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Background The most common complication of uncovered biliary self-expandable metal stents (SEMSs) is tumor ingrowth. The addition of an impenetrable covering may prolong stent patency. Objective To compare stent patency between uncovered and partially covered SEMSs in malignant biliary obstruction. Design Multicenter randomized trial. Setting Four teaching hospitals. Patients Adults with inoperable distal malignant biliary obstruction. Interventions Uncovered or partially covered SEMS insertion. Main outcome measures Time to recurrent biliary obstruction, patient survival, serious adverse events, and mechanism of recurrent biliary obstruction. Results From October 2002 to May 2008, 129 patients were randomized. Recurrent biliary obstruction was observed in 11 of 61 uncovered SEMSs (18%) and 20 of 68 partially covered SEMSs (29%). The median times to recurrent biliary obstruction were 711 days and 357 days for the uncovered and partially covered SEMS groups, respectively ( P = .530). Median patient survival was 239 days for the uncovered SEMS and 227 days for the partially covered SEMS groups ( P = .997). Serious adverse events occurred in 27 (44%) and 42 (62%) patients in the uncovered and partially covered SEMS groups, respectively ( P = .046). None of the uncovered and 8 (12%) of the partially covered SEMSs migrated ( P = .0061). Limitations Intended sample size was not reached. Allocation to treatment groups was unequal. Conclusions There was no significant difference in time to recurrent biliary obstruction or patient survival between the partially covered and uncovered SEMS groups. Partially covered SEMSs were associated with more serious adverse events, particularly migration. (Clinical trial registration number: NCT01047332.)

Background The aim of this study was to describe the endoscopic findings in patients with upper GI symptoms after Roux-en-Y gastric bypass surgery and to correlate clinical features with endoscopic findings. Methods Patients with symptoms after Roux-en-Y gastric bypass referred for endoscopy were studied. Endoscopy was performed in standard fashion with a 9.8-mm diameter endoscope. Results Forty-nine patients underwent a total of 69 upper endoscopy procedures between January 2001 and February 2003. The most common endoscopic findings were the following: normal post-surgical anatomy (21 patients, 43%), marginal ulcer (13 patients, 27%), stomal stenosis (9 patients [19%], including 5 with a concomitant marginal ulcer), and staple-line dehiscence (8 patients [16%], including one with a marginal ulcer). Abdominal pain was the most common symptom (26 patients, 53%) and was more frequent among patients with a normal endoscopy compared with those with an abnormal endoscopy ( p =0.04). Stomal stenosis was present in 39% of patients with nausea, vomiting, or dysphagia; it was not present in any patient without these symptoms ( p =0.001). Fifteen percent of procedures performed within the first 6 postoperative months were normal, compared with 53% of those performed beyond 6 months ( p =0.02). There was no complication of endoscopy. Conclusions Among patients with symptoms after Roux-en-Y gastric bypass presenting for endoscopy, normal post-surgical anatomy was the most common finding. Marginal ulcer was the most common abnormality. Presentation with abdominal pain and performance of endoscopy beyond the 6th post-operative month were predictive of a normal endoscopy, and lack of nausea, vomiting, and dysphagia predicted the absence of stomal stenosis.

GI endoscopists now have an integral role in the multidisciplinary treatment of obese patients undergoing bariatric surgery, particularly in the prevention and treatment of postoperative complications. Although it is controversial, routine preoperative upper endoscopy should be considered in all bariatric patients, especially those undergoing Roux-en-Y gastric bypass (RYGB) surgery. Endoscopists need to work in close coordination with their bariatric surgery colleagues in all phases of care in order to maximize the yield and safety of endoscopy in this patient population. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative, intraoperative, and postoperative management of bariatric surgery patients. As the performance of bariatric surgery continues to rise in response to the obesity epidemic, GI endoscopists are becoming increasingly involved in the preoperative and postoperative care of patients who had bariatric surgery. The American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee recently published its guidelines on the role of endoscopy in this patient population. 1 The purpose of this article is to complement those guidelines and to highlight the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative, intraoperative, and postoperative management of patients for bariatric surgery. THE ROLE OF PREOPERATIVE ENDOSCOPY