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15 Proximal pH Testing forLaryngopharyngeal Reux
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Multichannel Intraluminal Impedance (MII): pH
Testing
In addition to upper and lower esophageal pH measurements,
MII-pH testing allows for detection of esophageal bolus (liquid
and air) movements by sensing changes in electrical impedance
along the catheter. Classical pH monitoring measures only pH and
does not detect nonacid reux or some aerosolized molecules. A
detailed discussion is outside the scope of this chapter.
Conclusion
The techniques mentioned above can be very helpful in making
the diagnosis of LPR.It is important to emphasize that still a gold
standard to identify LPR patients is lacking. Currently, the diagnosis of LPR requires careful review of symptoms, physical ndings, and objective testing, ruling out other competing etiologies.
References
1. Lechien JR, Akst LM, Hamdan AL, Schindler A, Karkos PD, Barillari
MR, etal. Evaluation and management of laryngopharyngeal reux disease: state of the art review. Otolaryngol Head Neck Surg.
2019;160(5):762–82.
2. Koufman JA. The otolaryngologic manifestations of gastroesophageal
reux disease (GERD): a clinical investigation of 225 patients using
ambulatory 24-hour pH monitoring and an experimental investigation of
the role of acid and pepsin in the development of laryngeal injury.
Laryngoscope. 1991;101(4 Pt 2 Suppl 53):1–78.
3. Koufman JA, Aviv JE, Casiano RR, Shaw GY.Laryngopharyngeal reux:
position statement of the committee on speech, voice, and swallowing
disorders of the American Academy of Otolaryngology-Head and Neck
Surgery. Otolaryngol Head Neck Surg. 2002;127(1):32–5.
4. Campagnolo AM, Priston J, Thoen RH, Medeiros T, Assunção
AR.Laryngopharyngeal reux: diagnosis, treatment, and latest research.
Int Arch Otorhinolaryngol. 2014;18(2):184–91.
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5. Ayazi S, Lipham JC, Hagen JA, Tang AL, Zehetner J, Leers JM, etal. A
new technique for measurement of pharyngeal pH: normal values and
discriminating pH threshold. J Gastrointest Surg. 2009;13(8):1422–9.
6. Vailati C, Mazzoleni G, Bondi S, Bussi M, Testoni PA, Passaretti
S.Oropharyngeal pH monitoring for laryngopharyngeal reux: is it a reliable test before therapy? J Voice. 2013;27(1):84–9.
7. Johnston N, Dettmar PW, Ondrey FG, Nanchal R, Lee SH, Bock
JM. Pepsin: biomarker, mediator, and therapeutic target for reux and
aspiration. Ann N Y Acad Sci. 2018;1434(1):282–9.
8. Barona-Lleo L, Barona-De Guzman R, Krstulovic C.The diagnostic usefullness of the salivary pepsin test in symptomatic laryngopharyngeal
reux. J Voice. 2019;33(6):923–8.
9. Wang J, Zhao Y, Ren J, Xu Y.Pepsin in saliva as a diagnostic biomarker in
laryngopharyngeal reux: a meta-analysis. Eur Arch Otorhinolaryngol.
2018;275(3):671–8.
U. Kannan et al.
Endoscopic Evaluation
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oftheBariatric Surgery
16
Patient
SoaneEl Djouzi
Introduction
A frequently discussed advantage of upper endoscopy is its diagnostic and therapeutic potential compared to gastrointestinal
imaging studies (i.e., contrast upper gastrointestinal series). An
upper endoscopy allows for direct visualization of the foregut
mucosa, enables practitioners to obtain biopsy samples, and performs endoluminal interventions. Endoscopists must remain vigilant when concern exists for postoperative complications. As an
example, when a gastrointestinal staple line leak is suspected, a
water-soluble upper GI study should be performed as the initial
diagnostic test [1]. Air insufation of the foregut may be deleterious in patients that are less than 4weeks postsurgery, as it could
convert a small contained leak into a free perforation or disrupt a
healing anastomosis. In this setting, carbon dioxide, as opposed to
air insufation, should be used as its rapid absorption will prevent
persistent dilation of the GI tract.
S. El Djouzi (*)
Barijuve Surgical, Darien, IL, USA
e-mail: soane.eldjouzi@barijuve.com
© Society of American Gastrointestinal and Endoscopic Surgeons
(SAGES) 2023
A. D. Patel et al. (eds.), The SAGES Manual of Physiologic
Evaluation of Foregut Diseases,
https://doi.org/10.1007/978-3-031-39199-6_16
215
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S. El Djouzi
Periprocedural Recommendations
It is recommended that no food is taken 8hours before the upper
endoscopy. Clear liquids can be taken up to 2hours before endoscopy [2]. Antibiotic prophylaxis is not recommended due to the low
risk of infection from this procedure [3]. Pre-endoscopy laboratory
and imaging studies should be performed based on individual patient
risk factors. The risk of discontinuing antiplatelet therapy and systemic anticoagulation must require a case-by-case review [4].
Technical Considerations
To safely and successfully perform an upper endoscopy in a bariatric surgery patient, it is imperative to be familiar with the
patient’s operative reports, postoperative imaging, and select the
appropriate equipment required to complete the procedure [5].
Proper equipment, including the choice of the endoscope, will
depend on the patient’s surgical history. In patients that previously
underwent restrictive procedures, a standard adult gastroscope is
sufcient. A balloon-assisted enteroscope or pediatric colonoscope may become handy in those requiring evaluation of jejunojejunal anastomosis, retrograde evaluation of the biliopancreatic
limb, or bypassed stomach [6]. Balloon-assisted enteroscopy uses
a balloon attached to an over the tube to allow for a more distal
assessment of the gastrointestinal tract in patients who have
undergone Roux-en-Y gastric bypass (RYGB) with long (150cm)
Roux limb [7]. Regardless of the endoscopic technique, the
endoscopist must be familiar with the prior operative reports to
appreciate the possible variation in postsurgical anatomy.
Sedation
In most instances, periprocedural sedation requires conscious
sedation or monitored anesthesia care (MAC). That being said, a
patient with high body mass index (BMI) and obstructive sleep
apnea (OSA) might require endotracheal intubation under general
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anesthesia as it becomes much more challenging to proceed with
the procedure otherwise. In a study of patients undergoing
advanced endoscopic procedures, higher BMI patients had an
increased frequency of sedation-related complications, including
apnea, oxygen desaturations, and airway obstructions [8–10].
Such a statement should be taken into consideration when selecting ofce versus hospital-based endoscopy to minimize any periprocedural risks.
Conscious sedation is frequently performed using a combination of narcotic analgesia and benzodiazepine sedatives under the
surgeon or gastroenterologist’s direction performing the procedure. In a study comparing obese patients that have undergone
RYGB and those who have not, postsurgical patients required
more sedation, possibly from improved liver function post-op
[11]. The involvement of the anesthesia team might become vital
in the context of complex cases. A major advantage of conscious
sedation is that patients are sedated yet still able to follow commands during the procedure. Alternatively, MAC anesthesia is
performed under the direct care of an anesthesiologist or Certied
Registered Nurse Anesthetist (CRNA) supervised by an anesthesiologist.
The patient’s sedation is titrated to a level that preserves spontaneous breathing and airway reexes [10]. Patients undergoing
MAC anesthesia are unconscious but still breathing without the
assistance of a ventilator. The safety of conscious sedation in bariatric surgery patients with metabolic syndrome has been challenged before. Nonetheless, one study of 1385 patients reported a
cardiopulmonary event rate during conscious sedation of 0.6% in
Roux-en-Y gastric bypass patients [11], which is similar to 0.9%
described in the general population [11, 12].
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Procedural Technique
Pre- or postbariatric surgery upper endoscopy is frequently performed in the outpatient setting. The choice of anesthesia is dictated by the patient’s clinical characteristics and the operator’s
experience level.
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Upper endoscopy begins with passage of the endoscope
through the mouth into the oropharynx to evaluate for upper
esophageal abnormalities. Next the endoscope is advanced down
the esophagus to the esophagogastric junction to evaluate the
squamocolumnar junction or Z-line. Biopsies may be taken
through cold or hot forceps to evaluate for any mucosal abnormalities (i.e., Barrett’s esophagus and distal esophagitis). Next,
the scope is passed into the stomach and retroexed to look for
a hiatal hernia. From this point, it all depends on whether the
patient has or has not had weight loss surgery yet. It also depends
on the layout of the Foregut anatomy. The rest of the stomach is
examined as well as the gastrojejunal anastomosis or the duodenum depending on the patient’s surgery. Biopsies, mucosal
brushings, and cultures may be taken throughout the procedure.
Any adjunct to the procedure depends on the indication(s) of the
intervention and the goals yet to be achieved. More details on
those technical aspects are detailed along the subsequent sections of the chapter.
S. El Djouzi
Timing ofEndoscopy Evaluation intheBariatric
Patient
The Preoperative Period
It is well accepted and endorsed that patients with symptomatic
gastroesophageal reux disease (GERD) or a history of chronic
upper gastrointestinal complaints should have an upper GI
endoscopy before undertaking the planned bariatric procedure
[13, 14]. However, routine preoperative endoscopic evaluation
of all bariatric patients remains controversial [15, 16]. Multiple
studies have reported the routine use of preoperative
esophagogastroduodenoscopy (EGD) with variable incidence of
ndings of clinically relevant abnormalities such as hiatal hernia, esophagitis, Barrett’s esophagus, esophageal dysplasia,
duodenitis, ulcers, and tumors [15, 17, 18]. On the other hand, a
large study reported that over half of the patients were found to
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be harboring endoscopically signicant ndings while remaining clinically asymptomatic [17]. Such results delayed or altered
the planned surgical procedure in 1.7–7.6% of the patients [15,
17, 18].
Evidence of reux esophagitis and hiatal hernia is more concerning if a vertical sleeve gastrectomy (VSG) is planned as these
ndings are relative contraindications due to the increased risk of
developing de novo GERD.Several studies have shown incidence
variability in the development of de novo GERD, Barrett’s esophagus, erosive esophagitis, as well as the increased use of proton
pump inhibitors (PPIs) after VSG [19, 20]. If a hiatal hernia is
discovered at the time of the endoscopy, the repair is highly recommended at the time of the weight loss surgery [21].
The most recent recommendations by the Standards of Practice
Committee of the American Society for Gastrointestinal
Endoscopy (ASGE) along with the Society of Gastrointestinal
and Endoscopic Surgeons (SAGES) and the American Society for
Metabolic and Bariatric Surgery (ASMBS) were published in
2015. The recommendation to perform preoperative screening
endoscopy should be individualized based on patient need, symptomatology, discussion with the surgeon, and type of procedure to
be performed [22].
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The Intraoperative Period
The intraoperative use of endoscopy remains controversial, with
some surgeons making it mandatory. It is used primarily to test for
intraoperative gastrointestinal staple line leak, evaluate the anatomy outlook during revisional procedures, identify and control
bleeding, and access surgical lumen and anastomosis diameter
[23]. Upon researching the surgical literature, two studies assessing the value of the routine application of intraoperative endoscopy at the time of bariatric surgery identied abnormalities such
as staple and suture line leaks and other technical errors that were
promptly corrected. Luckily, the incidence of such ndings was
very low [24, 25].
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S. El Djouzi
The Postoperative Period
Endoscopy is not the rst line of assessment in the postoperative
period. It remains indicated when other non-invasive testings have
remained inconclusive in the evaluation of persistent nausea,
vomiting, intolerance to oral intake, and new epigastric pain [1].
There are a number of etiologies behind such symptoms. While
some could be managed expectantly along with counseling and
behavioral modications, others might require surgical or endoscopic intervention.
GERD
Postoperative GERD is not uncommon after certain bariatric procedures. As related earlier, reux symptoms and the development
of de novo GERD are more prevalent after VSG.On the other
hand, the RYGB has proven to be an excellent surgical indication
for GERD treatment in patients who also suffer from obesity [26,
27]. Postoperative GERD symptoms should rst be managed
medically for an extended period of time [28]. Weight loss alone
could potentially reduce or ablate the complaints [29]. If medical
management fails, endoscopy could be considered to investigate
for any anatomical abnormalities such as severe gastrojejunal
anastomotic stricture or gastrogastric stula after RYGB, and
twisted gastric tube after VSG [22].
Adjustable Gastric Band (AGB) Slippage andErosion
AGB slippage and erosion into the gastric lumen can be assessed
endoscopically (it could also be suspected through contrast imaging studies). A meta-analysis of 19 studies and 500 patients
recently estimated the rates of slippage and erosion to be 5% and
1%, respectively [30]. Band erosion may cause an array of symptoms (abdominal pain, nausea, vomiting, port site infection,
increased food intake with weight gain, and GI bleeding), or it
may remain asymptomatic [31]. If any portion of the band is seen
on endoscopy, the surgeon needs to be consulted for further management [22]. Similarly, band slippage can cause abdominal pain,
weight gain, reux symptoms, or dysphagia. Acute band slippage
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can lead to life-threatening gastric necrosis and require a prompt
surgical correction [32, 33].
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Marginal Ulcers
Marginal ulcers typically occur after RYGB surgery with an incidence of 0.6–36% [34–36]. Patients may present with abdominal
pain, bleeding, and nausea or could potentially be asymptomatic.
The ulcers are usually on the intestinal side and believed to be due
to many possible mechanisms (i.e., local ischemia, acidic effects
on the intestinal mucosa, staple line disruption, and exposed staple or suture material on the intraluminal side) [37]. Other factors
include the presence of a gastrogastric stula, H pylori infection,
smoking, uncontrolled diabetes, excessive gastric pouch length,
and chronic use of NSAIDs or corticosteroids [34, 36, 37].
Marginal ulcers are rst treated medically with acid reduction and
cytoprotective agents. Refractory ulceration will require revisional surgery [38].
Gastric Leak andFistulae
Gastric leaks and gastric stulae have an incidence of 1–6% in
weight loss surgery patients and can result in enterocutaneous stula, peritonitis, abscess, sepsis, organ failure, and death [39–43].
Leaks after RYGB most commonly occur at the gastrojejunal
anastomosis. Jejunojejunal leaks, though exceedingly rare, can
occur and may require reoperation [44]. After VSG, leaks typically occur along the very proximal staple line and most commonly at the proximal one-third of the greater curvature of the
staple line [45]. Diagnosis is usually made with an upper GI contrast study or CT.However, early endoscopy can be performed if
there is diagnostic uncertainty or for endoscopic intervention [46,
47]. The injection of brin glue, application of clips, placement of
self-expandable metal stents (SEMS), or insertion of the pigtail
catheter are all handy tools to manage such leaks [48, 49]. Gastric
stulae can also be treated endoscopically using brin glue [50,
51] or SEMS [52–54]. These patients may eventually need surgi-
cal closure of the stula as endoscopic interventions typically
serve as a bridge to denitive management [55].
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S. El Djouzi
Anastomotic Strictures
Gastrojejunal anastomotic strictures, dened as anastomoses less
than 10mm in diameter (accepted normal diameter is 14–16mm),
are not uncommon complications of the RYGB.Such complication triggers nausea, vomiting, and or dysphagia. A stricture can
be diagnosed with an upper GI contrast study but endoscopy is
preferred as it is both diagnostic and therapeutic [56].
Anastomotic strictures can be dilated endoscopically with
either through-the-balloon dilators or wire-guided bougie dilators
[57, 58]. These should be serially dilated over multiple sessions to
prevent perforation [59]. There is debate over dilating the stoma
to >15mm due to concern of weight regain. However, one study
noted the reduced need for repeat dilation and no association with
weight regain [58].
One important consideration in RYGB patients is whether the
Roux limb was delivered in antecolic or retrocolic fashion. A tight
tunnel created through the transverse colon mesentery can cause
narrowing of the Roux limb and subsequent obstruction [60]. On
endoscopy, there will be a normal gastrojejunal anastomosis with
dilated jejunum distally until the point where the Roux limb traverses the mesocolon. Dilation at this point is not advised given a
high risk for perforation [61].
Short-segment gastric lumen stenosis after VSG can be treated
endoscopically. However, long-segment stenosis may require surgical intervention, such as seromyotomy or revision to gastric
bypass [62].
Foreign Body andBezoars
Lodged foreign material and bezoars can be diagnosed and
retrieved endoscopically. Foreign material includes staple and
suture material that can contribute to marginal ulcers, stomal stenosis, abdominal pain, and dysphagia [63, 64]. These should be
removed once the gastrojejunal anastomosis has matured. Food
bezoars usually occur after AGB [65, 66], but can occur after
RYGB within the gastric pouch or at the jejunojejunal anastomosis [67–69]. These can be removed endoscopically after fragmentation [70].
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