59J Contemp Med Sci | Vol. 4, No. 2, Spring 2018: 59–62 Research Preoperative upper endoscopy and bariatric surgeries Abdolreza Pazouki, Vahid Rezaei, Adnan Tizmaghz, Ali Kabir Minimally Invasive Surgery Research Center, Center of Excellence, Iran University of Medical Sciences, Tehran, IR Iran. Correspondence to Ali Kabir (email: aikabir@yahoo.com). (Submitted: 04 July 2017 – Revised version received: 12 August 2017 – Accepted: 02 October 2017 – Published online: 26 June 2018 ) Objectives In this study, the frequency rate of incidental findings in esophageal and gastric endoscopy of morbid obese subjects’ candidate for bariatric surgery was determined. Methods and Materials In this observational study, 1663 consecutive patients candidate for bariatric obesity in Rasool-Akram Hospital were enrolled and the upper endoscopy was done and the frequency rate of incidental findings was determined. Results In this study, 41, 31, 27.3, 6, 0.8, 0.8% respectively had Helicobacter pylori infection, hiatal hernia, esophagitis, esophageal ulcer, gastric ulcer and polyp. Esophagitis and esophageal ulcer were significantly more common among male subjects (9% males, 5% females and 33% males, 25% females) and the mean age was higher among those with esophageal ulcer and H. pylori infection (P = 0.01 and 0.007 respectively). In general it can be concluded that about 1/3 of patients (35%) with morbid obesity have incidental findings on endoscopy. Conclusion Totally, according to the obtained results, it may be concluded that nearly 1/3 of morbid obese subjects candidate for bariatric surgery have incidental findings in preoperative upper endoscopy. Keywords bariatric surgeries, esophagogastroduodenoscopy, incidental findings Introduction Obesity and overweight is correlated with some chronic dis- eases such as coronary artery, diabetes mellitus, most of can- cers and musculoskeletal problems.1 The fat stored in a body acts as an energy source. When the body intake a lot of energy, additional energy accumulates in fats and contribute with weight gain. Obesity is as the result of sedentary life and intake of a lot of energy. The obesity -associated diseases include type II mellitus diabetes, dyslipidemia, obstructive sleep apnea and the increased risk of coronary artery dis- eases.2 The obesity could lead to increasing pressure on the spine and also the thermo-regulation disorder in warm weather condition. The treatment of obesity depends upon the alternation of life style and mostly emphasis on diet and exercise. Obese people (BMI = 35–45) with associated dis- ease are those that just changing the life style is not effective, thus FDA recommended to administrate drugs or do opera- tion for these kinds of patients.3 The annual cost of weight loss is estimated to be more than 117 billion dollars each year. Weight loss was a major goal of the world in 2010 to promote the quality of people’s health.4 The medicine and sport collage of USA had proposed various methods such as diet, exercise, administration of different drugs and behav- ioral strategies, to lose weight. Weight loss leads to reduction of LDL, TG and increase of HDL, improvement of glucose tolerance, decrease of insulin resistance and reduce fast glu- cose rates and inflammatory markers like CRP that is corre- lated with coronary artery diseases. Heart, Lung and Blood Institute Guideline recommended at least 10% of weight loss in reducing the risk of VCD.5 Bariatric surgery is one of the most effective procedure for immediate weight loss in patients and mostly this surgery is performed in stomach and esophagus, so the endoscopic evaluation of these organs become impossible.3 For example, hiatal hernia can be diagnosed through endoscopy and in-patients with this problem, gastric banding is contraindi- cated. Gastric Ulcers in remnant stomach would be ignored otherwise the effect of obesity on incidence of different gastro-esophageal disorders is not clearly understood. It is important to treat most of these disorders before the bari- atric surgery.3 So the aim of this study was to find the preva- lence of gastro-esophageal disorders in morbid obese patients. The bariatric surgery is the most effective and long lasting remedy for obese patients which depends on sequential exer- cise after surgery.2 However, research demonstrate that about 80% of patients undergoing surgery do not take the recom- mendation of doctors to do an exercise for more than 150 minutes in a week.1 Because in bariatric surgeries, large part of stomach is involved these parts always become inaccessible to endos- copy. So the possible finding from endoscopy of upper GI tracts before surgery could be helpful to make the right decision for patients.2,3 For instance, the gastric band sur- gery is a contraindicated in the presence of Hiatus hernia that could be easily diagnosed by endoscopy before the sur- gery. Also ulcers will be inaccessible in endoscopy after gastric bypass, that they should be diagnosed and treated before the surgery. Thus given the importance of this issue, this study evaluated the frequency of accidental find- ings of esophagi and gastric endoscopy before the bariatric surgery. Material and Methods In this cross-sectional study, all 1663 patients with obesity (defined as BMI ≥ 40 or BMI ≥ 35 along with underlying risk factors like diabetes) that referred to Obesity Clinic of Rasool-Akram Hospital, a referral who were candidate for bariatric surgery during 2012–2013 were enrolled in this study. People asked to fill the consent form before upper GI endoscopy and the frequency of accidental findings in eso- phagus and stomach were determined. All data were regis- tered in Iran National Obesity Surgery Database (www. obesitysurgery.ir). After collection of information, data were analyzed with SPSS version 13 Software. The frequency for qualitative variables ISSN 2413-0516 60 J Contemp Med Sci | Preoperative upper endoscopy and bariatric surgeries Research Abdolreza Pazouki et al. and means and standard deviations were calculated for quan- titative variables. Chi-square and Fisher’s exact test and inde- pendent T-test were used for interpretation of results and the P-value less than 0.05 consider significant. Results Of 1663 patients, 82.7% were females and 17.3% were males. The mean age of people were 40.8 + 10.5 years. The average of BMI was 45.7% + 5.33 kg/m2. Among patients who underwent the preoperative upper endoscopy, 41.2% had Helicobacter pylori infection, 31% hiatal hernia, 27.3% esophagitis, 6% esophageal ulcer, 0.8% peptic ulcer, and 0.8% polyp (Figure 1). There was statistically rela- tion with mean age of patients with esophageal ulcer (P = 0.002) and H. pylori infection (P = 0.001), also the fre- quency of esophageal ulcer was higher in female than male (9.1% vs 5.3%) and this difference was statistically relevant (P = 0.014). On the other hand, the frequency of hiatus hernia, peptic ulcer, and BMI had not any statistical relation with mean age of patients. Also the rest esophagogastroduodenos- copy findings had not any statistical correlation with sex, too (P = 0.007). Peptic ulcer, polyp and H. pylori infection had no correlation with BMI of patients. Discussion Unfortunately routine endoscopy examination of upper GI tract before bariatric surgery in asymptomatic patients is not recommended in reference books but type of bariatric surgery and treatment of patients can be influenced by most of the endoscopy findings such as peptic ulcers, hiatal hernia, eso- phagitis and reflux. Thus, in current study we aimed to eval- uate prebariatric surgery endoscopy incidental findings and its effects on choosing appropriate type of bariatric surgery for the patients. Also treatment of some gastric disorders that accidentally diagnosed may have a great impact on outcomes of operation. For example, in-patients with hiatal hernia, gastric banding is not recommended. In gastric bypass surgery, a part of the stomach is permanently unavailable from endo- scopic evaluations and this is important to have preoperative screening endoscopy, especially in patients with a family his- tory of stomach cancer or esophageal metaplasia.3 In this study 41.2% of patients had been infected with H. pylori, 31% of people hiatal, 27.3% had esophagitis hernia, 6% esophagitis ulcer, 0.8% peptic ulcer, and 0.8% had polyp. The incidence of esophagitis and ulcers of esophagus among men was significantly higher and also the mean age of patients was significantly higher in patients with esophagitis, ulcer of esophagus and infection of H. pylori. One study conducted in Spain showed that 48.7% of people from 194 candidate for bariatric surgery treatment, had a gastric disorders in upper GI tract. Three patients (1.5%) had a peptic ulcer and 69.3% had H. pylori infection.4 However, the frequency of positive results of endoscopy and existence of H. pylori in our study was less than current study; the frequency of ulcer was somewhat similar. Because of the importance of gastric ulcers endoscopy appears to be reasonable. In one study in Brazil, 57.9% of 126 candidate for bariatric surgery had a one positive finding in endoscopy. In overall 3.2% of patients had an ulcer and 53.2% were positive for H. pylori infection.5 In our study the frequency of positive cases was similar, however, the overall frequency of endo- scopic findings and positive H. pylori infection was less than this study. In our study frequency of gastric ulcers was twice and this can show the importance of endoscopy. Table 2. The distribution of endoscopy symptoms with age and BMI Disease Age BMI Positive Negative Positive Negative Mean SD Mean SD P-value Mean SD Mean SD P-value Hiatus hernia 40.89 10.68 40.87 10.55 >0.05 45.36 5.93 45.67 6.51 >0.05 Esophageal ulcer 44.06 10.95 40.68 10.53 0.002 45.73 6.89 45.55 6.29 >0.05 Peptic ulcer 41.71 10.24 40.87 10.59 >0.05 45.26 8.43 45.57 6.31 >0.05 H. pylori 42.73 10.06 45.77 6.21 0.0001 45.77 45.41 6.21 6.42 >0.05 Polyp 39.15 9.69 46.63 7.74 >0.05 46.63 7.74 45.56 6.32 >0.05 Esophagitis 41.79 10.72 40.54 10.52 0.032 45.37 5.88 45.65 6.51 >0.05 Table 1. Percentage of endoscopic finding in relation with sex* Gender Disease Hiatal hernia Esophagitis Esophageal ulcer Peptic ulcer H. pylori Polyp Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Male 32.80 67.20 33.80 66.20 9.10 90.90 1.70 98.30 42.50 57.50 1 99 Female 42.20 69.30 25.90 74.10 5.30 94.70 7 99.30 40.90 59.10 10 99.30 P-Value >0.05 0.007 0.0014 >0.05 >0.05 >0.05 Pos.: positive, Neg.: negative. *Values are percentages. Vol. 4, No. 2, Spring 2018: 59–62 Abdolreza Pazouki et al. 61J Contemp Med Sci | Research Preoperative upper endoscopy and bariatric surgeries Table 3. Comparison of our results with similar studies* Present study Spain study, 2006 Chili study, 2007 Brazil study, 2009 UAE study, 2010 Belgium study, 2013 H. pylori infection 41 69 53 53 85 17 Hiatal hernia 31 - - - 13 24 Esophagitis 27.3 - - - - 30 Esophageal ulcer 6 - - - - - Peptic ulcer 0.8 1 2 3 - 7 Gastric polyp 0.8 - - - - - Gastritis - - - - 67 36 *All values are in percentages. In one study done by Al-Akwaa et al.6 in UAE in 2010, 62 patients were enrolled in that study that 85.5% were positive for H. pylori infection and 67.7% had gastritis and 13% has hiatus hernia.6 In current study, 31% of patients had hiatus hernia and 41% were positive for H. pylori infection that were almost half of the rate of infection in comparison with current study. Hiatal hernia in our study was higher and due to its role in the type of surgery, endoscopy can be useful. de Palma et al. in Italia published a review article in 2012 which proclaim that it cannot be definitely recommend to do upper GI endoscopy before bariatric surgery and the need to conduct further studies in this field indicates the importance of our survey.7 In retrospective study that conducted by Praveenraj et al.8 from India in 2015, 283 patients were enrolled that 54 patients (54.4%) had an abnormal findings in endoscopy and hiatus hernia in 2 patients was observed. In current research, the incidence of positive cases were less but the hiatus hernia was more prevalent. The high prevalence of hiatal hernia in our study increases the need for endoscopy. Csendes et al. from Chili in 2007 evaluated 426 candidate for bariatric surgery in pre-operative endoscopy, 55% had a positive criteria 2.6% had peptic ulcer. H. pylori infection was 53% in the patients.9 Peptic ulcer was high incidence in cur- rent study, whereas H. pylori positive cases has higher than Chili’s survey. In retro prospective study conducted by D’Hondt et al.10 from Belgium in 2013, 652 patients were enrolled in that survey, 68.1% had an abnormal finding in endoscopy results, 24.3% had hiatus hernia, esophagitis was observed in 30.8%, and gastritis in 36.2% and ulcer in 7.5% of patients; and 17.6% were positive for H. pylori infection. All cases in this study was higher than our research but the incidence of H. pylori infection due to low level of health condition in Iran was higher than this study. Our study has some limitation that just conducted in one obesity center and the endoscopy performed by multi-spe- cialist; but this cannot affect our result because the pathologic findings are objective and can be detected by each specialist. But overall for the first time, the large sample, about 1663 cases, were examined during 1 year. Conclusion In conclusion, this is inferred that about 1/3 of obese patients that were candidate for bariatric surgery had an accidental findings in esophagus and stomach endoscopy (35%), so administration of upper GI tract endoscopy before bariatric surgery is may be useful for selecting the type of appropriate procedure for the obese patients. At last, it is proposed that to achieve more accurate results that could be cited or general- ized, conduct multicenter studies with larger sample sizes. Acknowledgments This study has been funded and supported by Iran university of medical sciences (IUMS); Grant no 91-01-140-17375. We used data from National Obesity Surgery Database, Iran, Tehran. We would like to express our thanks from National Obesity Surgery Database team who prepared us useful data. Conflict of Interest None.  References 1. Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009;41:459–471. 2. Aldana SG, Greenlaw RL, Diehl HA, Salberg A, Merrill RM, Ohmine S, et al. Effects of an intensive diet and physical activity modification program on the health risks of adults. J Am Diet Assoc. 2005;105:371–381. 3. Andersen RE, Wadden TA, Bartlett SJ, Zemel B, Verde TJ, Franckowiak SC. Effects of lifestyle activity vs structured aerobic exercise in obese women: a randomized trial. JAMA. 1999;281:335–340. 4. Diez-Rodriguez R, Ballesteros-Pomar MD, Vivas-Alegre S, Barrientos- Castaneda A, Gonzalez-de Francisco T, Olcoz-Goni JL. [Upper endoscopy findings in obese morbid patients candidates for bariatric surgery]. Gastroenterol Hepatol. 2015;38:426–430. 5. Dietz J, Ulbrich-Kulcynski JM, Souto KE, Meinhardt NG. Prevalence of upper digestive endoscopy and gastric histopathology findings in morbidly obese patients. Arq Gastroenterol. 2012;49:52–55. 6. Al-Akwaa AM. Prevalence of Helicobacter pylori infection in a group of morbidly obese Saudi patients undergoing bariatric surgery: a preliminary report. Saudi J Gastroenterol. 2010;16:264–267. 7. De Palma GD, Forestieri P. Role of endoscopy in the bariatric surgery of patients. World J Gastroenterol. 2014;20:7777–7784. 8. Praveenraj P, Gomes RM, Kumar S, Senthilnathan P, Parathasarathi R, Rajapandian S, et al. Diagnostic yield and clinical implications of preoperative Vol. 4, No. 2, Spring 2018: 59–62 62 J Contemp Med Sci | Preoperative upper endoscopy and bariatric surgeries Research Abdolreza Pazouki et al. upper gastrointestinal endoscopy in morbidly obese patients undergoing bariatric surgery. J Laparoendosc Adv Surg Tech A. 2015;25:465–469. 9. Csendes A, Burgos AM, Smok G, Beltran M. Endoscopic and histologic findings of the foregut in 426 patients with morbid obesity. Obes Surg. 2007;17:28–34. 10. D’Hondt M, Steverlynck M, Pottel H, Elewaut A, George C, Vansteenkiste F, et al. Value of preoperative esophagogastroduodenoscopy in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass. Acta Chir Belg. 2013;113:249–253. This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly. dx.doi.org/10.22317/jcms.06201801 Vol. 4, No. 2, Spring 2018: 59–62