Transnasal small-caliber esophagogastroduodenoscopy for preoperative evaluation of the high-risk morbidly obese patient.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is an important facet of the preoperative evaluation for bariatric surgery. Morbidly obese patients are at high risk for airway complications during this procedure, and an attractive alternative is transnasal EGD. This report describes a series of patients evaluated successfully using this technique. METHODS: All patients undergoing preoperative transnasal small-caliber EGD for morbid obesity surgery between September 2004 and June 2005 at a Veterans Affairs Hospital were included in the analysis. The variables assessed were the adequacy of the examination, patient tolerance, the need for sedation, and the ability to perform interventions. RESULTS: The study enrolled 25 patients (17 men and 8 women) with an average age of 55 years (range, 44-63 years) and an average body mass index (BMI) of 47 kg/m2 (range, 38-69 kg/m2). All the patients met the 1991 National Institutes of Health (NIH) Consensus Conference Criteria for bariatric surgery and were undergoing preoperative evaluation. The most common comorbidities were hypertension (82%), diabetes mellitus (80%), and obstructive sleep apnea (68%). All 25 patients had successful cannulation of the duodenum's second portion with excellent tolerance. There were no sedation requirements for 23 (92%) of the 25 patients. Significant pathology was found in 14 (56%) of the 25 patients, including hiatal hernia (28%), gastritis (16%), esophageal intestinal metaplasia (16%), esophagitis (12%), gastric polyps (8%), gastric ulcer (4%) and esophageal varices (4%). Biopsies were indicated for 12 patients and successful for all 12 (100%). CONCLUSION: Transnasal small-caliber EGD is a feasible and safe alternative to conventional EGD for the preoperative evaluation of patients undergoing bariatric surgery. It requires minimal to no sedation in a population at high risk for complications in this setting. In addition, this technique is effective in identifying pathology that requires preoperative treatment and offers a complete examination with biopsy capabilities. This technique should be considered for all morbidly obese patients at high risk for airway compromise during EGD.

The impact of preoperative weight loss in patients undergoing laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a widely performed bariatric operation. Preoperative factors that predict successful outcomes are currently being studied. The goal of this study was to determine if preoperative weight loss was associated with positive outcomes in patients undergoing LRYGBP. METHODS: A retrospective analysis was performed of all patients undergoing LRYGBP at our institution between July 2002 (when a policy of preoperative weight loss was instituted) and August 2003. Outcome measures evaluated at 1 year postoperatively included percent excess weight loss (EWL) and correction of co-morbidities. Statistical analysis was performed by multiple linear regression. P<0.05 was considered significant. RESULTS: The study included 90 subjects. Initial BMI ranged from 35.4 to 63.1 (mean 48.1). Preoperative weight loss ranged from 0 to 23.8% (mean 7.25). At 12 months, postoperative EWL ranged from 40.4% to 110.9 % (mean 74.4%). Preoperative loss of 1% of initial weight correlated with an increase of 1.8% of postoperative EWL at 1 year. In addition, initial BMI correlated negatively with EWL, so that an increase of 1 unit of BMI correlated with a decrease of 1.34% of EWL. Finally, preoperative weight loss of >5% correlated significantly with shorter operative times by 36 minutes. Preoperative weight loss did not correlate with postoperative complications or correction of co-morbidities. CONCLUSIONS: Preoperative weight loss resulted in higher postoperative weight loss at 1 year and in shorter operative times with LRYGBP. No differences in correction of co-morbidities or complication rates were found with preoperative weight loss in this study. Preoperative weight loss should be encouraged in patients undergoing bariatric surgery.

Laparoscopic antireflux surgery.

Laparoscopic antireflux surgical procedures were introduced into clinical practice a little more than a decade ago. Today, they constitute a well-established treatment modality for gastro-esophageal reflux disease. With the introduction of laparoscopy, there has been a significant increase in the number of antireflux procedures performed annually in the United States. This most likely indicates more willingness by patients and referring physicians to consider the less invasive approach, rather than a change in the indications of surgical therapy. The main indications for surgical treatment continue to be relapse on medical therapy, intolerance of medications or the patient's choice of not taking medications chronically. A key to successful outcome following antireflux surgical procedures is careful patient selection and work-up. The use of endoscopy, contrast studies, esophageal manometry and 24-h pH studies is of paramount importance. Typical of many laparoscopic operations, antireflux procedures evolved with time and underwent several technical refinements. There continues to be considerable debate on some of the technical aspects of these procedures and on the long-term difference in outcome between partial and complete fundoplication. The superiority of the laparoscopic approach over the open approach has been established, with short-term advantages observed. Long-term outcome between the open and laparoscopic approaches appears to be equivalent. Failures of surgical therapy can be broadly divided into 2 groups: 1) improper patient selection and work-up and 2) technical failures. Redo laparoscopic antireflux operations are technically challenging but feasible in experienced hands.

Minimally invasive approaches to inguinal hernia repair.

The technique of laparoscopic inguinal hernia repair has evolved during the past decade to become an effective and safe alternative for inguinal herniorrhaphy. In experienced hands, the procedure can be performed with low morbidity and with recurrence rates comparable to those following open repair using mesh. Several studies have shown a significant advantage for the laparoscopic approach, with less postoperative analgesic requirement and earlier return to work. Its limitations continue to be higher cost and complexity and the requirement for general anesthesia. The results and cost-effectiveness are maximized when applied to properly chosen patients by surgeons experienced in the procedure.

Percutaneous endoscopic gastrostomy.

Accessing the stomach via a gastrostomy is the preferred method for providing enteral nutritional support when supplementation is required for more than three or four weeks. Since its introduction in the early 1980s, percutaneous endoscopic gastrostomy has become the most popular method for creating a gastrostomy. It is a quick and cost-effective method and has supplanted open gastrostomy for the establishment of a gastrocutaneous fistula to provide access to the stomach for numerous indications. It is associated, however, with serious and potentially lethal complications which must be completely understood by the endoscopist. In addition, patient selection and thorough attention to details are paramount to the performance of a safe percutaneous endoscopic gastrostomy.