Role of endoscopy in the bariatric surgery patient This is one of a series of statements discussing the uti- frankly obese, and 4.8% had a BMI R 40 kg/m2.Further- lization of GI endoscopy in common clinical situations.
more, several studies showed that obesity is associated The Standards of Practice Committee of the American with an increased risk for morbidity and all-cause Society for Gastrointestinal Endoscopy (ASGE) prepared mortality.In recognition of these risks and the evidence this text. In preparing this guideline, MEDLINE and for risk reduction associated with weight loss,the National PubMed databases were used to search for publications Institutes of Health has recommended weight loss surgery from the last 15 years that are related to endoscopy by us- as an appropriate alternative in carefully selected individ- ing the keyword ‘‘endoscopy'' and each of the following: uals with severe obesity (BMI R 40 kg/m2 or those with ‘‘bariatric,'' ‘‘obesity,'' ‘‘gastroplasty,'' ‘‘gastric bypass,'' a BMI R 35 kg/m2 and with serious comorbid conditions) ‘‘Roux-en-Y,'' and ‘‘weight loss.'' The search was supple- when dietary, behavioral, and pharmacotherapy interven- mented by accessing the ‘‘related articles'' feature of tions failed.
PubMed with articles identified on MEDLINE and Bariatric surgery results in durable and significant PubMed as the references. Pertinent studies published weight loss. The rising prevalence of obesity and the suc- in English were reviewed. Studies or reports that cess of surgical interventions led to a marked increase in described fewer than 10 patients were excluded from the number of weight-loss surgeries performed in the analysis if multiple series with more than 10 patients United States, from 13,365 in 1998 to 102,794 in that addressed the same issue were available. The resul- Early bariatric surgical techniques (eg, jejunoileal bypass) tant quality indicators were adequate for analysis. The are no longer performed because they resulted in clini- reported evidence and recommendations based on cally significant and serious vitamin deficiencies, steatohe- reviewed studies were graded on the strength of the patitis, and even cirrhosis in some patients.Instead, supporting evidence .
various procedures that cause weight loss through volume Guidelines for appropriate utilization of endoscopy restriction, limited malabsorption and maldigestion, be- are based on a critical review of the available data havioral modification, or some combination thereof and expert consensus. Further controlled clinical studies were developed. The most commonly used bariatric sur- may be needed to clarify aspects of this statement, and geries are laparoscopic or open Roux-en-Y gastrojejunal revision may be necessary as new data appear. Clinical bypass (RYGB) and laparoscopic adjustable gastric band- consideration may justify a course of action at variance ing (LOther surgeries include vertical banded to these recommendations.
gastroplasty (VBG), and sleeve gastrectomy alone orwith duodenal switch and biliopancreatic diversion (DS/BPD). It is useful to understand the anatomical alterationscreated by these operations as they pertain to the mecha- nisms for weight loss (, ), expected compli-cations, and considerations for endoscopic evaluation.
Obesity in the United States is a major health problem that contributes to increased morbidity and mortality andto a host of disease processes.Body mass index (BMI) is EVALUATION OF THE PREOPERATIVE PATIENT calculated as weight/height2 (kg/m2) and is commonlyused to classify overweight (BMI 25.0-29.9 kg/m2) and obese The role of upper endoscopy in the preoperative (BMI R 30.0 kg/m2) adults. Based on data obtained from evaluation of patients undergoing bariatric surgery may the National Health and Nutrition Examination Survey be based, in part, on the presence or absence of symp- from 2003 to 2004, 61% of adults over the age of 20 years toms. The performance of an upper endoscopy in a patient in the United States are overweight or obese, 32.2% are with reflux symptoms, dysphagia, and/or dyspepsia hasbeen covered in recent guidelines and is equally relevantin the preoperative patHowever, because RYGBand DS/BPD render the distal stomach and/or duodenuminaccessible by a standard upper endoscope, the thresh- Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy0016-5107/$32.00 old for performing a preoperative endoscopic evaluation of the upper-GI tract is lower than for other surgeries.
Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 1 Role of endoscopy in the bariatric surgery patient TABLE 1. Grades of recommendation Grade of recommendation Clarity of benefit Methodologic strength support- Randomized trials without Strong recommendation; can be important limitations applied to most clinical settings Randomized trials with important Strong recommendation; likely to limitations (inconsistent results, apply to most practice settings nonfatal methodologic flaws) Overwhelming evidence from Strong recommendation; can apply observational studies to most practice settings in mostsituations Observational studies Intermediate-strengthrecommendation; may changewhen stronger evidence is available Randomized trials without important limitations recommendation; best action maydiffer depending on circumstancesor patients' or societal values Randomized trials with important Weak recommendation; alternative limitations (inconsistent results, approaches may be better under nonfatal methodologic flaws) some circumstances Observational studies Very weak recommendation;alternative approaches likely to bebetter under some circumstances Expert opinion only Weak recommendation; likely tochange 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.
studies in this group. However, the presence of a large hi- TABLE 2. Mechanism of weight loss for common obesity atal hernia represents a relative contraindication to LAGB because of an increased risk for band slippage.In addi-tion, some surgeons advocate crural tightening in patients with a hiatal hernia when these patients are undergoing any weight loss operat Multiple studies have been published that demonstrate that routine endoscopy before LAGB,and Roux-en-Y can identify a variety of pathologies, including hiatal hernia, esophagitis, and gastric ulcers. The majority of patients with pathology in these studies were asymp- tomatic. Importantly, no malignancies were identified, al- though, in 2 studies, the endoscopic findings resulted inan alteration of the surgical approach or a delay in sur- The rationale for performing an EGD before bariatric sur- geryGuidelines from outside the United States rec- gery is to detect and/or treat lesions that might potentially ommend preoperative upper endoscopy in all patients affect the type of surgery performed, cause complications before bariatric surgery, regardless of the presence or in the immediate postoperative period, or result in symp- absence of symAlthough an upper endoscopy toms after surgery. In particular, a recent meta-analysis in patients without symptoms can identify lesions that showed that obesity was associated with a significantly in- may alter surgical management, there are no studies that creased risk of GERD, erosive esophagitis, and esophageal evaluated the effect of a preoperative endoscopy on surgi- adenocarcinoma.The value of a routine endoscopy be- cal outcome. Contrast studies may be an alternative to an fore bariatric surgery in the patient without symptoms re- endoscopy and can provide complementary information mains controversial because of limited observational 2 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008

Role of endoscopy in the bariatric surgery patient Figure 1. Illustrations of various weight loss surgeries. A, VBG. B, Laparoscopic adjustable gastric band. C, RYGB. (Courtesy Ethicon Endo-Surgery, Inc.) Helicobacter pylori infection is present in 30% to 40% of patients scheduled for bariatric surgery, and preopera-tive testing in these patients may be usefIn onestudy of patients without symptoms who were scheduledfor an RYGB, the patients with a positive rapid urease testwere significantly more likely to have an abnormal endos-copy than those who tested negative (94% vs 51%).Inanother study, patients with H pylori infection weremore likely to develop postoperative marginal ulcersIn patients without symptoms and who were not undergo-ing an endoscopy, noninvasive H pylori testing, followedby treatment, if positive, is recommended.
ENDOSCOPY IN THE POSTOPERATIVE PATIENT General principles When an endoscopy is considered in a patient who had bariatric surgery, the endoscopist should be aware of the Figure 2. Illustration of sleeve gastrectomy. (Courtesy Ethicon Endo-Sur- operative procedure performed and the findings on preprocedural imaging studies, and must understand theexpected anatomy, including the extent of resection andthe length of surgically created limbs. Direct communica- radiography as an initial diagnostic test. Contrast studies tion with the surgeon, if possible, is advisable. Feitoza and are complementary to an endoscopy and are also helpful published a detailed review of endoscopy in in delineating anatomy.
patients with postsurgical anatomy, including information The expected endoscopic findings after an RYGB in- on the equipment needed for successful completion of di- clude a normal esophagus and gastroesophageal junction.
agnostic and therapeutic procedures, and tips on access- The size of the gastric pouch varies. Special care should be ing the distant or excluded portions of the GI tract. The made to examine the pouch and suture line for fistulas choice of endoscope will depend on the indication and and ulcerations. The gastrojejunal stoma should be care- the need for intubation of the excluded limb or therapeu- fully examined. The width of the anastomosis is generally tic intervention (eg, ERCP). In patients who are in the 10 mm to 12 mm in diameter. Beyond the anastomosis, early postoperative period, air insufflation may have a short, blind limb is often visible alongside the efferent potentially detrimental effects in the presence of leaks jejunal limb. The jejunojejunal anastomosis can some- and/or tenuous anastomoses. If there is suspicion of times be reached with an upper endoscope, depending a leak, then the endoscopist should consider contrast on the length of the Roux limb. It should be noted that Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 3

Role of endoscopy in the bariatric surgery patient TABLE 3. Signs and symptoms prompting possibleendoscopic evaluation after bariatric surgery Upper-GI symptoms TABLE 4. Upper-GI postbariatric surgical complications Figure 3. Illustration of DS/BPD. (Courtesy Ethicon Endo-Surgery, Inc.) the length of the Roux limb after an RYGB can vary signif- Band erosion and slippage icantly from standard Roux limbs created for nonbariatric procedures and can range from 50 to 150 cm. The distal orexcluded stomach cannot be visualized in the absence ofa fistula with a regular gastroscope. A VBG produces a gas-tric pouch somewhat similar in appearance to an RYGB.
INDICATIONS FOR AN ENDOSCOPY IN THE The banded stoma is generally 10 to 12 mm in diameter, PATIENT AFTER GASTRIC BYPASS OR WITH and, once traversed, the distal stomach and duodenum A PREVIOUS BYPASS can be visualized.
The sleeve gastrectomy produces a long tubular stom- ach limited in expansion by a staple line that parallels Nausea, vomiting, and abdominal pain are among the the lesser curvature. The staple line should be examined most commonly encountered symptoms after bariatric sur- for defects and ulcerations. The duodenal switch proce- gery and may result from one or several structural and func- dure is often performed in conjunction with a sleeve gas- tional etiologies. Symptoms are frequently associated with trectomy, but also includes a duodeno-jejunal anastomosis dietary noncompliance as to the volume and type of foods visible just distal to an intact gastric pylorus. In the latter, eaten, rapid ingestion, or inadequate chewing. Patients the ampulla is thus not available for visualization or ERCP with persistent symptoms, despite counseling and behavior in a standard fashion.
modification, should be evaluated, because these symp- Laparoscopic adjustable gastric bands produce a vari- toms may indicate the development of marginal ulcers, gas- able amount of extrinsic circumferential compression on trogastric fistulas, postsurgical reflux disease, or partial or the proximal stomach that is evident on upper endoscopy.
complete anastomotic obstruction. An endoscopy is the At the time of endoscopic evaluation, the endoscopist preferred strategy, unless there is a suspicion of leaks or fis- should note the length of the pouch as measured from tulas, when contrast radiography is more appropriate. Pa- the gastroesophageal junction to the impression of the tient history may be helpful in differentiating the etiology band to assess for pouch dilatation or band slippage.
of pain and in guiding the type of investigation. Nausea, The endoscopist should also evaluate for the possible vomiting, abdominal distention, and bloating alone or in presence of band erosion into the gastric walThere conjunction with abdominal pain can suggest an obstruc- are a variety of symptoms and unique postsurgical compli- tive cause, such as strictures, internal hernias, or bezoars, cations after bariatric surgery These will but may also be an indication of dumping syndrome. Also, be discussed in the following sections.
dysphagia can result from esophageal dysmotility or 4 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008 Role of endoscopy in the bariatric surgery patient gastrojejunal anastomotic stenosis. In one study, 62% of pa- can result in cutaneous fistula, peritonitis, abscess, sepsis, tients who were seen with persistent nausea and vomiting organ failure, and dClinical manifestations include and 30% of those who are seen with abdominal pain or dys- tachycardia; fever; nausea; vomiting; and flank, abdominal, pepsia after an RYGB had significant findings on upper en- or chest pain. Most leaks occur at the gastrojejunal anasto- doscopy, including marginal ulcers, stomal stenosis, and mosis, with nearly all the rest occurring in the remnant staple-line dehiscence (excluded) stomach; leaks from the jejunojejunal anasto-mosis are less common but do occur and usually require reoperation. Early postoperative extraluminal leaks are Marginal ulcers are typically seen 1 to 6 months after usually diagnosed by upper-GI contrast studies or CT, al- surgery and may present with abdominal pain, bleeding, though the false-negative rate was reported at or nausea, although they may also be asymptomatic There is little role for an endoscopy in the presence of The ulcers occur at the gastrojejunal anastomosis, usually known leaks or fistulas in the early postoperative period.
on the intestinal side, and are thought to arise from a num- An endoscopy can be considered if the patient is clinically ber of factors, including local ischemia, staple-line disrup- stable, there is uncertainty of the diagnosis, or if there is tion, effects of acid on exposed intestinal mucosa, and the a planned endoscopic interventio presence of staples or suture material. Factors that in- Chronic gastrogastric fistulas may be found in the pres- crease the risk of marginal ulcers include smoking and ence of marginal ulcers, and patients may present with nonsteroidal anti-inflammatory drug use, whereas proton nausea, vomiting, epigastric pain, and weight gain. An pump inhibitor use appears to decrease the risk. The true upper-GI contrast study is sensitive for their detection. A incidence of a marginal ulcer after an RYGB is uncertain, large fistula can also be visualized by an endoscopy.
with reports that range from !1% to 36%.
Endoscopic therapy for postoperative fistulas has beenperformed by using fibrin-glue injectioor self-ex- panding stents.Case reports and small case series in- Obesity itself is a risk factor for GERD, and symptomatic dicate that fistula closure may also be achieved by using GERD is frequent in the bariatric population, with a preva- various combinations of mucosal ablation, glue, the lence of 30% to The effects of bariatric interven- application of endoscopic clips, the placement of self- tions on GERD appear to be variable. Both gastric banding expanding stents, and endoscopic suturing devices.
and RYGB were shown, in multiple series, to reduce GERD However, these interventions cannot be routinely re- symptoms at rates that approach or exceed commended at this time, because of a lack of controlled However, other studies suggest the converse, with in- creased symptoms after surgeryand endoscopic evi-dence of reflux esophagitis in up to 56% of patients Postoperative GERD may be related to gastrojejunal anas- Gastrojejunal stomas are generally between 10 and tomotic stenosis. In addition, patients who have postoper- 12 mm in diameter to maximize the restrictive nature of ative symptoms may have underlying motility disorders; the operation. Anastomotic strictures, defined as anasto- one study suggests that gastric bands may aggravate symp- moses that are smaller than 10 mm in diameter, are a com- toms of GERD in this population.The variable results mon complication of RYGB that occur in 3% to 28% of may also represent differences in the size of the gastric patients.The occurrence of gastrojejunal strictures pouch or band position. It is suggested that the size of may be associated with marginal ulcers. Patients with the pouch and quantity of acid secretion influence the anastomotic strictures generally present with nausea, incidence and severity of GERD symptoms.
vomiting, or dysphagia, usually within the first year after Symptoms of GERD after surgery should be managed surgery.Stenosis can be identified by contrast radiogra- as in patients who did not have a byAn endoscopy phy, but direct endoscopic visualization is preferable, should be reserved for the evaluation of symptoms refrac- because it has high sensitivity.In addition, marginal tory to medical therapy or to rule out complications of ulceration can be identified, and dilation of strictures GERD and inciting factors, such as obstruction of the gas- can be performed.
trojejunal anastomosis, increased pouch size, or distal Endoscopic dilation of anastomotic strictures can be limb obstruction. Nonacid regurgitation in patients with performed safely and effectively by using through-the- a band might indicate an inappropriately tight band scope balloon dilators and wire-guided bougie dila- adjustment, and these patients should be referred to their tors.If the stenosis cannot be traversed by an surgeon for additional evaluation.
endoscopy, then fluoroscopy is useful to allow guidewirepassage. Gradual dilation over multiple sessions may reduce the risk of perforaEven with multiple ses- Gastric leaks and gastrogastric fistulas are potentially sions, some stenoses cannot be adequately dilated by en- serious complications of gastric bypass surgery and occur doscopic means, and reoperation is needed.It is in 1% to 6% of patients.Extraluminal gastric leaks controversial if dilation to a diameter larger than 15 to Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 5 Role of endoscopy in the bariatric surgery patient 16 mm should be performed, because it could possibly phy. Band erosion may be asymptomatic or can produce lead to weight regain. However, in one study, dilation to abdominal pain, nausea, vomiting, abdominal access- at least 15 mm was not associated with weight regain, port–site infection, increased food intake or weight gain, yet, it was associated with a reduced need for more and GI bleeding. Band slippage may present with weight gain, increasing reflux symptoms, or obstruction. Endo- It is important to recognize that, in patients with an scopic findings of band slippage may include an enlarged RYGB, the Roux limb can be delivered to the upper abdo- pouch size and reflux esophagitis, gastritis, or ulcers. In se- men to connect with the gastric pouch in an antecolic fash- vere cases, band slippage can lead to gastric necrosis, a po- ion, in front of the transverse colon, or through a retrocolic tentially life-threatening conditIn patients with tunnel created in the transverse mesocolon. If this tunnel VBG, endoscopic removal of the polypropylene mesh is created too tightly or if postoperative stricturing occurs, that had eroded into the stomach was repor then this limb can be narrowed and lead to obstructivesymptoms.On endoscopic examination, the gastrojeju- Bleeding and anemia nal anastomosis will be normal, but the jejunum beyond Bleeding in the patient after bariatric surgery may be the anastomosis will be dilated until the point where it tra- acute or chronic, and may present as iron deficiency ane- verses the mesentery where the stricture will be seen. Be- mia.Bleeding may arise anywhere in the upper-GI tract, cause the risk of perforation is high, dilation in these cases including the bypassed (excluded) portion of the stomach is not adviseA review of the operative note and com- in patients who had an RYGB. In the early postoperative munication with the operating surgeon are helpful in period, bleeding occurred from the anastomotic staple knowing which type of limb delivery was used.
lines in approximately 1% to 4% of patients who under-went an RYGB.Bleeding is rare in patients who undergo LAGB, with reported incidences as low as 0.1Pa- Dumping syndrome is related to rapid emptying from tients with signs or symptoms of acute or chronic bleeding the stomach into the small bowel and does not occur after should be evaluated with an endoscopy. Accessing the VBG, LAGB, or DS/BPD. Symptoms may occur early excluded portion of the stomach and the ‘‘Roux'' limb (within 15-20 minutes) or be delayed (up to 2 hours) after can be difficult and frequently requires the use of a colono- a meal and include tachycardia, palpitations, diaphoresis, scope or a double-balloon enteroscope.Recently, Shape- flushing, diarrhea, nausea, and vomiting. The mechanism lock technology (USGI Medical, Inc, San Clemente, Calif) is believed to be related to rapid fluid shifts, release of va- was used to access and evaluate the defunctionalized soactive peptides, and fluctuations in serum glucose. The stomacWhen traditional approaches to an endoscopy true incidence in patients who have had bariatric surgery in the patient with bleeding or anemia are unsuccessful, is unknown but has been reported to be 14% in a meta- access may be gained through a surgically created analysis of 62 studiIndividual studies reported rates as high as 70%.The diagnosis of dumping syndrome is Iron deficiency is also a common feature after an RYGB, made based upon clinical presentation, but an endoscopy with an estimated prevalence of 30% to 50%.It has may be considered to rule out other causes of associated also been described with varying prevalence in patients who have undergone DS/BPD.The mechanism ofiron deficiency is multifactorial. If GI bleeding is sus- pected, then an appropriate workup should include endo- Food bezoars can occur in patients who had weight- scopic evaluation.
loss surgery, most commonly after gastric banding.They may form within the first month after surgery or Diarrhea and nutritional deficiencies be seen later, with symptoms of nausea, vomiting, and Some bariatric procedures are designed to cause intes- dysphagia.Bezoars can be diagnosed and treated by an tinal malabsorption. A full description of the nutritional is- endoscopy with fragmentation and reAssociated sues in these patients is beyond the scope of this gastrojejunal anastomotic stenoses, if present, should be guideline. An endoscopic evaluation for symptoms of diar- managed with dilation.
rhea or nutritional deficiencies should only be pursued ifthere is a suspicion of small-bowel mucosal disease as Band slippage and erosion a cause for diarrhea.
Band erosion into the gastric lumen and band slippage In patients with diarrhea, evaluation should follow algo- can occur after an LAGB. In a long-term study, a 9.5% rate rithms similar to those advocated for the evaluation of pa- of band erosion and a 6.3% rate of pouch dilatation/band tients without a history of bariatric surgery. The role of slippage were seen. In another study, band erosion was endoscopy in the evaluation of diarrhea was reviewed in identified in 11% of 75 patients with symptoBand a separate guideline.Bacterial overgrowth can also occur erosions are best diagnosed at an endoscopy, whereas because of a blind loop syndrome in the excluded small band slippage may best be diagnosed by contrast radiogra- bowel. An empiric trial of antibiotics can be useful in 6 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008 Role of endoscopy in the bariatric surgery patient patients with clinical features consistent with bacterial gastric fistula from staple-line dehiscence, a large patulous overgrowth and is a reasonable initial approach. In pa- gastrojejunal anastomosis that fails to restrict food intake, tients who do not respond to antibiotics, breath testing or dilatation of the gastric pouch. While these may be di- for bacterial overgrowth or endoscopic aspiration for agnosed by contrast radiography, confirmation of the di- quantitative bacterial culture from the excluded segment agnosis or visualization by an endoscopy may be should be considered. Obstruction of the excluded desirable. Furthermore, some small gastrogastric fistula segment can be ruled out with an endoscopy.
can be managed endoscopically.Excessively patulousgastrojejunal anastomoses were treated successfully with Choledocholithiasis and ERCP after bypass 4-quadrant endoscopic injection of sodium morrhuate Morbid obesity is a risk factor for gallstone formation, into the stoma to cause scarBy using this method, and rapid weight loss is an independent and potentially a stomal size of %12 mm was achieved in 18 of 28 compounding risk factor. Patients who had bariatric sur- patients (64%). Emerging technologies may allow endo- gery have a high rate of preoperative cholelithiasis and scopic revision of the gastrojejunal anastomosis and re- postoperative gallstone formation. Preoperative and intra- duction of the pouch size in patients with weight regain operative studies indicated incidences of cholelithiasis of 27% in band candand 14% in patients with a gastricbypass, respectively.Postoperative rates of gallstone de-tection may be as high as 22% to 71%, and cholecystec- Endoscopic treatments for obesity tomy was required in 7% to 41% of patients who Endoscopic therapy for morbid obesity is desirable.
underwent gastric bypass.Rates of choledocholithiasis Currently, the endoscopic devices used for the treatment after a gastric bypass are unknown. Whereas an ERCP of obesity are space occupying. The first device used in usually can be performed after gastric banding, an ERCP the United States was the Garren-Edwards gastric bubble in a patient with an RYGB presents significant technical (American-Edwards Laboratories, Irvine, Calif), a 220-mL challenges. No large series of ERCP has been published polyurethane cylindrical device with a self-sealing valve.
in this population, and success rates of duodenal intuba- A double-blind crossover sham study demonstrated no tion are likely dependent on operator skill and surgical benefit over diet and behavioral modifications.Compli- factors, such as jejunal limb and afferent loop length.
cations included gastric erosions, ulcers, small-bowel Both side-viewing endoscopes and forward-viewing endo- obstruction, Mallory-Weiss tears, and esophageal lacera- scopes have been used successfully. In the largest re- tions.There may be a role for such devices in patients ported series composed of 15 patients, the papilla was who are massively obese before consideration of bariatric reached and successfully cannulated in 66% of patients surgery. One study found that preoperative placement of Needle-knife sphincterotomy, sphincter of Oddi manome- the Garren-Edwards gastric bubble induced a 10% mean try, stone extraction, and biliary stent placement were suc- weight loss over 3 montAnother study reported cessfully perforIn cases that are not accessible by that preoperative placement significantly reduced liver standard endoscopy, laparoscopically assisted transgastric volume, possibly facilitating an RYGB.Other endo- ERCP was reported.In another series, percutaneous scopic treatments are currently under investigation.
gastroenterostomy tubes were placed into the gastric rem-nant, and a pediatric duodenoscope was advanced intothe gastric remnant.Alternative means of diagnosis(eg, MRCP) and therapy (eg, percutaneous transhepatic SUMMARY AND RECOMMENDATIONS intervention) should be considered when treating patientswith an RYGB with choledocholithiasis. Because of the ex- Bariatric surgical intervention presents new challenges ceedingly high incidence of cholelithiasis and symptom- to the endoscopist: atic gallbladder disease after biliopancreatic diversion An upper endoscopy should be performed in all and a distal (extremely long) RYGB, many surgeons per- patients with upper-GI–tract symptoms who are to form prophylactic cholecystectomy at the time of the ini- undergo bariatric surgery. (Level 2C) Upper endoscopy should be considered in all patients cholecystectomy in patients without symptoms and who who are to undergo an RYGB, regardless of the pres- are undergoing standard RYGB and LAGB remains contro- ence of symptoms. (Level 3) versial, prophylactic administration of ursodiol in these In patients without symptoms and who are not undergo- patient populations appears to reduce the incidence of ing an endoscopy, noninvasive H pylori testing followed by treatment, if positive, is recommended. (Level 3) In patients without symptoms and who were undergo- ing gastric banding, a preoperative upper endoscopy Failing to lose weight or regaining weight after an ini- should be considered to exclude large hernias that tial weight loss may indicate the development of a gastro- may change the surgical approach. (Level 2C) Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 7 Role of endoscopy in the bariatric surgery patient An endoscopic evaluation is useful for diagnosis and 20. Verset D, Houben JJ, Gay F, et al. The place of upper gastrointestinal management of postoperative bariatric surgical symp- tract endoscopy before and after vertical banded gastroplasty for toms and complications. (Level 2C) morbid obesity. Dig Dis Sci 1997;42:2333-7.
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8 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008 Role of endoscopy in the bariatric surgery patient 43. Gould JC, Garren MJ, Starling JR. Lessons learned from the first 100 66. Hwang RF, Swartz DE, Felix EL. Causes of small bowel obstruction cases in a new minimally invasive bariatric surgery program. Obes after laparoscopic gastric bypass. Surg Endosc 2004;18:1631-5.
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79. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a system- 55. Merrifield BF, Lautz D, Thompson CC. Endoscopic repair of gastric atic review and meta-analysis. JAMA 2004;292:1724-37.
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Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 9 Role of endoscopy in the bariatric surgery patient 91. Kiewiet RM, Durian MF, van Leersum M, et al. Gallstone formation bypass: a possible new option for patients with weight regain.
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104. Meshkinpour H, Hsu D, Farivar S. Effect of gastric bubble as a weight 92. Villegas L, Schneider B, Provost D, et al. Is routine cholecystectomy reduction device: a controlled, crossover study. Gastroenterology required during laparoscopic gastric bypass? Obes Surg 2004;14: 105. Gostout CJ, Rajan E. Endoscopic treatments for obesity: past, present 93. Wudel LJ Jr, Wright JK, Debelak JP, et al. Prevention of gallstone and future. Gastroenterol Clin North Am 2005;34:143-50.
formation in morbidly obese patients undergoing rapid weight 106. Alfalah H, Philippe B, Ghazal F, et al. Intragastric balloon for preoper- loss: results of a randomized controlled pilot study. J Surg Res ative weight reduction in candidates for laparoscopic gastric bypass with massive obesity. Obes Surg 2006;16:147-50.
94. Puzziferri N, Austrheim-Smith IT, Wolfe BM, et al. Three-year follow- 107. Frutos MD, Morales MD, Luja´n J, et al. Intragastric balloon reduces up of a prospective randomized trial comparing laparoscopic versus liver volume in super-obese patients, facilitating subsequent laparo- open gastric bypass. Ann Surg 2006;243:181-8.
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97. Martinez J, Guerrero L, Byers P, et al. Endoscopic retrograde cholan- giopancreatography and gastroduodenoscopy after RYGB. Surg ASGE STANDARDS OF PRACTICE COMMITTEE Michelle A. Anderson, MD, MSc 98. Martinez J, Guerrero L, Byers P, et al. Endoscopic retrograde cholan- giopancreatography and gastroduodenoscopy after RYGB. Surg Robert D. Fanelli, MD, SAGES Representative Todd H. Baron, MD, Chair 99. Mason EE, Renquist KE. Gallbladder management in obesity surgery.
Subhas Banerjee, MD Obes Surg 2002;12:222-9.
Brooks D. Cash, MD 100. Sugerman HJ, Brewer WH, Shiffman ML, et al. A multicenter, placebo- Jason A. Dominitz, MD, MHS controlled, randomized, double-blind, prospective trial of prophylac- M. Edwyn Harrison, MD tic ursodiol for the prevention of gallstone formation following Steven O. Ikenberry, MD gastric-bypass-induced rapid weight loss. Am J Surg 1995;169:91-6, Sanjay B. Jagannath, MD discussion 96-7.
David R. Lichtenstein, MD 101. Miller K, Hell E, Lang B, et al. Gallstone formation prophylaxis after gastric restrictive procedures for weight loss: a randomized Kenneth K. Lee, MD, NASPGHAN Representative Trina Van Guilder, RN, SGNA Representative Leslie E. Stewart, RN, SGNA Representative 102. Catalano MF, Rudic G, Anderson AJ, et al. Weight gain following This document is a product of the Standards of Practice Committee. This bariatric surgery as a result of a large gastric stoma: endotherapy document was reviewed and approved by the Governing Board of the with sodium morrhuate may prevent the need for surgical revision.
American Society for Gastrointestinal Endoscopy.
Gastrointest Endosc 2007;66:240-5.
This document was reviewed and endorsed by the SAGES Guidelines 103. Thompson CC, Slattery J, Bundga ME, et al. Peroral endoscopic reduc- Committee and Board of Governors.
tion of dilated gastrojejunal anastomosis after Roux-en-Y gastric 10 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008


Rime e ritmi

di Giosue Carducci Letteratura italiana Einaudi Edizione di riferimento:a cura di Luigi Banfi, Mursia, Milano 1987 Letteratura italiana Einaudi Alla signorina Maria A. 1Nel chiostro del Santo 2Jaufré Rudel 3In una villa 4Piemonte 6Ad Annie 12A C. C. 13Bicocca di San Giacomo 14La guerra 20Nicola Pisano 23Cadore 26Carlo Goldoni 33A Scandiano 36Alla figlia di Francesco Crispi 37Alla città di Ferrara 39Mezzogiorno alpino 46L'ostessa di Gaby 47Esequie della guida E. R. 48La moglie del Gigante 50Per il monumento di Dante a Trento 52La mietitura del Turco 54La chiesa di Polenta 55Sabato Santo 60In riva al Lys 61Elegia del Monte Spluga 62Sant'Abbondio 64Alle Valchirie 65Presso una Certosa 67Congedo 68


JBC Papers in Press. Published on May 31, 2011 as Manuscript M111.253674 OPTOGENETIC CONTROL OF MOTOR COORDINATION BY Gi/o PROTEIN-COUPLED VERTEBRATE RHODOPSIN IN CEREBELLAR PURKINJE CELLS. Davina V. Gutierrez2, Melanie D. Mark1, Olivia Masseck1, Takashi Maejima1, Denise Kuckelsberg1, Robert A. Hyde2, Martin Krause1, Wolfgang Kruse1, and Stefan Herlitze1,2