Is endoscopy normal in a patient with Roux-en-Y gastric bypass (RYGB)?

From the Guidelines

Endoscopy in a patient with Roux-en-Y gastric bypass (RYGB) is not considered a normal procedure and requires specialized expertise and equipment due to the altered anatomy. The procedure involves navigating through the gastrojejunal anastomosis and may require the use of pediatric or balloon-assisted enteroscopes to access the excluded stomach and duodenum 1. According to the AGA clinical practice update, endoscopic evaluation in post-gastric bypass patients differs from standard endoscopy and carries additional risks, including perforation at anastomotic sites 1.

Key Considerations

• The altered anatomy of RYGB patients requires careful navigation and specialized equipment during endoscopy
• Common indications for endoscopy in gastric bypass patients include abdominal pain, nausea, vomiting, gastrointestinal bleeding, or suspected marginal ulcers
• Endoscopists performing these examinations should have experience with bariatric surgery anatomy to ensure safe and effective evaluation
• The use of carbon dioxide for insufflation and caution when advancing the endoscope into the small bowel are recommended to minimize pressure along the fresh staple lines 1

Specialized Equipment and Techniques

• Pediatric or balloon-assisted enteroscopes may be necessary to access the excluded stomach and duodenum
• The procedure often takes longer and carries additional risks, including perforation at anastomotic sites
• In cases where the patient is critically ill or the interventional endoscopist lacks extensive experience, the endoscopy should be performed in the operating room with a surgeon present 1

From the Research

Endoscopy in Patients with Roux-en-Y Gastric Bypass (RYGB)

• Endoscopy can be a useful tool in the management of complications after RYGB, as demonstrated by studies such as 2 and 3.
• The safety and feasibility of upper gastrointestinal endoscopy in the early postoperative period after RYGB have been established, with no reported anastomotic disruptions or leaks in a study of 190 patients 3.
• Therapeutic interventions, such as balloon dilation and feeding tube placement, can be performed safely and effectively during endoscopy in patients with RYGB 3.

Technical Considerations

• The use of specialized techniques, such as device-assisted enteroscopy and laparoscopic-assisted methods, may be necessary to access the excluded stomach and biliary tree in patients with RYGB 4, 5.
• A novel endoscopic technique, termed EUS-Directed Transgastric ERCP (EDGE) or Gastric Access Temporary for Endoscopy (GATE), has been developed to facilitate access to the remnant stomach and pancreatobiliary tree in patients with RYGB 4.
• Laparoscopic transgastric endoscopy is a safe and reliable method to access the excluded stomach and biliary tree in patients with RYGB 5.

Sedation and Safety Considerations

• Conscious sedation for upper endoscopy in patients with RYGB is safe, with a low prevalence of cardiopulmonary adverse events 6.
• The dose of sedation required is predicted by procedural time, rather than body mass index (BMI) 6.
• Upper endoscopy can be safely performed in patients with RYGB under conscious sedation, with a similar cardiopulmonary risk profile to that of standard endoscopy 6.