As technology develops, the utilization of endoscopy in the diagnosis and treatment of gastrointestinal disorders continues to expand. While the majority of these procedures occur in patients with native anatomy, the cohort of patients with altered gastrointestinal anatomy continues to rise. A solid understanding of the variations and implications of surgically-altered anatomy is paramount to effectively performing endoscopy in postsurgical patients. Additionally, the ability to distinguish normal from abnormal findings is essential to identifying and reporting problems. This article will describe common postsurgical anatomy that the endoscopist is likely to encounter. We discuss normal and abnormal findings and suggest techniques for obtaining accurate diagnostic information. Additionally, we highlight the essential components of the endoscopic evaluation and discuss how to communicate that information to the requesting provider to help direct patient care.
Morrell D, Pauli E, Juza R. Endoscopy in surgically altered anatomy. Ann Laparosc Endosc Surg 2019;4:41.
What was your motivation in evaluating the use of endoscopy in surgically altered anatomy?
Our motivation came from recognizing the need to align the understanding and knowledge base of surgeons and gastroenterologists regarding postoperative endoscopy. The creation of a common language to improve communication and treatment is essential and that comes from a sound understanding of the postoperative anatomy. Endoscopic technology is advancing and, subsequently, is more applicable to both diagnostic and therapeutic measures in patients with surgically altered anatomy. This advancement allows for endoscopy to be used as a guide to subsequent surgical treatment or as a primary form of treatment. Whether the purpose of the endoscopy is diagnostic or therapeutic, a sound understanding of the anatomy, and the ability to accurately convey that knowledge, is crucial to effectively treat and care for these patients. The standardization of the language used by providers is critical if we want to improve patient care.
You mention in your article that "operative reports do not always effectively reflect the critical details of a procedure." Can you elaborate?
I think the primary reason for this is that it’s difficult to accurately convey everything that is done during an operation in a clear concise manner. There are many nuances associated with a major operation and I think we tend to overestimate what is implied or assumed about the operation. When documenting what occurred during a surgical procedure, it is important that we remember that some of our colleagues, whether surgical or medical, may not be as familiar with the key components of the procedure. Additional details will not only be helpful, but critical in helping to create a mental diagram of the patient’s postoperative anatomy.
What are some details an every endoscopist should document in their report for a roux-en-gastric bypass?
Roux-en Y gastric bypass is one of the most common post-surgical anatomies encountered by endoscopists both for diagnostic and treatment purposes. Some of the key points to document are the appearance and size of the gastric pouch and gastrojejunal anastomosis. These details are helpful in creating a differential diagnosis when a patient presents with complaints such as weight regain. In the article we suggest techniques to measure the pouch and anastomosis which can help the surgeon determine whether or not the bypass needs to be revised. Pain is another common complaint in the post-bariatric patient and may be caused by a marginal ulcer. The mucosa at the gastrojejunal anastomosis should be surveilled circumferentially for evidence of ulceration and if found, estimate what percent of the anastomosis is involved and to what depth. Most marginal ulcers will heal with medical therapy. Large or very deep ulcers are more likely to be refractory and require surgical revision to treat. Finally, the length of the blind end of the alimentary limb should be measured and examined for any retained food which may cause chronic abdominal pain and nausea and require resection of the blind limb.
What are some details every endoscopist should document in their report for a sleeve gastrectomy?
Sleeve gastrectomy has surpassed Roux-en-Y gastric bypass as the most common weight loss operation performed in the US and consequently more patients are undergoing postoperative upper endoscopy. Key points of endoscopy are determining the location of the GE junction and commenting on the presence or absence of a hiatal hernia. As the endoscope passes through the GE junction, the general appearance of the sleeve should be documented. The mucosa should be pink, healthy, and well-perfused. There should be minimal retained fundus as this can lead to weight regain. A single continuous staple line extending along the left lateral border of the sleeve with a gentle curve at the incisura would be the expected anatomy. Evidence of tortuosity, irregularity, or angularity particularly at the incisura may cause symptoms of pain or nausea with eating as the sleeve cannot empty appropriately. Additionally, the diameter of the sleeve should be measured and recorded. Sleeve gastrectomy functions by removing the distensible portion of the stomach. If the diameter of the sleeve is very wide, the patient will not feel restriction and will likely experience weight regain.
What are some details every endoscopist should document in their report for an adjustable gastric band?
Adjustable gastric band placement is no longer a commonly performed weight loss procedure however there are patients who still have them in place. The key details to document on endoscopy include the appearance of the pouch above the band. The mucosa should be healthy and well-perfused. The pouch should be relatively small in size to create the restrictive component of the operation. The lumen created by the band should be roughly the size of an adult endoscope and permit easy passage into the gastric body. If the lumen is large, the patient will experience weight gain. Too small, and the patient may experience excessive weight loss and frequent vomiting. Band erosion into the gastric lumen is also a known complication of the procedure. The band, which is externally placed, should not be visible on endoscopy. The site of the band should be inspected prograde and retrograde to look for any early signs of band erosion such as mucosal erythema or ischemia. If the band is visible at any point it should be removed. This can be done laparoscopically or even endoscopically in some cases.
Is there a concern regarding performing an endoscopy in the acute post-operative bariatric patient?
With proper technique, I believe upper endoscopy is safe even in the acute post-operative bariatric patient. In this setting though, the use of carbon dioxide insufflation is essential to avoid pneumoperitoneum and to allow the gas to dissipate quicker to minimize patient discomfort. Evaluation of the gastric pouch and gastrojejunal anastomosis is standard but I would not attempt to reach the jejunojejnual anastomosis is that situation because of the amount of force the endoscope would apply at the gastrojejunal anastomosis. Otherwise, using standard safe endoscopic principles keeping the lumen visualized and gently passing the scope, it is perfectly safe.
What suggestions do you have for surgeons to improve their dictations in order to better serve future endoscopists?
I believe that every surgeon should perform their own endoscopies for two reasons. First is that endoscopy is a core component of the surgeon skillset and something that we should be able to provide for our patients. Second, and more relevant to this question, is that having a solid understanding of endoscopic anatomy will help you understand key points for the operative dictation to accurately convey information to future providers.
Dr. Ryan Juza
Assistant Professor of Surgery
University Hospitals
Cleveland, USA
References
Novitsky YW, Sing RF, Kercher KW, et al. Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents. Am Surg 2005;71:627-31; discussion 631-2.
Stogryn S, Hardy K, Vergis A. Bariatric operative reporting: quality assessment and perceptions among bariatric surgeons. Surg Obes Relat Dis 2017;13:429-35.
Vergis A, Stogryn SE, Mullan MJ, et al. Electronic synoptic reporting: assessing the completeness of synoptic and narrative reports for Roux-en-Y gastric bypass. Surg Obes Relat Dis 2017;13:1863-8.
American Society for Metabolic and Bariatric Surgery. Story of obesity surgery 2018. [updated 2018, access January 20, 2019]. Available online: https://asmbs.org/resources/story-of-obesity-surgery
American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers, 2011-2017. [Access January 10, 2019]. Available online: https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers
Angrisani L, Santonicola A, Iovino P, et al. IFSO worldwide survey 2016: primary, endoluminal, and revisional procedures. Obes Surg 2018;28:3783-94.
Ugale S, Vennapusa A, Katakwar A, et al. Laparoscopic bariatric surgery-current trends and controversies. Ann Laparosc Endosc Surg 2017;2:154.
Valli PV, Gubler C. Review article including treatment algorithm: endoscopic treatment of luminal complications after bariatric surgery. Clin Obes 2017;7:115-22
Monaco-Ferreira DV, Leandro-Merhi VA. Weight regain 10 years after Roux-en-Y gastric bypass. Obes Surg 2017;27:1137-44.
Juza R, Rogers A. PEG and PEJ in the post-bariatric surgery patient. In: Pauli E, Marks J, eds. Percutaneous Endoscopic Gastrostomy (PEG): Techniques, Effectiveness and Potential Complications: Hauppauge, NY: Nova Science Publishers, 2016.
Attam R, Leslie D, Freeman M, et al. EUS-assisted, fluoroscopically guided gastrostomy tube placement in patients with Roux-en-Y gastric bypass: a novel technique for access to the gastric remnant. Gastrointest Endosc 2011;74:677-82.
Shaikh SH, Stenz JJ, McVinnie DW, et al. Percutaneous gastric remnant gastrostomy following Roux-en-Y gastric bypass surgery: a single tertiary center's 13-year experience. Abdom Radiol (NY) 2018;43:1464-71.
Buwen JP, Kammerer MR, Beekley AC, et al. Laparoscopic sleeve gastrectomy: the rightful gold standard weight loss surgery procedure. Surg Obes Relat Dis 2015;11:1383-5.
O’Brien PE, McPhail T, Chaston TB, et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg 2006;16:1032-40.
McShea S. Obesity. Physician Assistant Clin 2017;2:87-106.
Marchesini JCD, Noda RW, Haida VM, et al. Transenteric ERCP for treatment of choledocholithiasis after duodenal switch. Surg Laparosc Endosc Percutan Tech 2017;27:e28-e30
Schouten R, van Dielen FM, van Gemert WG, et al. Conversion of vertical banded gastroplasty to Roux-en-Y gastric bypass results in restoration of the positive effect on weight loss and co-morbidities: evaluation of 101 patients. Obes Surg 2007;17:622-30.
Milone M, Elmore U, Musella M, et al. Safety and efficacy of laparoscopic wedge gastrectomy for large gastrointestinal stromal tumors. Eur J Surg Oncol 2017;43:796-800.
Nunobe S, Hiki N. Function-preserving surgery for gastric cancer: current status and future perspectives. Transl Gastroenterol Hepatol 2017;2:77.
Robinson M, Davidson A. Aspiration under anaesthesia: risk assessment and decision-making. Contin Educ Anaesth Crit Care Pain 2014;14:171-5
Blouhos K, Boulas KA, Tsalis K, Hatzigeorgiadis A. Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions? World J Gastrointest Surg 2015;7:190-5
Cui LH, Son SY, Shin HJ, et al. Billroth II with Braun enteroenterostomy is a good alternative reconstruction to Roux-en-Y gastrojejunostomy in laparoscopic distal gastrectomy. Gastroenterol Res Pract 2017;2017:1803851
Paye F. The pancreatic stump after pancreatoduodenectomy: the "Achille's heel" revisited. J Visc Surg 2010;147:e13-20.
Donahue TR, Reber HA. Surgical management of pancreatic cancer--pancreaticoduodenectomy. Semin Oncol 2015;42:98-109.
Shao XD, Qi XS, Guo XZ. Endoscopic retrograde cholangiopancreatography with double balloon enteroscope in patients with altered gastrointestinal anatomy: a meta-analysis. Saudi J Gastroenterol 2017;23:150-60
Watanabe M, Mine S, Nishida K, et al. Reconstruction after esophagectomy for esophageal cancer patients with a history of gastrectomy. Gen Thorac Cardiovasc Surg 2016;64:457-63.
Farnes I, Johnson E, Johannessen HO. Management of gastric conduit retention following hybrid and minimally invasive esophagectomy for esophageal cancer: two retrospective case series. Int J Surg Case Rep 2017;41:505-10
Nguyen NT, Rudersdorf PD, Smith BR, et al. Management of gastrointestinal leaks after minimally invasive esophagectomy: conventional treatments vs. endoscopic stenting. J Gastrointest Surg 2011;15:1952-60.
Frazzoni M, Piccoli M, Conigliaro R, et al. Laparoscopic fundoplication for gastroesophageal reflux disease. World J Gastroenterol 2014;20:14272-9.
Smith CD, McClusky DA, Rajad MA, et al. When fundoplication fails: redo? Ann Surg 2005;241:861-9; discussion 869-71
Mosby's Medical Dictionary. anastomosis. (n.d.) 2009 [updated 2009, 8th ed] Available online: https://medical-dictionary.thefreedictionary.com/anastomosis
Arezzo A, Bini R, Lo Secco G, et al. The role of stents in the management of colorectal complications: a systematic review. Surg Endosc 2017;31:2720-30.
Abbas MA. Endoscopic management of acute colorectal anastomotic complications with temporary stent. JSLS 2009;13:420-4
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