7 WORLD GASTROENTEROLOGY NEWS MAY 2016 Editorial | Expert Point of View | Gastro 2016: EGHS-WGO | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events non-healing ulcers, or inadequate weight loss. Complications or weight loss failure after LAGB is the most common reason, making up to 75% of reversal operations 6. Gastroenterologists play an integral role in the pre- and post-operative management of patients undergoing bariatric surgery. It is recommended that upper gastrointestinal endoscopy should be performed in all bariatric patients irrespective of symptoms, more so in patients undergoing RNYGBP or BPD/DS as it will be difficult to evaluate the excluded distal stomach and duodenum post operatively. It may also be important to detect abnormalities which may influence the choice of surgery or the development of post-operative symp-toms and complications. VSG may be significantly more complicated by a hiatus hernia which requires addi-tional repair, while Barrett’s esophagus is an absolute contraindication to VSG 4. Other, clinically, significant pathologies for consideration prior to surgery include reflux esophagitis, gastric ulcers, Helicobacter pylori infec-tion, etc. To quote a few examples, H. pylori infection may increase the risk of anastomotic ulcers and VSG may worsen reflux 2. With an ever increasing number of surgeries being performed, the absolute number of complications is also increasing. The immediate post-operative complications, like anastomotic leak, bleeding, small bowel obstruction, etc., may need surgical intervention, but lately there has been a trend to manage the stable patient preferably endoscopically. The most common location for leaks is the staple line, no matter which type of bariatric surgery was performed. The use of self-expandable, covered stents inserted to cover the defect has a reported success rate of >80%. These stents can be left in place for a prolonged time and patients may resume oral feeding after 1-3 days. Stent migration is a complication and the leak might recur. Fully covered stents can be removed endoscopically 7. Also post-operative bleeding, most often at the site of the anastomosis, and more likely in patients with underlying diabetes mellitus might be amenable to endoscopic therapy. The use of hemostatic clips is preferred over the use of diathermy 5,7. How-ever, common symptoms prompt-ing endoscopy six weeks or more after bariatric surgery include upper abdominal pain, nausea, vomiting, dysphagia, and diarrhea. The etiology of these symptoms are multifactorial and include marginal ulcers, chronic anastomotic leaks, fistulae, strictures, band stenosis, erosion or slippage, staple line dehiscence, bezoars, cho-ledocholithiasis, etc. The endoscopic treatment of some of these conditions include balloon dilation of stric-tures, endoscopic removal of eroded bands, stenting of anastomotic leaks, endoscopic treatment of fistulae, and removal of bezoars and gall stones 2,4. There may be also be a role for preoperative gastrointestinal motility studies in some patients to select the appropriate type of surgery. LAGB is notorious for postoperative worsening of gastro-esophageal reflux (GERD) and can cause pseudo-achalasia due to an increase of the lower gastro-esophageal pressure and aperistalsis. Similarly, VSG has been shown to aggravate GERD and can cause de novo GERD. In contrast, RNYGBP has been demonstrated to improve GERD-like symptoms and maintains motility of the esophagus 8. Small intestinal bacterial overgrowth can oc-cur after RNYGBP and can result in a variety of symptoms. Early and late dumping syndromes are well reported late complications. Post-operative nutritional and metabolic complications are quite common and may be seen in as many as 30% of patients. The most common nutritional deficiencies, particularly after bypass operations, are iron, calcium, vitamin D, vitamin B12, copper, zinc, and other vitamins and micronutrients, and may present as anemia, metabolic bone disease, protein energy malnutrition, steator-rhea, Wernicke’s encephalopathy, polyneuropathy, visual disturbances, and skin problems. There is evidence for routine screening for essential fatty acids and vitamin E or K deficiency. The etiology is multifactorial, includ-ing reduced intake, altered dietary choices, and malabsorption due to altered anatomy. The nature and se-verity of deficiencies is dependent on the type of surgery, dietary habits, and the presence of other surgery related complications like nausea, vomiting, or diarrhea. The frequency of nutri-tional follow-up depends largely on the surgical procedure performed. Following LAGB, frequent nutritional follow-up is recommended. Guide-lines were reviewed and published in 2013 on the perioperative nutritional, metabolic, and non-surgical support of these patients 3. Routine post-operative nutritional monitoring and micronutrient supplementation is recommended in all bariatric pa-tients particularly after malabsorptive procedures. Here, treatment with oral calcium and vitamin D is indicated to prevent secondary hyperparathy-roidism. Hypophosphatemia is often associated with vitamin D deficiency. In individual cases, the monitoring of bone density is recommended. Hyperinsulinemic hypoglycemia is a rare complication after procedures like RNYGBP which is attributed to nesidioblastosis and needs to be differ-entiated from dumping syndrome 9. All patients should receive a multivita-min and mineral preparation 3. The endoscopist may have a very important role in the future with less invasive endoscopic procedures as alternatives for bariatric surgery,
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