity is a strong independent risk factor of gastroesophageal reflux disease (GERD) symptoms and hiatal hernia development. Pure restrictive bariatric surgery should not be indicated in case of hiatal hernia and GERD. However it is unclear what is the real incidence of disruption of esophagogastric junction (EGJ) in patients candidate to bariatric surgery. Actually, high resolution manometry (HRM) can provide accurate information about EGJ morphology. Aim of this study was to describe the EGJ morphology determined by HRM in obese patients candidate to bariatric surgery and to verify if different EGJ morphologies are associated to GERD-related symptoms presence. METHODS: All patients underwent a standardized questionnaire for symptom presence and severity, upper endoscopy, high resolution manometry (HRM). EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and < 2 cm); Type III, >2 cm separation. RESULTS: One hundred thirty-eight obese (BMI>35) subjects were studied. Ninety-eight obese patients referred at least one GERD-related symptom, whereas 40 subjects were symptom-free. According to HRM features, EGJ Type I morphology was documented in 51 (36.9%) patients, Type II in 48 (34.8%) and Type III in 39 (28.3%). EGJ Type III subjects were more frequently associated to Symptoms than EGJ Type I (38/39, 97.4%, vs. 21/59, 41.1% p < 0.001). CONCLUSIONS: Obese subjects candidate to bariatric surgery have a high risk of disruption of EGJ morphology. In particular, obese patients with hiatal hernia often refer pre-operative presence of GERD symptoms. Testing obese patients with HRM before undergoing bariatric surgery, especially for restrictive procedures, can be useful for assessing presence of hiatal hernia.

Endoscopic assessment of reflux esophagitis concurrent with hiatal hernia in male Japanese patients with obstructive sleep apnea.

OBJECTIVE: The pathogenetic relationship underlying the high prevalence of gastroesophageal reflux disease (GERD) in patients with obstructive sleep apnea (OSA) remains unclear. In addition, GERD has not been adequately assessed by endoscopy in patients with OSA. The purpose of this study was to use endoscopy to investigate potential interactions among reflux esophagitis, hiatal hernia (HH) and OSA. MATERIAL AND METHODS: A total of 243 consecutive male Japanese participants who underwent both overnight ambulatory polygraphic monitoring and esophagogastroduodenoscopy were retrospectively evaluated in a cross-sectional study. The prevalence and severity of HH and reflux esophagitis were assessed according to the Los Angeles classification and the Makuuchi classification, respectively. Associations among reflux esophagitis, HH and OSA were examined by univariate and multivariate analyses. RESULTS: OSA was diagnosed in 98 individuals (40.3%). Endoscopy-confirmed esophagitis (p = 0.027) and HH (p < 0.001) were significantly more prevalent among patients with OSA. Multivariate regression model analysis adjusted for age, body mass index, visceral obesity represented by waist circumference, presence of OSA, concurrence of OSA and HH, smoking, and alcohol consumption yielded OSA as the only variable significantly associated with HH (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.35-4.99; p = 0.004), while concurrence of OSA and HH was related to reflux esophagitis (OR, 3.59; CI, 1.87-6.92; p < 0.001). CONCLUSIONS: OSA was associated with HH and concurrent OSA and HH with reflux esophagitis in male Japanese patients with OSA. Our results support the hypothesis that complicating HH may link reflux esophagitis to OSA.

Endoscopic assessment of failed fundoplication: a case for standardization.

BACKGROUND: Preoperative endoscopic assessment of the failed fundoplication is instrumental in diagnosis and surgical management. Endoscopy is a routine and essential part of the workup for a failed fundoplication, but no clear guidelines exist for reporting endoscopic findings. This study aimed to compare endoscopic findings reported by community physicians (gastroenterologists and surgeons) with the findings of the authors (esophageal center) for patients who underwent reoperative intervention after a previous antireflux procedure. METHODS: Retrospective review of a prospectively maintained database was performed to identify patients who underwent reoperation after a failed antireflux operation between 1 December 2003 and 30 June 2010. Endoscopic findings as reported by the outside physician and by the esophageal center endoscopist were reviewed and compared. RESULTS: During the study period, 229 patients underwent reoperation. Of these patients, 20 did not have endoscopy performed by an outside physician and were excluded from the study, leaving 208 patients. The endoscopic reports of the esophageal center physician included 97 cases of hiatal hernia (64 type 1 and 33 types 2 and 3), 52 slipped fundoplications, 61 disrupted fundoplications, 30 intrathoracic fundoplications, 25 twisted fundoplications, 14 two-compartment stomachs, and 27 cases of Barrett's esophagus. Outside physicians identified 68% of the hiatal hernias and 61% of the paraesophageal hernias reported by the authors. Only 32% of the outside reports mentioned a previous fundoplication. Furthermore, only 17% of the slipped fundoplications and 30% of the disrupted fundoplications were so described. Outside physicians identified 19 of the 27 patients with Barrett's esophagus. CONCLUSION: Fundoplication changes described by the general endoscopist are inadequate. With an increasing population of patients who have undergone prior antireflux surgery, incorporation of fundoplication assessment in an endoscopic curriculum may be helpful.

Economic impact of extracolonic findings at computed tomographic colonography.

OBJECTIVE: To determine the prevalence of extracolonic findings at computed tomographic colonography (CTC) and estimate the cost of the workup of newly discovered potentially significant lesions. SUBJECTS AND METHODS: An electronic information system was used to review all patient data before and after the CTC in a mixed cohort of 376 patients. Extracolonic findings were categorized into the CT Colonography Reporting and Data System classification. The impact of additional diagnostic workup was estimated using Medicare reimbursement for relevant extra services. RESULTS: There were 51 patients (13.6%) with E3 and 16 (4.3%) with E4 findings. At least 1 extracolonic finding was found in 272 patients (72.3%). There were 520 extracolonic findings, of which, 447 (86.0%) were classified as low clinical significance, E2. Only 7 (12.5%) of 56 E3 lesions and 7 (41.2%) of 17 E4 lesions received additional diagnostic workup. The total additional cost of evaluating E3 and E4 lesions was $13.07 per CTC. CONCLUSIONS: A mixed (screening and nonscreening) CTC population has a low prevalence of high-risk lesions, and the additional cost of their evaluation is relatively small.

Is a barium swallow complementary to endoscopy essential in the preoperative assessment of laparoscopic antireflux and hiatal hernia surgery?

BACKGROUND: Barium swallow is considered essential in the preoperative assessment of gastroesophaeal reflux disease and hiatal hernias. The objective of this study was to investigate the effective value of a barium swallow if complementary to the commonly recommended endoscopy before laparoscopic antireflux and hiatal hernia surgery. METHODS: We prospectively evaluated 40 consecutive patients who were tested with preoperative barium swallow and endoscopy before laparoscopic surgery for gastroesophageal reflux disease and/or symptomatic hiatal hernia. Results regarding the presence and the type of hiatal hernia found by barium swallow and endoscopy were correlated with the intraoperative finding as the reference standard. RESULTS: Intraoperative findings revealed 21 axial, 7 paraesophageal, and 12 mixed hiatal hernias. Barium swallow and endoscopy allowed the diagnosis of hiatal hernia in 75% and 97.5%, respectively (p = 0.003). The correct classification of hiatal hernia was confirmed in 50% by barium swallow and 80% by endoscopy (p = 0.005). CONCLUSIONS: Although barium swallow is recommended as an important diagnostic tool in the workup before surgical antireflux and hiatal hernia therapy, our results suggest that if mandatory endoscopy is performed preoperatively, a barium swallow does not provide any further essential information. It seems that barium swallow can be omitted as a basic diagnostic test before primary laparoscopic antireflux and hiatal hernia surgery.

Laparoscopic antireflux surgery: disease-related quality of life assessment before and after surgery in GERD patients with and without Barrett's esophagus.

BACKGROUND: Several findings suggest that gastroesophageal reflux disease (GERD) has a significant impact on patients' quality of life. The aim of this prospective study was (a) to evaluate and compare quality-of-life data before and after laparoscopic antireflux surgery (LARS) in GERD patients with and without Barrett's esophagus (BE); and (b) to compare quality-of-life data of these patients to normative data for a comparable general population. METHODS: The Gastrointestinal Quality of Life Index (GIQLI) was administrated to 75 BE patients and to 174 patients with GERD without BE (Savary-Miller classification: grade 1: n = 49; grade 2: n = 69; grade 3: n = 56). The questionnaire was given to all patients preoperatively, 3months, 1 year, and 3 years after laparoscopic "floppy" Nissen fundoplication. RESULTS: Before surgery, BE patients (mean: 96.8 +/- 9.3 points) had a better but not significant (p<0.06) general score of the GIQLI when compared with patients without BE (mean: 86.4 +/- 10.1 points). This difference is solely based on the subdimension "gastrointestinal symptoms" which means that GERD symptoms are less intensively and frequently recognized in BE patients than in patients without BE. There are no other differences in the other four subdimensions of the GIQLI between both groups. Three months, 1 year, and 3 years after LARS, GIQLI was significantly (p<0.01) improved in both groups (BE patients mean after 3 years: 121.9 +/- 8.2 points; non-BE patients mean after 3 years: 122.8 +/- 9.3 points). This improvement was significantly better (p<0.05) in patients without BE than in BE patients. Before surgery, both groups scored significantly below average on all subscores of GIQLI compared to general population (mean: 122.6 +/- 8.5 points). After surgery, there are no differences detectable. CONCLUSION: As our data show, non-BE patients undergoing LARS achieve a better quality-of-life improvement than those patients with BE. However, after surgery GIQLI of both groups is comparable to the mean value of general population. This means that LARS is able to improve quality of life significantly in all GERD patients, with and without BE.

Computer-aided diagnosis of "dyspepsia".

Experience with computer-aided diagnosis of "dyspepsia" in a consecutive prospective series of 212 patients coming to surgery is described. Analysis is concentrated upon 122 patients who presented to an outpatient clinic de novo for diagnosis. During their first (outpatient) hospital contact, a firm diagnosis was made in just over half of these patients (though where made, it was usually correct). After full investigation, the diagnostic accuracy (prior to operation) was 92.6%. Using data elicited solely from the house surgeon's interview at the time of admission, the computer's overall diagnostic accuracy was 87.7%. The cost of each new computer diagnosis was around 25 new pence ($0.60). and the time taken was about 5 minutes. In a further small series designed to discriminate between organic and functional dyspepsia, the computer correctly assigned all but 1 of 23 patients with organic disease to the correct disease category. However, almost half of 33 patients with x-ray negative dyspepsia were predicted by the computer to have organic lesions. Time alone will tell whether the computer is a better early predictor of eventual organic disease than currently available radiologic methods.