Keywords
endoscopy - gastrointestinal stromal tumor - obesity - sleeve gastrectomy
Introduction
According to the World Health Organization (WHO), obesity is defined as excessive
and abnormal accumulation of fat in the body causing a health risk.[1] Fat accumulation is calculated as body mass index (BMI: weight [kg]/height2 [m]). The National Institute of Health defined morbid obesity as BMI higher than
40 kg/m2 or BMI higher than 35 kg/m2 with obesity-related health conditions.[2]
In 2015, the global rate of obesity was 39% of the population in the world, and the
prevalence of obesity was mostly higher in women than in men.[3] Obesity mainly results from imbalance between energy intake and consumption. Many
factors such as genetic, metabolic, hormonal, hypothalamic, psychological, inadequate
physical activity, and low socioeconomic level have roles in obesity.[2] Complications of obesity include hyperinsulinemia, insulin resistance, diabetes
mellitus, hypertension, sleep apnea syndrome, osteoarthritis, gallstone formation,
chronic kidney disease, cardiovascular diseases, and cancers such as colon, prostate,
and endometrium.[4]
The goal in the treatment of obesity is to decrease the body weight via supplying
the adequate basic nourishment to decrease the risks of obesity related morbidity
and mortality. Methods for the treatment of obesity should be multidisciplinary and
include diet, exercise, medical treatment, and surgical strategies.[5]
In recent years, bariatric surgery and especially sleeve gastrectomy gained popularity.
The patients should be evaluated in terms of comorbidities and postoperative adaptation.
They should also be undertaken to psychological and physical evaluation, laboratory
tests, and imaging. There is still not a consensus on the necessity of the preoperative
evaluation of the stomach (i.e., esophageal-gastro duodenoscopy and contrast radiography)
in workup of sleeve gastrectomy. The European Association of Endoscopic Surgery (EAES)
recommends one of these two imaging methods for all patients who are bariatric surgery
candidates. However, according to the American Society for Metabolic and Bariatric
Surgery (ASMBS), preoperative imaging is not necessary for patients without a complaint.[6]
The aim of this study was analysis of the incidental findings encountered in sleeve
gastrectomy pathology specimens and defining whether preoperative endoscopy is necessary.
Methods
This study was conducted in the Ankara Numune Teaching Hospital General Surgery Clinic,
Turkey, and approved by this hospital's Ethical Committee (approval number: E-16–1153).
All patients who underwent sleeve gastrectomy due to obesity in general surgery clinic
between 2011 and 2016 years were included in the study. Their pathology reports were
reviewed and accompanying incidental pathologies were evaluated.
The decision for operation of patients was taken according to “The Practical Guide
for Identification, Evaluation, and Treatment of Overweight and Obesity in Adults”
(NHLBI 2000). All patients were under the control of a dietician. Following the preoperative
blood tests and radiological scanning, routine consultations of internal diseases,
pulmonary diseases, endocrinology, dietician, and psychiatry were done. The informed
consent was taken from all patients. Preoperative respiratory exercises and prophylactic
anticoagulation treatment with low molecular weight heparin were initiated as patient
was hospitalized. All operations were performed by the surgeons working at the General
Surgery Clinic of the hospital.
The study included 45 males and 225 females (270 total) patients who underwent sleeve
gastrectomy. The files of the patients were evaluated retrospectively, and their gender,
age, height, preoperative weight, BMI, pathology reports, and preoperative endoscopy
findings were analyzed. The data were analyzed using SPSS 22.0 program.
Results
The age of the patients ranged between 15 and 64 years with a mean of 39.3 ± 10.8
years. The BMI values ranged between 33.18 and 97.70 kg/m2 with a mean of 47.74 ± 6.9 kg/m2. The investigation of pathological specimens showed chronic gastritis in 77% of patients
([Table 1]). A gastrointestinal (GI) stromal tumor (GIST) was observed in one male patient.
The rate of intestinal metaplasia among males was 6.7% and it was 3.6% among females.
Of note, one patient with postoperative stapler line leak had active ulceration on
gastric mucosa in pathology specimen.
Table 1
The findings in the pathological specimens of sleeve gastrectomy patients
|
Type of pathology
|
Total
|
|
Regular gastric tissue
|
Chronic gastritis
|
Intestinal metaplasia
|
Active gastric ulcer
|
GIST
|
|
Gender
|
Male
|
n
|
7
|
34
|
3
|
0
|
1
|
45
|
|
%
|
15.6
|
75.6
|
6.7
|
0
|
2.2
|
100.0
|
|
Female
|
n
|
43
|
173
|
8
|
1
|
0
|
225
|
|
%
|
19.1
|
76.8
|
3.6
|
0.5
|
0.0
|
100.0
|
|
Total
|
n
|
50
|
207
|
11
|
1
|
1
|
270
|
|
%
|
18.5
|
76.6
|
4.1
|
0.4
|
0.4
|
100.0
|
Abbreviation: GIST, gastrointestinal stromal tumor.
Out of 270 patients, preoperative upper GI endoscopy was applied to 144 patients.
Thirty-one patients had normal findings, 58 patients had gastritis, and 37 patients
had bulbitis. Additionally, 11 patients had hiatal hernia together with gastroesophageal
reflux disease (GERD), six patients had only GERD, and one patient had adjustable
gastric band in situ.
The 11 patients with pathological findings requiring postoperative follow-up, that
is, intestinal metaplasia and GIST, were evaluated. Six out of 11 patients who had
intestinal metaplasia in their pathological examination did not have preoperative
upper GI endoscopy. Of the five patients who had upper GI endoscopy preoperatively,
two had normal endoscopic findings, one had gastritis, one had bulbitis, and one had
hiatal hernia. Intestinal metaplasia was not detected preoperatively in these five
patients. The single patient whose pathological examination showed GIST did not have
GI endoscopy preoperatively. The GIST patient was a 55-year-old male without an additional
comorbidity. His BMI was 46 kg/m2. According to the pathology report, a rigid nodular lesion was observed measuring
up to 0.6 cm in diameter on the serosal surface, macroscopically. The tumor was located
through the muscular layer and the mitosis count was 2/50 high-power field (HPF),
microscopically. The CD117 and CD34 were found to be positive immunohistochemically.
The Ki-67 proliferation index was 1 to 2%.
Chronic gastritis was found in 75% of the patients who had postoperative stapler line
leak ([Table 2]). Prior to sleeve gastrectomy, 23 patients had obesity operations, and 15 (65.2%)
of them had chronic gastritis. Of these 15 patients, 13 had previous laparoscopic
adjustable gastric banding operation, 1 had intragastric balloon operation, and 1
had resleeve gastrectomy operation. None of these patients had intestinal metaplasia
or GIST ([Table 3]).
Table 2
Pathological findings in sleeve gastrectomy patients with a leak
|
n
|
%
|
Valid percent
|
Cumulative percent
|
|
Normal gastric tissue
|
1
|
12.5
|
12.5
|
12.5
|
|
Active gastric ulcer
|
1
|
12.5
|
12.5
|
25
|
|
Chronic gastritis
|
6
|
75
|
75
|
100.0
|
|
Total
|
8
|
100.0
|
100.0
|
|
Table 3
Pathological findings in the sleeve gastrectomy patients according to their previous
obesity operation (i.e., IGB, LAGB, and RSG) status
|
Previous obesity operation
|
Total
|
|
No
|
Yes
|
|
Pathology
|
Normal stomach tissue
|
n
|
42
|
8 LAGB
|
50
|
|
%
|
17.0
|
34.8
|
18.5
|
|
Chronic gastritis
|
n
|
192
|
13 LAGB
|
207
|
|
1 IGB
|
|
1 RSG
|
|
%
|
77.7
|
65.2
|
76.6
|
|
Intestinal metaplasia
|
n
|
11
|
0
|
11
|
|
%
|
4.5
|
0.0
|
4.1
|
|
GIST
|
n
|
1
|
0
|
1
|
|
%
|
0.4
|
0.0
|
0.4
|
|
Active gastric ulcer
|
n
|
1
|
0
|
1
|
|
%
|
0.4
|
0.0
|
0.4
|
|
Total
|
n
|
247
|
23
|
270
|
|
%
|
100.0
|
100.0
|
100.0
|
Abbreviation: GIST, gastrointestinal stromal tumor. IGB, intragastric balloon; LAGB,
laparoscopic adjustable gastric banding; RSG, resleeve gastrectomy.
Eight of the patients with previous obesity operation were received preoperative GI
endoscopy. Five patients had normal findings. One patient had adjustable gastric band
in situ, one patient with previous intragastric balloon had gastritis, and one patient
with resleeve gastrectomy had hiatal hernia together with GERD.
Discussion
To date, there is not a consensus on the requirement of upper GI endoscopy as a preoperative
evaluation for the patients planned to undergo sleeve gastrectomy. According to the
ASMBS medical guidelines, preoperative upper GI endoscopy is not required for the
sleeve gastrectomy patients.[7] The relation of postoperative abnormal histopathological findings to the BMI and
age is still a contentious topic. However, the EAES suggests a routine preoperative
upper GI endoscopic evaluation.[8]
In the present study, pathological findings of the patients who underwent sleeve gastrectomy
were analyzed, and the requirement of a preoperative upper GI endoscopic evaluation
was investigated. There was only one incidental GIST which did not alter the surgical
strategy. GISTs develop from the submucosa and have low possibility of identification
via upper GI endoscopy. Moreover, a GIST may not be detected during surgery. Roshanravan
et al[9] did not observe a mass during the sleeve gastrectomy operation of a 45-year-old
female, while GIST was detected in postoperative pathological examination. Finnell
et al[10] found 2% unexpected pathologic lesions during laparoscopic bariatric surgery and
Sanchez et al[11] found gastric GISTs as 0.8% during surgery upon investigation of the stomach before
partitioning.
There is controversy about the requirement of preoperative GI endoscopy for sleeve
gastrectomy patients. In the study of Sharaf et al,[12] covering 195 patients, application of a preoperative upper GI endoscopy was suggested
for the sleeve gastrectomy patients even when they were asymptomatic. Similarly, the
study of Muñoz et al,[13] including 626 patients, suggested preoperative GI endoscopic evaluation since the
pathological findings change the surgical approach. On the other hand, the results
of Korenkov et al[14] emphasized that the application of preoperative GI endoscopy is not necessary for
the asymptomatic patients. Ghassemian et al[15] applied preoperative GI radiography to 657 bariatric surgery patients but the pathological
findings did not change the surgical approach. Hence, they concluded that a preoperative
evaluation is not required because it is not cost-effective. Due to the lack of a
consensus on preoperative endoscopy set by guidelines, some of the surgeons preferred
omitting endoscopy but some chose to do it regularly in our study.
The pathologies which might change intraoperative management, such as cancer, were
not seen in our dataset. In such a situation, it is obvious that a more radical surgery
rather than obesity surgery would be performed. None of the other incidental findings
hinder the application of sleeve gastrectomy. The application of preoperative GI endoscopy
is suggested in situations requiring an additional surgical operation such as hiatal
hernia, Barrett's esophagus, or gastric adenocancer.[16]
Limitations
The limitation of our study is inadequate reporting the Helicobacter pylori organisms inside the specimens which have a role in gastritis and ulcer formation.
Secondary to this underreporting, we cannot comment on relation between complications
and presence of this organism. The second limitation of our study is that the surgical
procedures were performed by different surgeons with varied experience thus outcomes
were not standardized.
Conclusion
Our findings suggested that a routine GI endoscopy is not necessary prior to sleeve
gastrectomy. In this condition, the benefits of not doing endoscopy are reducing the
cost, as well as not exposing the patient to anesthesia and an invasive intervention
(i.e., endoscopy). In case of symptomatic patients with hiatal hernia and/or GERD,
the GI endoscopy is suggested. The high rate of chronic gastritis in patients with
postoperative leaks might suggest initiation of an antiulcer medication; however,
studies with large data are required to evaluate cost effectiveness and efficacy of
the process.
