Guideline:
Role of endoscopy in the bariatric surgery patient
Bibliographic Source(s)
- ASGE Standards of Practice Committee Anderson MA Gan SI Fanelli RD Baron TH Banerjee S Cash BD Dominitz JA Harrison ME Ikenberry SO Jagannath SB Lichtenstein DR Shen B Lee KK Van Guilder T Stewart LE. Role of endoscopy in the bariatric surgery patient. Gastrointest Endosc 2008 Jul;68(1):1-10. [108 references] PubMed
Guideline Status
This is the current release of the guideline.
Guideline Category
Assessment of Therapeutic Effectiveness
Evaluation
Management
Risk Assessment
Treatment
Intended Users
Physicians
Guideline Objective(s)
To provide evidence-based recommendations for the role of gastrointestinal (GI) endoscopy in bariatric surgery patients
Target Population
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).
Interventions and Practices Considered
- Use of upper endoscopy in the preoperative evaluation of patients undergoing bariatric surgery
- Use of endoscopy in patients following bariatric surgery
- Use of endoscopy in patients after gastric bypass or with a previous bypass to evaluate symptoms and postsurgical complications
- 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
- Endoscopic treatment of obesity
Major Outcomes Considered
- Effectiveness of endoscopy in evaluating the anatomical alterations created by bariatric surgery
- Expected complications and considerations for endoscopic evaluation in the bariatric surgery patient
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
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.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
See "Rating Scheme for the Strength of the Recommendations."
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Guidelines for the role of endoscopy are based on critical review of the available data and expert consensus.
Rating Scheme for the Strength of the Recommendations
| Grade of Recommendation | Clarity of Benefit | Methodologic Strength Supporting Evidence | Implications |
|---|---|---|---|
| 1A | Clear | Randomized trials without important limitations | Strong recommendation; can be applied to most clinical settings |
| 1B | Clear | Randomized trials with important limitations (inconsistent results nonfatal methodologic flaws) | Strong recommendation; likely to apply to most practice settings |
| 1C+ | Clear | Overwhelming evidence from observational studies | Strong recommendation; can apply to most practice settings in most situations |
| 1C | Clear | Observational studies | Intermediate-strength recommendation; may change when stronger evidence is available |
| 2A | Unclear | Randomized trials without important limitations | Intermediate-strength recommendation; best action may differ depending on circumstances or patients' or societal values |
| 2B | Unclear | Randomized trials with important limitations (inconsistent results nonfatal methodologic flaws) | Weak recommendation; alternative approaches may be better under some circumstances |
| 2C | Unclear | Observational studies | Very weak recommendation; alternative approaches likely to be better under some circumstances |
| 3 | Unclear | Expert opinion only | Weak recommendation; likely to change as data become available |
*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.
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
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.
Major Recommendations
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)
| Table. Signs and Symptoms Prompting Possible Endoscopic Evaluation after Bariatric Surgery |
|---|
Upper GI symptoms
|
| Diarrhea |
| Anemia/bleeding |
| Weight regain |
Definitions:
| Grade of Recommendation | Clarity of Benefit | Methodologic Strength Supporting Evidence | Implications |
|---|---|---|---|
| 1A | Clear | Randomized trials without important limitations | Strong recommendation; can be applied to most clinical settings |
| 1B | Clear | Randomized trials with important limitations (inconsistent results nonfatal methodologic flaws) | Strong recommendation; likely to apply to most practice settings |
| 1C+ | Clear | Overwhelming evidence from observational studies | Strong recommendation; can apply to most practice settings in most situations |
| 1C | Clear | Observational studies | Intermediate-strength recommendation; may change when stronger evidence is available |
| 2A | Unclear | Randomized trials without important limitations | Intermediate-strength recommendation; best action may differ depending on circumstances or patients' or societal values |
| 2B | Unclear | Randomized trials with important limitations (inconsistent results nonfatal methodologic flaws) | Weak recommendation; alternative approaches may be better under some circumstances |
| 2C | Unclear | Observational studies | Very weak recommendation; alternative approaches likely to be better under some circumstances |
| 3 | Unclear | Expert opinion only | Weak recommendation; likely to change as data become available |
*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.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Potential Benefits
Appropriate use of endoscopy in the bariatric surgery patient
Potential Harms
Not stated
Qualifying Statements
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.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Bibliographic Source(s)
- ASGE Standards of Practice Committee Anderson MA Gan SI Fanelli RD Baron TH Banerjee S Cash BD Dominitz JA Harrison ME Ikenberry SO Jagannath SB Lichtenstein DR Shen B Lee KK Van Guilder T Stewart LE. Role of endoscopy in the bariatric surgery patient. Gastrointest Endosc 2008 Jul;68(1):1-10. [108 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Society for Gastrointestinal Endoscopy
Guideline Committee
Standards of Practice Committee
Composition of Group that Authored the Guideline
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
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available from the American Society for Gastrointestinal Endoscopy Web site.
Print copies: Available from the American Society for Gastrointestinal Endoscopy 1520 Kensington Road Suite 202 Oak Brook IL 60523
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI Institute on September 15 2008. The information was verified by the guideline developer on October 31 2008.
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This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
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