This is the current release of the guideline.

Severe obesity requiring bariatric surgery

Assessment of Therapeutic Effectiveness
Evaluation
Management
Risk Assessment
Treatment

Gastroenterology
Internal Medicine
Surgery

Physicians

To provide evidence-based recommendations for the role of gastrointestinal (GI) endoscopy in bariatric surgery patients

Patients undergoing bariatric surgery* for severe obesity

*Bariatric surgical procedures include laparoscopic or open Roux-en-Y gastrojejunal bypass, laparoscopic adjustable gastric banding (LAGB), vertical banded gastroplasty (VBG), and sleeve gastrectomy alone or with duodenal switch and biliopancreatic diversion (DS/BPD).

1. Use of upper endoscopy in the preoperative evaluation of patients undergoing bariatric surgery
2. Use of endoscopy in patients following bariatric surgery
3. Use of endoscopy in patients after gastric bypass or with a previous bypass to evaluate symptoms and postsurgical complications
4. Use of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) for the evaluation of choledocholithiasis in patients who have had previous bariatric bypass surgery
5. Endoscopic treatment of obesity

• Effectiveness of endoscopy in evaluating the anatomical alterations created by bariatric surgery
• Expected complications and considerations for endoscopic evaluation in the bariatric surgery patient

Searches of Electronic Databases

MEDLINE and PubMed databases were used to search for publications from the last 15 years that are related to endoscopy by using the keyword "endoscopy" and each of the following: "bariatric," "obesity," "gastroplasty," "gastric bypass," "Roux-en-Y," and "weight loss." The search was supplemented by accessing the "related articles" feature of PubMed with articles identified on MEDLINE and PubMed as the references. Pertinent studies published in English were reviewed. Studies or reports that described fewer than 10 patients were excluded from analysis if multiple series with more than 10 patients that addressed the same issue were available. The resultant quality indicators were adequate for analysis.

Not stated

Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)

See "Rating Scheme for the Strength of the Recommendations."

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Guidelines for the role of endoscopy are based on critical review of the available data and expert consensus.

*Adapted from Guyatt G, Sinclair J, Cook D, et al. Moving from evidence to action. Grading recommendations: a qualitative approach. In: Guyatt G, Rennie D, editors. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

This document was reviewed and endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee and Board of Governors.

Definitions for the grades of recommendation (1A to 3) are provided at the end of the "Major Recommendations."

Summary and Recommendations:

Bariatric surgical intervention presents new challenges to the endoscopist:

• An upper endoscopy should be performed in all patients with upper-gastrointestinal (GI)–tract symptoms who are to undergo bariatric surgery. (Level 2C)
• Upper endoscopy should be considered in all patients who are to undergo a Roux-en-Y gastrojejunal bypass (RYGB), regardless of the presence of symptoms. (Level 3)
• In patients without symptoms and who are not undergoing an endoscopy, noninvasive Helicobacter pylori testing followed by treatment, if positive, is recommended. (Level 3)
• In patients without symptoms and who were undergoing gastric banding, a preoperative upper endoscopy should be considered to exclude large hernias that may change the surgical approach. (Level 2C)
• An endoscopic evaluation is useful for diagnosis and management of postoperative bariatric surgical symptoms and complications. (Level 2C)
• An endoscopic retrograde cholangiopancreatography (ERCP) is difficult in patients who had an RYGB, and a magnetic resonance cholangiopancreatography (MRCP) should be performed in cases where other noninvasive imaging studies are inconclusive. An ERCP in RYGB patients should be selectively performed. (Level 3)

Definitions:

*Adapted from Guyatt G, Sinclair J, Cook D, et al. Moving from evidence to action. Grading recommendations: a qualitative approach. In: Guyatt G, Rennie D, editors. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate use of endoscopy in the bariatric surgery patient

Not stated

Further controlled clinical studies may be needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness

Not applicable: The guideline was not adapted from another source.

2008 Jul

American Society for Gastrointestinal Endoscopy - Medical Specialty Society

American Society for Gastrointestinal Endoscopy

Standards of Practice Committee

Committee Members: Michelle A. Anderson, MD, MSc; S. Ian Gan, MD; Robert D. Fanelli, MD, SAGES Representative; Todd H. Baron, MD, (Chair); Subhas Banerjee, MD; Brooks D. Cash, MD; Jason A. Dominitz, MD, MHS; M. Edwyn Harrison, MD; Steven O. Ikenberry, MD; Sanjay B. Jagannath, MD; David R. Lichtenstein, MD; Bo Shen, MD; Kenneth K. Lee, MD, NASPGHAN Representative; Trina Van Guilder, RN, SGNA Representative; Leslie E. Stewart, RN, SGNA Representative

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on September 15, 2008. The information was verified by the guideline developer on October 31, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.