On the Spot: Controversies in Surgical Endoscopy

In this issue, I am tackling a familiar topic for the On the Spot column: surgical endoscopy. This time, I have looked at it from the standpoint of the Society of American Gastrointestinal and Endoscopic Surgeons, as well as what’s being addressed, discussed, debated and taught at the 2022 annual meeting. This topic transcends all surgical specialties, and I’d like to thank Rami Lutfi, MD, FACS, FASMBS, and Jaime Ponce, MD, FACS, for weighing in regarding the current debates in this field.

Should endoscopic approaches to gastroesophageal reflux disease be offered as first-line before surgical treatment with Nissen fundoplication? Should preoperative endoscopy before bariatric surgery be performed routinely and not only selectively? Should bariatric endoscopies have their own codes in order to be offered widely? Is the current requirement for minimum endoscopy numbers for general surgery residents adequate to allow graduates to perform safe and effective endoscopy? Read on to see what some of the experts think!

I would like to thank all contributors to this column. Their hard work and time make this a compelling and informative installment for all surgeons and endoscopists. Don’t forget to check out the Gut Reaction on page 14 as well for some quick candid thoughts from these contributors. Feel free to email me at colleen@cmhadvisors.com with any ideas for a debate. Thanks for reading!

—Colleen Hutchinson

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Colleen Hutchinson is a medical communications consultant at CMH Media, based in Philadelphia. She can be reached at colleen@cmhadvisors.com

Dr. Rami Lutfi: Agree. I believe endoscopy provides valuable information that may alter the management or choice of bariatric surgery. While not often a financial burden, it happens certainly enough to warrant its application.

In primary surgery, it shows the anatomy better than upper GI due to its ability to inspect the mucosa and obtain tissue samples, and rule out hiatal hernias, Barrett’s esophagus and other pathologies that may contraindicate certain surgeries. In revisional surgery, it’s more critical, as it shows the anatomy and certainly guides the decision and proper planning for revisions. More so, I believe, especially prior to revisions, endoscopy should only be performed by the surgeon to help him or her make proper judgment about the best revisional choice.

Dr. Matthew Kroh: On the fence, depending on which region of the world you are practicing in. Endoscopy is an invaluable tool and can detect anomalies that may change the planned operation. This occurs uncommonly in the United States but may be critical in areas of the world where endemic gastric cancer and other pathologies are high. Patients with foregut symptoms should routinely undergo preoperative endoscopy.

Dr. Manoel Galvao Neto: Agree. I’ve been saying this publicly since the beginning, and now it has been endorsed by societies, such as the International Federation for the Surgery of Obesity and Metabolic Disorders and the American Society for Metabolic and Bariatric Surgery, in their statements. Consider the most popular procedures like sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB). The sleeve is a known refluxogenic procedure, so endoscopy should be mandated to help rule out mild to severe GERD and associated conditions like large hiatal hernias and Barrett’s esophagus. And with RYGB there may be an excluded stomach left behind that needs to be cleared of any suspicious conditions prior to surgery. Not to mention, in doing pre-op endoscopy, Helicobacter pylori can be managed as well.

Dr. Amber Shada: On the fence. In an ideal world, yes! In our current reality, all patients undergoing sleeve gastrectomy need endoscopy (performed off proton pump inhibitors [PPIs]). All patients who take PPIs or have symptoms of heartburn, regurgitation or dysphagia need endoscopy. A comprehensive esophagogastroduodenoscopy should fully examine, and document, the lower esophageal sphincter (LES) anatomy including Hill grade and where the LES lies with respect to the diaphragm. It should include, at minimum, Seattle protocol biopsies of any irregularities of the gastroesophageal junction for metaplasia. The unfortunate reality is that endoscopy performance and reporting are too operator dependent and not standardized enough to give us this information reliably prior to bariatric surgery. With improvement in performance and documentation standards, I think routine endoscopy will prove to be high yield before all surgical bariatric operations. The data are not there yet, however.

Dr. Carolina Hoff: Agree. Absolutely. If we are talking about RYGB, where the surgeon is about to exclude a significant part of the stomach, we should perform a very thorough upper endoscopy to toss out premalignant lesions; sometimes, we could even treat those before performing surgery.

If we think of sleeve gastrectomy, it’s mandatory to rule out signs of GERD, as the literature shows us that this particular procedure leads to, or exacerbates, reflux. Signs of the illness could change the surgeon’s plans or even expand by adding an anti-reflux approach.

Dr. Galvao Neto: Agree. One of the major barriers to improve bariatric endoscopy adoption is indeed the actual lack of CPT codes that will eventually lead to reimbursement.

Dr. Lutfi: On the fence. As far as coding, yes, I agree that bariatric endoscopies earned their place to have unique codes. The problem is reimbursement, which is the logical next step after obtaining a code. On the one hand, insurance companies resist paying for therapy that’s often temporary (six-month balloons). We need more studies showing durability (such as the MERIT trial; clinicaltrials.gov/ct2/show/NCT03406975) to help us make the argument. Alternatively, while a code and fee schedule will increase access to care, I predict low relative value units for these procedures, resulting in much lower reimbursement. Therefore, adoption by many endoscopists may decrease as bariatric endoscopy moves away from the current lucrative cash-pay packages.

Dr. Kroh: Agree. The increasing diversity and complexity of bariatric endoscopy needs to be correctly coded and identified as a distinct procedure.

Dr. Shada: Disagree. CPT codes should be based on the procedure performed, not the indication for the endoscopy. It is important that the proper diagnosis codes are being used. For example, GERD is a better code to use for preoperative endoscopy compared with morbid obesity.

Dr. Hoff: Agree Since overweight and obese patients represent a significant parcel of the population, every single hospital should be prepared to perform bariatric endoscopy.

Dr. Hoff: Agree—couldn’t agree more. I’ll quote my mentor, Dr. Neto. Decades ago, we had medications and open-heart surgery to treat coronary artery disease. Suddenly and brilliantly, stents were introduced, permitting a minimally invasive procedure. Today we have incisionless and very effective treatments, such as the Stretta procedure and transoral incisional fundoplication (TIF) technique. These incisionless techniques are a game changer in current interventional endoscopy.

Dr. Kroh: Disagree. Endoscopic GERD therapies can be highly effective in correctly selected patients. These patients typically have fewer mechanical and motility abnormalities. Patients who are good candidates for endoscopic GERD therapies are often quite different from those who would benefit most from Nissen fundoplication. Endoscopic and surgical intervention should be tailored to specific patients and not necessarily a stepwise process.

Dr. Lutfi: On the fence. Medical management should certainly be the first-line treatment. We don’t have Level I evidence to change the standard of care. Much data are driven from industry, although good-quality data certainly exist. I do question the rapid adoption by endoscopists who have historically been resistant to refer patients—even those with suboptimal or poor response to PPIs—and now their practice patterns are changing, as they are the ones doing the procedure!

I also worry about practice patterns with profit sharing (high profit) with the combined approach, with a surgeon repairing the hernias—often the general surgeon since no fundoplication is needed—and endoscopist performing the endoscopic therapy.

Dr. Galvao Neto: Agree. Despite laparoscopic Nissen still being the gold standard, endoscopic methods, specifically TIF, are demonstrating equivalence on cases such as refractory GERD without hiatal hernias, and even in those cases with the c-TIF (concomitant laparoscopic hiatal hernia repair with TIF) that adds a laparoscopic hiatus repair. And there is less dysphagia and less gas bloat. So, if equivalence is demonstrated, why not give endoscopy a chance?

Dr. Shada: Disagree. Endoscopic approaches to GERD have not been shown to be superior to surgical treatments like Nissen. However, it is important to counsel patients on all available options to treat GERD, including endoscopic approaches, within formation that entails efficacy and durability. It is also important to differentiate between a purely endoscopic and an endoscopic/laparoscopic hybrid procedure (c-TIF, looking at you!). There are patients for whom an endoscopic approach to treat reflux is a very reasonable first-line treatment with appropriate preoperative counseling. But there’s a reason they have not yet overtaken the fundoplication as a first-line treatment for anti-reflux surgery.

Dr. Shada: Agree. The key words are “safe and effective,” and I believe the current case minimum of 35 upper endoscopies fulfills that for most trainees. There are a couple of things to think about in terms of this requirement, however. First, we’ve begun the transition to defining proficiency using progressive entrustment instead of purely case numbers for other operations in general surgical training. I believe there is space for changing the training paradigm for endoscopy similarly. Second, diagnostic endoscopy and advanced therapeutic endoscopy are very different, and will require different levels of training to achieve safety and efficacy.

Dr. Kroh: On the fence. The number is likely adequate for basic competency and practice of a graduating general surgery resident. However, exposure to more complex endoscopic procedures during residency will better prepare trainees to build upon that foundation in a bariatric or complex gastrointestinal surgery fellowship.

Dr. Lutfi: Agree. I am agreeing only because most graduating residents are not going to be performing endoscopies. I believe the current number is adequate for the bare minimum of exposure to the basics. For those moving on to becoming bariatric surgeons, endoscopy should be a core competency in their fellowship.

Dr. Hoff: Disagree. Minimum is often the synonym of basics. Residents are going to be able to deal with the diagnosis but won’t have the competence to deal with complications or accomplish sophisticated techniques. And as surgical patient quantities rise, so does the need for highly competent endoscopists. Suddenly surgery and endoscopy have been incorporated, so must our teaching methods considering general surgery residents.

Dr. Galvao Neto: On the fence. If we are attached to the previous numbers of 50 colonoscopies and 150 upper endoscopies, it is barely enough to perform diagnostic endoscopies. But now the trend is to perform therapeutic endoscopy to treat complications and start doing endobariatric therapy. And for those clinicians, these numbers are definitely not high enough.

This article is from the March 2022 print issue.