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12 Preoperative Endoscopy
145
abnormal ndings on endoscopy. Of the total cohort, 18.4% had changed their
planned operation after endoscopy results (Table12.1).
Wiltberger etal. [20] showed alterations in 76% of preoperative EGDs. The main
ndings were gastric or duodenal ulcers (53%)—mostly supercial and all deep
ulcers were related to H. pylori infection; erosive esophagitis (23%)—mostly Los
Angeles grade A; hiatal hernia (21%) usually small in size; gastric polyps (8%); and
gastric adenocarcinoma (1%).
In a systematic review and meta-analysis, Bennett etal. [21] showed the abnormal ndings in routine preoperative endoscopy before bariatric surgery. The main
endoscopic alterations were gastritis (37.6%), hiatal hernia (21.1%), and esophagitis (14.4%). H. pylori was present in 36.2% (biopsied if suspicious) and 20.2%
(routine biopsies) of cases. The proportion of EGDs resulting in a change of surgical
approach was 7.8%. Changes in medical management were seen in 27.5%, but after
eliminating H. pylori eradication, this was found to be only 2.5% (Table12.2).
Table 12.1 Pathologic ndings in asymptomatic and symptomatic patients in the entire study
cohort performed by Chang etal. [19]
Asymptomatic % Symptomatic % Total % P value
Number of patients 387 61.3 244 38.7 631
Esophagitis 91 23.5 76 31.1 167 26.5 0.034
Hiatal hernia 89 23.0 82 33.6 171 27.1 0.0035
Gastric ulcer 22 5.7 9 3.7 31 4.9 NS
Duodenal ulcer 1 0.3 1 0.4 2 0.3 NS
Barrett’s 16 4.1 13 5.3 29 4.6 NS
Duodenal mass 3 0.8 1 0.4 0.4 0.6 NS
Helicobacter pylori 33 8.5 21 8.6 54 8.6 NS
Total number of abnormal
ndings
255 65.9 203 83.2 458 72.6 <0.00001
Table 12.2
ndings in routine
preoperative endoscopy
before bariatric surgery in the
meta-analysis performed by
Bennett etal. [21]
Abnormal
Number of
studies
Pathology %
Gastritis 37.6 31 7.598
Hiatal hernia 21.1 39 9.723
Esophagitis 14.4 37 9.129
Bulbitis/duodenitis 5.2 20 5.974
Gastric ulcer 3.6 25 6.356
Barrett’s esophagus 2.1 19 5.802
Gastric intestinal
metaplasia
Duodenal ulcer 1.8 16 3.547
Gastric cancer 0.4 12 3.586
Esophageal cancer 0.2 5 1.278
HP (biopsied if
suspicious)
HP (routine biopsies) 20.2 23 5.650
reporting
2.2 5 1.126
36.2 8 1.652
Number of
patients (total)
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G. F. A. Farias and L. B. Silva
Table 12.3
ndings in routine
preoperative endoscopy
before bariatric surgery in the
meta-analysis performed by
Parkish etal. [18]
Abnormal
EGD ndings
Gastritis 1562 34.6
Hiatal hernia 889 19.7
Helicobacter pylori 888 19.7
Esophagitis (all grades) 786 17
Duodenitis 226 5
Gastric ulcer 97 2
Duodenal ulcer 14 0.3
Barrett’s esophagus 45 0.1
Carcinoma 4 0.08
Number of patients
(N=4511) %
In a systematic review and meta-analysis performed by Parikh etal. [18], the
patients were grouped based on EGD ndings: Group 1—ndings that did not signicantly change management; Group 2—ndings that delayed, altered, or canceled surgery. Overall, 92.4% (n= 6.112) of the patients had a normal EGD or
ndings that did not change clinical management (group 1) and 7.6% (n=504) had
ndings that delayed or altered surgery (group 2) (Table12.3).
A position statement by IFSO showed that abnormal EGD ndings are likely to
be found in at least 55.5% of patients prior to bariatric surgery. The most common
abnormal ndings were gastritis, hiatal hernia, and esophagitis. Conditions that
would lead to modication or delay of surgery were less commonly found, with
16.5% ndings that led to modication or delay of the planned procedure and 0.2%
that had surgery cancelled [22].
12.2.2 Testing andTreatment ofH. pylori
There are conicting data for preoperative testing and treatment of H. pylori related
to surgical outcomes.
Marginal ulceration after RYGB is diagnosed in 1% to 16% of patients and preoperative H. pylori infection is twice as common among the patients who had marginal ulceration (32%) as among those who had not (12%) (p=0.02) [23]. Patients
tested for H. pylori have a lower incidence of postoperative marginal ulcers (n=5,
2.4%) than patients who do not undergo this screening (n=354, 6.8%, P<0.05) [24].
The incidence of postoperative perforation is higher in patients who do not
undergo screening/treatment for H. pylori (5% vs. 0%; P=0.09) [25]. Although
most studies show the benet of H. pylori screening and treatment in patients who
will undergo RYGB, Papasavas et al. [26] did not show an association between
H. pylori infection and marginal or gastric ulcers. The evidence is unclear regarding
the benet of H. pylori eradication prior to sleeve gastrectomy [27].
12 Preoperative Endoscopy
147
ASGE suggests that testing and eradication of H. pylori before bariatric surgery
should be individualized [17] and the European Association for Endoscopic Surgery
(EAES) concluded that no recommendation can be made for an ordinary routine
H. pylori eradication or no eradication prior to bariatric surgery on the basis of
available evidence [28].
References
1. Schlottmann F, Nayyar A, Herbella FAM, Patti MG. Preoperative Evaluation in Bariatric
Surgery. J Laparoendosc Adv Surg Tech A. 2018;28(8):925–9.
2. Runkel N, Colombo-Benkmann M, Huttl TP, Tigges H, Mann O, Sauerland S.Bariatric surgery. Dtsch Arztebl Int. 2011;108(20):341–6.
3. Mandeville Y, Van Looveren R, Vancoillie PJ, Verbeke X, Vandendriessche K, Vuylsteke P,
etal. Moderating the enthusiasm of sleeve gastrectomy: up to fty percent of reux symptoms
after ten years in a consecutive series of one hundred laparoscopic sleeve gastrectomies. Obes
Surg. 2017;27(7):1797–803.
4. De Palma GD, Forestieri P. Role of endoscopy in the bariatric surgery of patients. World J
Gastroenterol. 2014;20(24):7777–84.
5. Genco A, Soricelli E, Casella G, Maselli R, Castagneto-Gissey L, Di Lorenzo N, et al.
Gastroesophageal reux disease and Barrett’s esophagus after laparoscopic sleeve gastrectomy:
a possible, underestimated long-term complication. Surg Obes Relat Dis. 2017;13(4):568–74.
6. Gorodner V, Buxhoeveden R, Clemente G, Sole L, Caro L, Grigaites A.Does laparoscopic
sleeve gastrectomy have any inuence on gastroesophageal reux disease? Preliminary results.
Surg Endosc. 2015;29(7):1760–8.
7. Sheppard CE, Sadowski DC, de Gara CJ, Karmali S, Birch DW. Rates of reux before and
after laparoscopic sleeve gastrectomy for severe obesity. Obes Surg. 2015;25(5):763–8.
8. Haenen FW, Gys B, Moreels T, Michielsen M, Gys T, Lafullarde T.Linitis plastica of the
bypassed stomach 7 years after Roux-en-Y gastric bypass: a case report. Acta Chir Belg.
2017;117(6):391–3.
9. Azagury D, Dumonceau JM, Morel P, Chassot G, Huber O.Preoperative work-up in asymptomatic patients undergoing Roux-en-Y gastric bypass: is endoscopy mandatory? Obes Surg.
2006;16(10):1304–11.
10. Korenkov M, Sauerland S, Shah S, Junginger T.Is routine preoperative upper endoscopy in
gastric banding patients really necessary? Obes Surg. 2006;16(1):45–7.
11. Zeni TM, Frantzides CT, Mahr C, Denham EW, Meiselman M, Goldberg MJ, etal. Value of
preoperative upper endoscopy in patients undergoing laparoscopic gastric bypass. Obes Surg.
2006;16(2):142–6.
12. Loewen M, Giovanni J, Barba C.Screening endoscopy before bariatric surgery: a series of 448
patients. Surg Obes Relat Dis. 2008;4(6):709–12.
13. Mong C, Van Dam J, Morton J, Gerson L, Curet M, Banerjee S. Preoperative endoscopic
screening for laparoscopic Roux-en-Y gastric bypass has a low yield for anatomic ndings.
Obes Surg. 2008;18(9):1067–73.
14. Sauerland S, Angrisani L, Belachew M, Chevallier JM, Favretti F, Finer N, etal. Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES).
Surg Endosc. 2005;19(2):200–21.
15. Committee SG. SAGES guideline for clinical application of laparoscopic bariatric surgery.
Surg Obes Relat Dis. 2009;5(3):387–405.
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16. Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, etal. Clinical
practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the
bariatric surgery patient-2013 update: Cosponsored by American association of clinical endocrinologists, The obesity society, and American society for metabolic & bariatric surgery*.
Obesity (Silver Spring). 2013;21(Suppl 1):S1–S27.
17. Asge Standards of Practice C, Evans JA, Muthusamy VR, Acosta RD, Bruining DH,
Chandrasekhara V, et al. The role of endoscopy in the bariatric surgery patient. Surg Obes
Relat Dis. 2015;11(3):507–17.
18. Parikh M, Liu J, Vieira D, Tzimas D, Horwitz D, Antony A, etal. Preoperative endoscopy
prior to bariatric surgery: a systematic review and meta-analysis of the literature. Obes Surg.
2016;26(12):2961–6.
19. Chang VC, Pan P, Shah SK, Srinivasan A, Haberl E, Wan C, etal. Routine preoperative endoscopy in patients undergoing bariatric surgery. Surg Obes Relat Dis. 2020;16(6):745–50.
20. Wiltberger G, Bucher JN, Schmelzle M, Hoffmeister A, Dietrich A. Preoperative endoscopy
and its impact on perioperative management in bariatric surgery. Dig Surg. 2015;32(4):238–42.
21. Bennett S, Gostimir M, Shorr R, Mallick R, Mamazza J, Neville A.The role of routine preoperative upper endoscopy in bariatric surgery: a systematic review and meta-analysis. Surg
Obes Relat Dis. 2016;12(5):1116–25.
22. Brown WA, Johari Halim Shah Y, Balalis G, Bashir A, Ramos A, Kow L, etal. IFSO position
statement on the role of esophago-gastro-duodenal endoscopy prior to and after bariatric and
metabolic surgery procedures. Obes Surg. 2020;30(8):3135–53.
23. Rasmussen JJ, Fuller W, Ali MR.Marginal ulceration after laparoscopic gastric bypass: an
analysis of predisposing factors in 260 patients. Surg Endosc. 2007;21(7):1090–4.
24. Schirmer B, Erenoglu C, Miller A.Flexible endoscopy in the management of patients undergoing Roux-en-Y gastric bypass. Obes Surg. 2002;12(5):634–8.
25. Hartin CW Jr, ReMine DS, Lucktong TA. Preoperative bariatric screening and treatment of
Helicobacter pylori. Surg Endosc. 2009;23(11):2531–4.
26. Papasavas PK, Gagne DJ, Donnelly PE, Salgado J, Urbandt JE, Burton KK, etal. Prevalence
of Helicobacter pylori infection and value of preoperative testing and treatment in patients
undergoing laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2008;4(3):383–8.
27. Brownlee AR, Bromberg E, Roslin MS.Outcomes in patients with helicobacter pylori undergoing laparoscopic sleeve gastrectomy. Obes Surg. 2015;25(12):2276–9.
28. Di Lorenzo N, Antoniou SA, Batterham RL, Busetto L, Godoroja D, Iossa A, et al. Clinical
practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP. Surg Endosc.
2020;34(6):2332–58.
Chapter 13
Postoperative Care
LéonieBouvet
13.1 Introduction
The experience of our group with biliopancreatic diversion with duodenal switch
(BPD-DS) goes back to the early 1990s [1]. Years of experience with the care of
patients undergoing malabsorptive surgery has led to the development of multiple
time-tested postoperative protocols.
Even in experienced hands, laparoscopic BPD-DS has a slightly higher rate of
perioperative complications when compared to sleeve gastrectomy or gastric bypass
[2]. This difference is partly explained by the complexity of the technic and proportionally longer operative time. It also relates to the fact that such procedures are
usually offered to patients with higher BMIs (>50kg/m2) and more severe comorbidities. On the other hand, standardized postoperative pathways contribute to
decrease the complication rate and allow for early recognition of complications.
Implementation of postoperative enhanced recovery protocols that take into consideration the particularities of BPD-DS is a central component of safe perioperative care. This chapter will review the different aspects of postoperative management
following laparoscopic BPD-DS.
L. Bouvet (*)
Department of Surgery, Quebec City Heart and Lung Institute, Laval University,
Quebec City, QC, Canada
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_13
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L. Bouvet
13.2 Multidisciplinary Team
As for many aspects of the bariatric surgery process, postoperative management of
patients undergoing BPD-DS is facilitated by the involvement of an experienced
multidisciplinary team. It includes bariatric surgeons and dedicated nurses, dieticians, and pharmacists. Internal medicine specialists are also routinely implicated in
the perioperative care, especially for diabetic patients.
13.3 Postoperative Unit
After undergoing laparoscopic BPD-DS, most patients can safely be discharged
from the postanesthesia care unit to the regular oor on a dedicated bariatric oor.
Patients with sleep apnea that are adequately treated with noninvasive positive pressure ventilation make no exception [3]. Use of intensive care units is exceptional
and limited to particular intraoperative events, or to patients with severe cardiopulmonary comorbidities.
13.4 Analgesia
Multimodal analgesia is a cornerstone in pain control after BPD-DS.In addition to
intraoperative strategies, it contributes to reducing opioid use and their side effects.
Postoperative analgesic medication protocols include regular doses of nonsteroidal
anti-inammatory drugs (NSAIDs) and acetaminophen. Every patient is also prescribed a proton pump inhibitor (PPI) for gastric protection and control of early
gastroesophageal reux symptoms.
13.5 Diet
On the day of surgery, patients are given intravenous uids and sips of water are
permitted 2h after extubation. Nausea is frequent after surgery, and liberal use of
intravenous antiemetic medication is routine, particularly for patients undergoing
one stage BPD-DS due to the sleeve component. Clear liquids diet is initiated on
postoperative day 1 and advanced to full liquids diet the next day. All patients are
evaluated and counseled by a clinical dietician during their hospital stay. The importance of high levels of protein intakes is reinforced and patients are counselled on
different protein supplements that can be safely added to their diet even at an early
stage. The different steps of postoperative diet progression are summarized in
Table 13.1. Patients are also given elaborated documentation with examples of
13 Postoperative Care
151
Table 13.1
diet progression
Postoperative
Type of diet Duration
Step 1 Clear liquids POD 1
Step 2 Full liquids 1week
Step 3 Pureed 1week
Step 4 Minced 2weeks
Step 5 Tender 1week
Step 6 Regular Remaining
appropriate meals for every step. The same dietary progression is used either for the
rst stage or second stage BPD-DS.Unsurprisingly, diet progression is easier for
second stage BPD-DS patients [4] but the recent duodenoileal anastomosis warrants
the same careful progression of texture. Food intolerance is rare, but failure to progress to the next step should lead to reevaluation by the dietician or the bariatric
surgeon to avoid early protein malnutrition.
13.6 Thromboprophylaxis
Deep venous thrombosis (DVT) and pulmonary embolism (PE) are the leading
causes of major morbidity and mortality after bariatric surgery. In a study reporting
1000 consecutive cases of BPD-DS, incidence rate of PE was 0.4% following laparoscopic procedures and caused the only perioperative mortality (0.1%) [5]. After
bariatric surgery, the majority of venous thromboembolism (VTE) events occur
after the patients are discharged home, with an average time of diagnosis of
11.6days [6]. Thromboprophylaxis is therefore mandatory in the early perioperative period and extended postdischarge therapy for high-risk patients have been recommended [7].
Sequential compression devices are initiated intraoperatively and kept until the
patients resume adequate ambulation, usually on postoperative day 1. Early ambulation is routine and starts with the help of caregivers on the day of surgery. By postoperative day 1, patients are expected to ambulate in the hallway by themselves.
One dose of unfractionated subcutaneous heparin is given on the rst evening
after surgery and low-molecular-weight heparin is started on postoperative day 1.
Doses are adjusted for patient’s BMIs with the majority of patients receiving
Dalteparin 7500IU daily [8]. For patients who weigh greater than 180kg, or with
previous history of DVT or PE, doses are increased to 10,000IU daily. Dalteparin
is preferred to other low-molecular-weight heparins because daily injections are
sufcient for most high BMI patients.
Given that the great majority of BPD-DS patients will be considered high-risk
for VTE on risk calculator scales, all patients at our institution are prescribed lowmolecular- weight heparin upon discharge for a total of 20days. This regimen has
not led to an increase in postoperative bleeding events.
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13.7 Investigations
Accordingly with enhanced recovery protocol principles, any routine use of surgical
drains, urinary catheter, and nasogastric tube are avoided. Current literature states
that it does not prevent perioperative complication and can delay recovery [9–11].
Frequent vital signs and urinary output are recorded. Usual blood work on postoperative day 1 and 2 includes complete blood count, creatinine, and ions. Interestingly,
postoperative bleeding rarely occurs following either one-stage or two-stages
BPD-DS compared to sleeve gastrectomy alone. This is likely because delayed
bleeding complications are associated more with the sleeve component. As the
sleeve is performed at the beginning of the operation in BPD-DS, it allows for a
second look of the hemostasis at the end of the procedure.
No routine leak test is done, as they do not prevent complications, can be falsely
reassuring, and can cause delays in diet initiation [12]. Every patient is assessed at
least once daily by an experienced bariatric surgeon. Any unexplained tachycardia
or pulmonary distress should raise suspicion for anastomotic or gastric leaks.
CT-scan with intravenous and oral contrast is the examination of choice to identify
a leak for stable patients. Nonetheless, even with a reassuring CT scan, diagnostic
laparoscopy should be performed in worsening patients.
13.8 Adjustments ofComorbidity Treatments
The improvement of obesity-related diseases after BPD-DS outstands the results of
any other bariatric surgery. A meta-analysis by Buchwald etal. reported resolution
of hypertension in 81%, improvement of dyslipidemia in 99%, and improvement or
remission of type 2 diabetes mellitus (T2DM) in 98% [13]. Second stage BPD-DS
results are similar to one-stage in regards to correction of obesity-related
comorbidities.
13.9 Antihypertensive Medication
The principal mechanisms through which obesity-related hypertension occurs is
excess plasma volume expansion and increased cardiac output with a concomitant
decrease in natriuresis due to excess body mass. Accordingly, mechanisms through
which weight loss helps resolve hypertension are well described [14]. Nonetheless,
more recent data suggests that immediate postsurgical changes in gut hormones are
likely to contribute to hypertension control. This is also supported by the increased
remission rate of hypertension following metabolic surgeries when compared to
purely restrictive procedures. Independently of weight loss, glucagon-like peptide 1
(GLP-1), ghrelin, leptin, and peptide YY (PYY) alterations seem to inuence hypertension remission following BPD-DS.
13 Postoperative Care
These more recent ndings further support holding or reducing anti-hypertensive
therapy, starting in the immediate postoperative period. Cessation of diuretics,
angiotensin-converting-enzyme inhibitors (ACE inhibitors), and angiotensin receptor blockers (ARBs) is done preferentially to avoid the risk of acute renal failure
secondary to decreased uid intake following surgery. In patients with persistent
hypertension upon discharge, calcium channel blockers (CCBs) are either continued or added to reach good tension control. Known cardiac diseases also warrant the
represcription of cardioprotective molecules like beta-blockers.
153
13.10 Dyslipidemia Medication
BPD-DS has a sustainable effect on the metabolic syndrome, including dyslipidemia. Marceau etal. reported a decreased total cholesterol, low-density lipoprotein
cholesterol (LDL), and triglycerides, with high-density lipoprotein cholesterol
(HDL) remaining stable after a mean follow-up of 7.9±4.6years [15]. This supports cessation of dyslipidemia medication after BPD-DS with the exception of
patients in which statins are also indicated for further treatment of known atherosclerosis disease.
13.11 Diabetic Medication
Malabsorptive bariatric procedures improve T2DM using multiple pathways, most
of them preceding signicant weight loss [16–18]. These metabolic inuences are
initiated immediately after surgery by caloric restriction, increased GLP-1 levels,
decreased nutrient absorption, changes in bile acid, incretin effect, and modication
of intestinal microbiome [19]. A recent study evaluating the early perioperative
mechanisms of glycemic control after BPD-DS conrmed that caloric restriction
increases insulin sensitivity and secretion [20]. Therefore, rapid resolution of hyperglycemic state is observed in the immediate postoperative period supporting the
dramatic reduction or cessation of diabetic medications. To avoid postoperative
hypoglycemia, insulin secretagogues, sodium-glucose cotransporter-2 inhibitors,
and thiazolidinediones are discontinued. Similarly, insulin doses should be signicantly reduced. To reach tight glycemic control, frequent glycemic measurements
and use of subcutaneous rapid-acting insulin adjustment protocols are routine after
BPD-DS.Changes in diabetes treatment at the time of discharge are made proportionally to the severity of T2DM.For example, patients with severe T2DM will
usually resume taking metformin or incretin-based therapies once they are tolerating liquid diet. Control of hyperglycemia in the early postoperative stage will sometimes necessitate reintroduction of basal long-acting insulin, at reduced doses. Thus,
diabetologists are implicated in the postoperative care of any patient with a more
complex treatment regimen. In a study addressing long-term results for
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insulin- treated T2DM after BPD-DS, 97% of patients were off insulin and 68%
were in complete remission. Mean time to reach remission was 40.4months [21].
Therefore, frequent follow-up for diabetes treatment downstaging are warranted in
the weeks, months, and even years after BPD-DS.
13.12 Contraceptive Counselling
After BPD-DS, pregnancy should be postponed for at least 2years. Weight should
be stabilized and nutritional parameters proven normal on routine post-bariatric
blood works. Pregnancy occurring within 2years of surgery are at increased risk of
gestational complications.
For female patients, fertility is increased following bariatric surgery. Furthermore,
oral contraceptives are no longer reliable after BPD-DS due to malabsorption. To
avoid incidental early pregnancy after surgery, discharge counselling should include
recommendations for effective contraception for all female patients. Intrauterine
devices are the preferred contraception methods after BPD-DS.They can be inserted
before surgery without increased risk of VTE.
13.13 Vitamins
Upon discharge, patients are given a prescription for daily vitamins and mineral
supplementations. They are advised to introduce these supplements 1month after
surgery, allowing patients a period of adaptation to their reduced gastric volume.
Importance of lifelong supplementation is again reinforced. Usual initial prescription doses are summarized in Table13.2. Vitamin B12 dosage tends to increase on
long-term follow-up after BPD-DS even with low dose supplements of 20–40 mcg
included within the multivitamin complex. Therefore, vitamin B12–specic supplements are not included in our initial postoperative prescriptions as they rarely need
to be added on subsequent follow-up in our experience. Blood works are planned
every 4months in the rst postoperative year. Vitamin supplements will be adjusted
in time following these routine blood works.
Table 13.2
doses of vitamins and
minerals supplementations
Initial daily
Multivitamin and mineral complex 2 tablets
Calcium carbonate 1000mg
Ferrous sulfate 300mg
Vitamin D3 20,000IU
Vitamin A 30,000IU
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