Barium Swallow Research Articles

A Comparison of Functional Luminal Imaging Probe With High-resolution Manometry, Timed Barium Esophagram, and pH Impedance Testing to Evaluate Functional Luminal Imaging Probe's Diagnostic Capabilities.

The aims of this study are to determine the functional luminal imaging probe's (FLIP) diagnostic utility by comparing FLIP measurements with results from other esophageal evaluation standards. The FLIP is an esophageal evaluation technique performed at the time of endoscopy. Few studies have evaluated FLIP diagnostic capabilities compared with the established testing techniques, including high-resolution manometry (HRIM), time barium esophagram (TBE), and 24-hour impedance-pH monitoring. A retrospective review was performed for 413 preintervention patients who underwent FLIP testing during endoscopy. Data from HRIM, 24-hour pH monitoring, and TBE were compared. Abnormal Distensibility Index (DI) was associated with abnormal integrated relaxation pressure (IRP; P = 0.003). Average DI was higher in patients with abnormal IRP (>15 mm Hg) when a hiatal hernia was present (P = 0.025). The total agreement between correlated diagnoses from FLIP and HRIM was 33.5%. DI was not associated with acid exposure time on pH monitoring. Agreement between FLIP and TBE was 49% with a sensitivity of 98.1% and a specificity of 36.5%. A 60 mL distension had a significantly lower detection rate than 40 mL and 50 mL for active peristalsis and was unaffected by pressure (P < 0.05). FLIP as an adjunct to HRIM is supported by strong metric correlation. FLIP was not correlated to pH monitoring findings, suggesting FLIP is not useful in reflux assessment. The agreement between FLIP and TBE was lower than in previous studies. Hiatal hernia impacted the normality between DI and IRP, not between FLIP and TBE. We suggest analyzing peristaltic patterns on panometry at all fill volumes to optimize detection.

Role of N-acetylcysteine and vitamin B complex in improving outcomes of corrosive ingestion.

Corrosive ingestion remains a worldwide public health problem. To date, there are no specific medications with approved efficacy in reducing gastrointestinal injury progression following corrosive ingestion. The current study assessed the efficacy of N-acetylcysteine (NAC) and vitamin B complex as adjuvant therapy in improving the outcome of patients with corrosive ingestion. The study included 92 patients with acute corrosive ingestion admitted to Alexandria Poison Center. Patients were distributed into four equal-sized groups and managed as such; Group I received the standard treatment protocol. The other three groups received IV antioxidants in addition to the standard treatment; Group II received NAC, Group III received vitamin B complex, and Group IV received both NAC and vitamin B complex. To assess occurrence of delayed complications, barium swallow and meal were done 21days after acute corrosive ingestion, and every patient was followed up for one year. Start of oral intake was earliest among patients in Group II, and as a result, the need for parenteral nutrition decreased significantly with a subsequent decrease in duration of hospitalization. The highest percentage of patients showing normal findings of barium swallow and meal was among the two groups that received NAC (72.7% in Group II and 77.8% in Group IV). Group IV patients who received NAC and vitamin B complex had no esophageal strictures with improved outcomes. NAC and vitamin B complex enhanced recovery in the acute stage, in addition to prevention of delayed complications, especially esophageal strictures. Acute corrosive ingestion is associated with high morbidity because of its catastrophic presentation and lifelong complications.This study was conducted on 92 patients admitted to Alexandria Poison Center (APC).IV NAC significantly decreased the time needed for starting oral intake after acute corrosive ingestion and consequently, the need for parenteral nutrition and duration of hospitalization.No patients suffered from esophageal strictures in the group which received both IV NAC and vitamin B complex.Both NAC and vitamin B complex improved the outcome of patients after ingestion of corrosives whether acids or alkalis.

Superior mesenteric artery syndrome: A tough nut to crack – A rare complication in the management of oligometastatic colorectal carcinoma

The superior mesenteric artery (SMA) syndrome is a rare cause of intestinal obstruction. However, conditions associated with rapid weight loss, including malignancy, burns, bariatric surgery, and trauma, can precipitate the syndrome. Recognition of the syndrome requires a high index of suspicion and a multidisciplinary approach in conjunction with the radiologist. Here, we present the case of a patient with metastatic colon cancer, who developed symptoms of abdominal pain and hematuria after undergoing a local ablative procedure for liver metastases. He was extensively evaluated, in view of a history of abdominal pain in the supine position and relieved in the prone position, along with a history of similar complaints following an earlier colectomy procedure and a history of weight loss. In view of this unusual symptom complex coupled with the radiologic findings on the ultrasound, he underwent a barium swallow which showed duodenal dilation and a reduced aortomesenteric angle. Thus, a diagnosis of the SMA syndrome with the nutcracker phenomenon was made. The patient was managed conservatively and is on regular follow-up. The case highlights the need for a multidisciplinary approach, with an innocuous observation in tandem with the clinical history being pivotal in clinching a rare diagnosis.

Sequelae of dawdled presentation of accidental buttonbattery ingestion – A case report on emerging hazard

Aim:To present a case report of button battery ingestion in a 1-year-old child brought after 16 h of ingestion.Methodology:The child was brought with complaints of button battery ingestion. X-ray of the chest with abdomenwas done to confirm position. An immediate rigid esophagoscopy was done and deformed leaking battery wasremoved from cricopharynx, leaving circumferential blackish slough with ulcer from 12 to 15 cm.Results:The child was under constant observation for monitoring complications. On day 5, feeding gastrostomywas done. On follow-up day 25, barium swallow showed no leakage or stricture formation. Day 45 follow-up uppergastrointestinal scopy revealed short segment stricture and was dilated with endoscopic and fluoroscopic guidedballoon. The child is thriving well and is under regular follow-up to track expected complications earlier.Conclusion:The increased marketing and use of lithium cells is responsible for the rise in incidence ofbutton battery ingestion. Button batteries are characterized by damage progression and a wide spectrum ofcomplications. Clinicians must do their best in early removal, avoiding and expecting delayed complications, andtreat as they arise. Afterall, prevention needs to be the prime goal.

Exploring the reticulo-ruminal motility pattern in goats through medical barium meal imaging technology.

The motility pattern of the reticulo-rumen is a key factor affecting feed intake, rumen digesta residence time, and rumen fermentation. However, it is difficult to study reticulo-ruminal motility using general methods owing to the complexity of the reticulo-ruminal structure. Thus, we aimed to develop a technique to demonstrate the reticulo-ruminal motility pattern in static goats. Six Xiangdong black goats (half bucks and half does, body weight 29.5 ± 1.0 kg) were used as model specimens. Reticulo-ruminal motility videos were obtained using medical barium meal imaging technology. Videos were then analyzed using image annotation and the centroid method. The results showed that reticulo-ruminal motility was divided into primary (stages I, II, III, and IV) and secondary contraction, and the movements of ruminal digesta depended on reticulo-ruminal motility. Our results indicated common motility between the ruminal dorsal sac and ruminal dorsal blind sac. We observed that stages I (3.92 vs. 3.21 s) (P < 0.01), II (4.81 vs. 4.23 s) (P < 0.01), and III (5.65 vs. 5.15 s) (P < 0.05); interval (53.79 vs. 50.95 s); secondary contraction time (10.5 vs. 10 s); and were longer, whereas stage IV appeared to be shorter in the bucks than in the does (7.83 vs. 14.67 s) (P < 0.01). The feasibility of using barium meal imaging technology for assessing reticulo-ruminal and digesta motility was verified in our study. We determined the duration of each stage of reticulo-ruminal motility and collected data on the duration and interval of each stage of ruminal motility in goats. This research provides new insights for the study of gastrointestinal motility and lays a solid foundation for the study of artificial rumen.

Global progress and future prospects of early gastric cancer screening.

Gastric cancer is a prevalent malignancy that poses a serious threat to global health. Despite advances in medical technologies, screening methods, and public awareness, gastric cancer remains a significant cause of morbidity and mortality worldwide. Early gastric cancer frequently does not present with characteristic symptoms, while advanced stage disease is characterized by a dismal prognosis. As such, early screening in gastric cancer is of great importance. In recent years, advances have been made globally in both clinical and basic research for the screening of early gastric cancer. The current predominant screening methods for early gastric cancer include imaging screening, endoscopic screening and serum biomarker screening. Imaging screening encompasses upper gastrointestinal barium meal, multidimensional spiral computed tomography (MDCT), Magnetic resonance imaging (MRI), and ultrasonography. Endoscopic screening methods include white light endoscopy, chromoendoscopy, computed virtual chromoendoscopy, and other endoscopic techniques like endocytoscopy, confocal laser endomicroscopy, optical coherence tomography and so on. Biomarkers screening involves the assessment of conventional biomarkers such as CEA, CA19-9 and CA72-4 as well as more emerging biomarkers such as peptides (PG, G-17, GCAA, TAAs and others), DNA (cfDNA, DNA methylation, MSI), noncoding RNA (miRNA, lncRNA, circRNA, and tsRNA) and others. Each screening method has its strengths and limitations. This article systematically summarizes worldwide progress and future development of early gastric cancer screening methods to provide new perspectives and approaches for early diagnostic and treatment advancements in gastric cancer worldwide.

Detection of Esophageal Cancer Lesions Based on CBAM Faster R-CNN

Esophageal cancer is a common malignant tumor in daily life, which seriously affects human health. Esophageal cancer in China. The incidence rate is among the highest in the world, and there are a large number of new cases of esophageal cancer every year. At present, the diagnosis of esophageal cancer is mainly based on the use of electronic gastroscopy, which reflects the observed situation on the fluorescent screen and conducts detection through the fluorescent screen. With the increasing number of patients, the pressure and intensity of the doctor's work are getting greater and greater[1]. From the perspective of molecular level, the occurrence and development of esophageal cancer, like other cancers, are related to the activation of proto-oncogenes and the inhibition of anti-apoptosis genes. CBAM Faster R-CNN is proposed to solve the problems such as the esophageal region is not obvious and the background region occupies a large proportion in the feature map obtained by the backbone network of Faster R-CNN in barium meal imaging. CBAM is added to the convolutional attention module CBAM on the basis of the original Faster R-CNN model. To enhance the saliency of the features of the esophageal region in the feature map. CBAM Faster R-CNN model was used to train the training set after data enhancement, and Recall, Precision and AP values were used for evaluation and analysis.

Presence of esophageal contractility after achalasia treatment is associated with improved esophageal emptying.

Some achalasia patients exhibit esophageal contractile activity on follow-up after treatment, yet its importance remains unclear. We aimed to identify factors associated with presence of contractility after treatment and to assess its impact on timed barium esophagram (TBE) and clinical outcomes. Patients with type I or II achalasia on baseline high-resolution manometry (HRM) who completed HRM, TBE, and functional lumen imaging probe (FLIP) after treatment were retrospectively identified. Contractility was defined on post-treatment HRM as presence of at least 1 supine swallow with DCI ≥100 mmHg s cm. One hundred twenty-two patients were included (mean age 48 ± 17 years, 50% female). At follow-up evaluation after treatment (54% peroral endoscopic myotomy, 24% pneumatic dilation, 22% laparoscopic Heller myotomy), 61 (50%) patients had contractility on HRM. Patients with contractility (compared to those without) more frequently had type II achalasia (84% vs 57%, p = 0.001) and a post-treatment normal EGJ opening classification on FLIP (69% vs 49%; p < 0.001). In the subgroup of patients with post-treatment integrated relaxation pressure <15 mmHg and normal EGJ opening on FLIP (n = 53), those with contractility had a lower median column height on TBE at 1 min (4 vs 7 cm, p = 0.002) and 5 min (0 vs 5 cm, p = 0.001). In patients with "abnormal" EGJ metrics, patients with contractility showed lower symptom scores (median Eckardt score 2 vs 3, p = 0.03). Occurring more frequently in type II achalasia, and if adequate EGJ opening is achieved after treatment, esophageal contractility may contribute to improved esophageal emptying and improved symptoms in non-spastic achalasia. Preservation of esophageal body muscle could improve outcomes in these patients.

A Literature Review of Infracolic Gastrostomy Techniques and Outcomes

AbstractPercutaneous radiologic gastrostomies are traditionally done using a supracolic approach due to the perceived increased risk of postprocedural hemorrhage associated with an infracolic approach. Many interventional radiologists will decline attempts at placing a gastrostomy tube in situations of colonic interposition, requiring patients to undergo surgery. The goal of this review was to understand the safety and technique of infracolic gastrostomies to assess the validity of these concerns. There were 12 cases of infracolic gastrostomies identified across two retrospective studies and one case report. All gastrostomy tubes were inserted successfully with no abandoned procedures with the only minor variation in technique being that the colon was displaced superiorly as opposed to inferiorly like in the traditional supracolic approach. Across the two retrospective studies, the percentage of infracolic gastrostomies done during the study period was 1.18% (6 out of 508) and 0.43% (5 out of 1,156). There were no immediate postprocedural complications reported in the study done with six patients who underwent infracolic gastrostomies, but there were two deaths during the follow-up period, both of which were attributed to disease progression. In the study with five patients who had undergone infracolic gastrostomies, there was one minor complication of site soreness along with one case of death due to sepsis secondary to aspiration of the barium contrast used to delineate the colon prior to the procedure. This is a rare complication that can occur when a barium swallow is done, especially in this case where the patient was older and had comorbidities that increased the aspiration risk. Evidently, infracolic gastrostomies have been inserted in the past with minimal complications. However, due to the limited sample size, the safety of this technique cannot be established without future prospective studies.

Enigma of Esophageal - Respiratory Fistula in Advanced Esophageal Cancer

Background: The incidence of malignant esophageal-respiratory fistulas in esophageal cancer patients is not so frequent. The fistula development in esophageal cancer may be due to advanced disease or a radiotherapy-related complication. Rarely, a pulmonary abscess may develop, which is the most dreadful complication resulting in dismal outcomes. Here, we reported 2-cases of esophageal-respiratory fistula; one with esophageal bronchial fistula and the other with esophageal pleural fistula.&#x0D; Case reports: A 46-year-aged man presented with complaints of difficulty in swallowing for 4 months. CECT chest showed an esophageal growth of 8.5 cm in the lower esophagus. The patient received palliative radiotherapy followed by palliative chemotherapy and showed some improvement in dysphagia. Nine months after the start of treatment, the patient’s dysphagia began to worsen, and he was put on oral metronomic chemotherapy. After 1-year of metronomic chemotherapy, the patient developed cough and chest pain and was diagnosed with an esophageal-pleural fistula with chest wall collection and pleural effusion. The patient was managed conservatively and later lost to follow-up. Another 65-year-old patient presented with dysphagia for 3-months. CECT chest showed an esophageal growth of 5.5 cm in the middle esophagus. The patient received palliative radiotherapy, after which the dysphagia improved. In 3rd month of follow up patient’s dysphagia worsened; barium swallow showed esophageal-bronchial fistula. The patient was managed symptomatically and later lost to follow-up.&#x0D; Conclusions: Fistula formation and subsequent abscess results in a poor prognosis. With advancing disease and compromised general condition of the patient, palliation of symptoms is a significant challenge. Treatment becomes difficult due to the rare occurrence of fistulas and the non-standardization of the treatment protocol. Invasive treatment includes esophageal-pulmonary resection, endoscopic placement of self-expandable covered stents, drainage of empyema and obliteration of empyema cavity, esophageal diversion, and non-invasive treatment includes best supportive care. However, even with appropriate treatment, the outcome is dismal.

Small Bowel Follow-Through: Treatment for Small Bowel Obstruction or Delaying the Inevitable?

Over 400,000 patients are admitted annually for small bowel obstruction (SBO), of which 20-40% require operative intervention, representing more than 2.3 billion dollars in healthcare expenses. Recurrence of SBO increases with a longer duration of follow-up with up to 15-20% recurrence rates within a five-year period. Small bowel follow-through (SBFT) consisting of serial X-rays with oral contrast has been shown to decrease overall length of stay (LOS) in patients with adhesive SBO. The aim of this study is to determine if SBFT administered to patients with SBO decreases 30-day and up to five-year readmission rates secondary to recurrent SBO. The institutional review board (IRB) approved a single institution retrospective study from 2010 to 2020 that included a total of 742 patients. These patients were organized into groups of those who received the SBFT <24 hours after admission (n=40), those who received the SBFT >24 hours (n=198), and the third group of patients who did not receive the SBFT (n=658). Readmission rates <30 days, <one year, one to three years, and three to five years were evaluated using analysis of variance. Risk factors such as age groups of <30, 30-50, 50-70, >70 years along with BMI<25, 25-29.9, 30-34.9, 35-39.9, >40, as well as the number of intraabdominal surgeries, gender, and need for operative intervention during the admission were evaluated to assess for any associations with recurrence. Readmission within 30 days and up to five years were compared. There were no significant differences in recurrence rates between groups with SBFT <24 hours (p=0.338) or SBFT >24 hours (p=0.889) when compared to the no SBFT group. There was nearly a 48% chance of readmission for another episode of an SBO for patients who did not undergo an operative intervention. While patients who underwent operative intervention had around a 29% chance of having a subsequent episode of an SBO. This is consistent with a statistically significant decrease in one-year (p=0.027) recurrences in patients who underwent operative intervention. There was no significant difference in recurrences with gender, most BMI groups, or in groups who underwent an SBFT. Operative intervention is associated with a statistically significant decrease in recurrence rates of SBO within one year of presentation.

Multicentre positive deviance seminar to generate best practice recommendations to reduce anastomotic leak and length of stay for patients undergoing oesophagectomy

BackgroundWe describe a novel process using positive deviance (PD) with the Canadian Association of Thoracic Surgeons members, to identify perioperative best practice to minimise anastomotic leak (AL) and length of...

Esophageal anatomy and physiology vary across spastic and non-spastic phenotypes of disorders of esophagogastric junction outflow.

Pathophysiologic mechanisms of disorders of esophagogastric junction (EGJ) outflow are poorly understood. We aimed to compare anatomic and physiologic characteristics among patients with disorders of EGJ outflow and normal motility. We retrospectively evaluated adult patients with achalasia types 1, 2, 3, EGJ outflow obstruction (EGJOO) or normal motility on high-resolution manometry who underwent endoscopic ultrasound (EUS) from January 2019 to August 2022. Thickened circular muscle was defined as ≥1.6 mm. Characteristics from barium esophagram (BE) and functional lumen imaging probe (FLIP) were additionally assessed. Of 71 patients (mean age 56.2 years; 49% male), there were 8 (11%) normal motility, 58 (82%) had achalasia (5 (7%) type 1, 32 (45%) classic type 2, 21 (30%) type 3 [including 12 type 2 with FEPs]), and 7 (7%) had EGJOO. A significantly greater proportion of type 3 achalasia had thickened distal circular muscle (76.2%) versus normal motility (0%; p < 0.001) or type 2 achalasia (25%; p < 0.001). Type 1 achalasia had significantly wider mean maximum esophageal diameter on BE (57.8 mm) compared to type 2 achalasia (32.8 mm), type 3 achalasia (23.4 mm), EGJOO (15.9 mm), and normal motility (13.5 mm). 100% type 3 achalasia versus 0% type 1 achalasia/normal motility had tertiary contractions on BE. Mean EGJ distensibility index on FLIP was lower for type 3 achalasia (1.2 mmHg/mm2 ) and EGJOO (1.2 mmHg/mm2 ) versus type 2 (2.3 mmHg/mm2 ) and type 1 achalasia (2.9 mmHg/mm2 ). Our findings suggest distinct pathologic pathways may exist: type 3 achalasia and EGJOO may represent a spastic outflow phenotype consisting of a thickened, spastic circular muscle, which is distinct from type 1 and 2 achalasia consisting of a thin caliber circular muscle layer with more prominent esophageal dilation.

Hiatal hernia reporting: time to remove subjectivity?

The size of a hiatal hernia (HH) is a key determinant of the approach for surgical repair. However, endoscopists will often utilize subjective terms, such as "small," "medium," and "large," without any standardized objective correlations. The aim of this study was to identify HHs described using objective axial length measurements versus subjective size allocations and compare them to their corresponding manometry and barium swallow studies. Retrospective chart reviews were conducted on 93 patients diagnosed endoscopically with HHs between 2017 and 2021 at Newton-Wellesley Hospital. Information was collected regarding their HH subjective size assessment, axial length measurement (cm), manometry results, and barium swallow readings. Linear regression models were used to analyze the correlation between the objective endoscopic axial length measurements and manometry measurements. Ordered logistic regression models were used to correlate the ordinal endoscopic and barium swallow subjective size allocations with the continuous axial length measurements and manometry measurements. Of the 93 endoscopy reports, 42 included a subjective size estimate, 38 had axial length measurement, and 12 gave both. Of the 34 barium swallow reads, only one gave an objective HH size measurement. Axial length measurements were significantly correlated with the manometry measurements (R2 = 0.0957, p = 0.049). The endoscopic subjective size estimates were also closely related to the manometry measurements (R2 = 0.0543, p = 0.0164). Conversely, the subjective size estimates from barium swallow reads were not significantly correlated with the endoscopic axial length measurements (R2 = 0.0143, p = 0.366), endoscopic subjective size estimates (R2 = 0.0481, p = 0.0986), or the manometry measurements (R2 = 0.0418, p = 0.0738). Mesh placement was significantly correlated to pre-operative endoscopic axial length measurement (p = 0.0001), endoscopic subjective size estimate (p = 0.0301), and barium swallow read (p = 0.0211). However, mesh placement was not significantly correlated with pre-operative manometry measurements (0.2227). Endoscopic subjective size allocations and objective axial length measurements are associated with pre-operative objective measurements and intra-operative decisions, suggesting both can be used to guide clinical decision making. However, including axial length measurements in endoscopy reports can improve outcomes reporting.

OGBN P28 Accuracy of Barium Swallow and PH Manometry on Pre-operative Anti-reflux surgery

Abstract Background Fundoplication is one of the common surgical procedures offered to patients who have not responded to medical or conservative treatment for Gastroesophageal-Reflux-Disease.Within our trust routine-PH manometry,barium swallow and OGD are preferred pre-op investigations.According to the guidelines set forth by SAGES(Society of American Gastrointestinal and Endoscopic Surgeons)-PH manometry and endoscopy are recommended as the preferred methods for pre-operative assessment.PH manometry is considered the gold standard for detecting reflux and dysmotility.Our objective is to evaluate and compare the local practice with published literature on identifying the accuracy of pre-operative barium swallow and ph manometry in diagnosing reflux and dysmotility. Methods A retrospective review of electronic medical records of patients who had Nissen fundoplication at Ealing Hospital between January2017-December2022 was included in the study. Among these, patients who had both pre-operative assessments - barium swallow and Ph manometry were included in the cohort. Initial data was retrieved from the Surgical operating service list and was further analyzed with the help of EPRO ( Electronic information provider) for information on Barium swallow, Ph manometry studies, and postoperative outcome. Results In a study of 54 Nissen Fundoplication patients (mean age M&amp;F 58), 25 underwent pH manometry and barium swallow- Concordant positive results were found in 13 patients (52%), indicating reflux. Discordant results occurred in 11 patients (44%) with positive manometry but negative barium swallow, favoring pH manometry's sensitivity. Of the 25 patients analyzed, 20 (80%) had good symptom control, while 3 (12%) experienced symptom recurrence, and 2 (8%) missed follow-ups. Barium swallow missed 8 dysmotility cases, while pH manometry missed 4. Among 46 patients with detected hiatus hernia by OGD, only 26 (54%) were accurately diagnosed using barium swallow. Conclusions Our study demonstrated that Ph manometry is a reliable pre-operative assessment tool for anti-reflux surgery, achieving 100% accuracy in detecting reflux compared to only 55% accuracy with barium swallow. With dysmotility, Ph manometry showed better results of 67% whereas barium swallow identified only 33%. Barium swallow should be used as an additional investigation for failed pH studies and reflux-related dysphagia symptoms. It can also be valuable in post-operative cases to evaluate wrap position and potential complications due to tightness. These findings were presented at the local surgical audit meeting, and future cycles will focus on guideline compliance assessment.

OGBN P04 Achalasia: A single-centre experience of surgical management over 14 years

Abstract Background Achalasia is a rare motility disorder of the oesophagus with likely autoimmune aetiology, characterised by absent oesophageal peristalsis and impaired lower oesophageal sphincter relaxation. Typical symptoms include dysphagia, regurgitation and weight loss. Different treatment modalities are available, predominantly aimed at improving quality of life. No UK guidelines currently exist for the management of achalasia; the US-based SAGES guidelines (2011) do however provide evidence-based recommendations, albeit of varying strength. A published survey of UK surgeons revealed variation in certain aspects. We sought to explore our institution's experience in management of achalasia, primarily focusing on surgery (laparoscopic Heller’s cardiomyotomy). Methods An electronic database search was performed to identify all patients either newly diagnosed with achalasia and / or who received treatment for achalasia at our institution between 2009 and 2022. Patients who had already received endoscopic, radiological or surgical treatment prior to 2000, or at another institution at any time were excluded. Demographics, diagnostic investigations, treatment (Botox injection, dilatation, cardiomyotomy) and surgical outcomes were retrospectively recorded in a database and analysed. Results 128 patients met the inclusion criteria above; 127 were adults, 66 male. 70 patients (54.7%) underwent laparoscopic Heller’s cardiomyotomy with anterior fundoplication. All patients had OGD, 63 (90.0%) barium swallow and 54 (77.1%) high resolution manometry pre-operatively. Major intra-operative bleeding occurred in one patient from lower oesophageal ulceration. 12 patients had mucosal breaches, repaired intra-operatively. Iatrogenic oesophageal perforations occurred in two patients requiring return to theatre. No mortalities occurred. 31 patients (44.3%) experienced long-term symptom resolution post-operatively. 8 patients (20.5%) with recurrent symptoms had laparoscopic re-do surgery, 11 Botox (28.2%) and 11 dilatation (28.2%) - several had combination of modalities. Conclusions Access to regional, then latterly local, high resolution manometry has facilitated full diagnostic assessment, as SAGES strongly recommends all patients undergo along with OGD and barium swallow. Surgical management of achalasia at our institution over this 14-year period has been very standardised, owing to the operations being performed by two consultant surgeons only. A good proportion of operated patients had a successful outcome with long-term resolution of symptoms. Serious complications in our cohort were rare; these patients required re-operation and ultimately recovered. Laparoscopic Heller’s cardiomyotomy with anterior fundoplication can be a safe and effective management option for achalasia.

OGC P35 A clinical audit looking at how efficient the current pathways are for detecting upper oesophageal cancer

Abstract Background Dysphagia is a red flag symptom of possible oesophageal cancer. Patients are referred to gastroenterology, Upper GI Surgery or Otolaryngology. The referral pathway is determined by whether the symptoms are thought to be oropharyngeal or oesophageal in nature. Often, correlation between patient’s perception of the level of dysphagia and the anatomical location of the underlying cause is unreliable. This can result in a number of patients receiving either a delayed complete examination of the oesophagus or not receiving one at all. Our aim was to identify potential delays in the diagnostic pathway of patients with suspected upper oesophageal malignancy. Methods A retrospective analysis of 348 patients with a confirmed histological diagnosis of oesophageal cancer between January 2021 – March 2023 was performed. Only patients with cervical oesophageal cancer up to 20cm were included. The time between GP referral and commencement of treatment was compared against NHS England standards. The initial investigation ordered for those patients after being referred to the specialist was reviewed in order to identify any diagnostic delays. According to NICE guidelines, all patients with dysphagia should be referred for oesophago-gastro-duodenoscopy (OGD) urgently. Barium swallow should not be the first line investigation for suspected oesophageal cancer. Results 14 cervical oesophageal cancer cases were identified. 5 cases discussed at UGI Multidisciplinary meeting with incidental diagnosis were excluded. All remaining 9 cases were discussed at both Head and Neck and UGI MDMs. 6/9 patients were first referred to ENT with dysphagia. The remaining 3/9 were referred to either Gastroenterology or UGI. 4/9 patients had OGD whereas 5/9 had barium swallow and 7/9 rigid oesophagoscopy organized by ENT. Interestingly, 4/5 barium swallow tests were the first line investigation. Median interval from GP referral till start of treatment was 108 days which is almost double compared to the standards (62 days). Conclusions This study highlights significant delays in the diagnostic pathway of patients referred from GP with dysphagia and suspected cervical oesophageal cancer. It appears that this group of patients enters a pathway without a clear diagnostic consensus. Patients with red flag dysphagia symptoms for suspected malignancy should have direct visualisation of the oesophagus irrespective of whether the initial assessment occurs within head and neck or upper gastrointestinal suspected cancer pathways.

Changing Roles of a Radiographer in Fluoroscopy:

Fluoroscopic imaging services in Zambia have been available since 1972 when the first equipment was installed at the University Teaching Hospital (UTH). However, there is limited fluoroscopy equipment use due to a critical shortage of radiologists who are traditionally trained to carry out this role. Radiologists work alongside radiographers who provide technical support and patient care. To address the shortage of radiologists, radiographers in the United Kingdom (UK) have explicitly expanded their scope of practice and started performing and reporting on fluoroscopic examinations such as barium swallow, barium meal, small bowel follow-through, barium enema, and videofluoroscopy after undergoing appropriate training. Literature from the UK shows that gastrointestinal (GI) radiographers’ performance is of a high-quality standard. The initiative has been very effective and made a significant contribution to the delivery of fluoroscopic services in that country. Therefore, the aim of this article was to review the literature on role extension for GI radiographers to guide the development and practice of fluoroscopic studies in Zambia. It is anticipated that this article will bring awareness to stakeholders such as the Ministry of Health (MOH), Schools of Radiography, the Radiological Society of Zambia (RSZ), and the Zambia Medical Association (ZMA) on this important subject.

Exploring the neural mechanisms underlying achalasia: A study of functional connectivity and regional brain activity

Background and AimsThe pathophysiology of achalasia, which involves central nuclei abnormalities, remains unknown. We investigated the resting-state functional MRI (rs-fMRI) features of patients with achalasia. MethodsWe applied resting-state functional MRI (rs-fMRI) to investigate the brain features in patients with achalasia (n = 27), compared to healthy controls (n = 29). Focusing on three regions of interest (ROIs): the dorsal motor nucleus of the vagus (DMV), the nucleus ambiguus (NA), and the nucleus of the solitary tract (NTS), we analyzed variations in resting-state functional connectivity (rs-FC), fractional amplitude of low-frequency fluctuations (fALFF), and regional homogeneity (ReHo). ResultsAchalasia patients demonstrated stronger functional connectivity between the NA and the right precentral gyrus, left postcentral gyrus, and left insula. No significant changes were found in the DMV or NTS. The fMRI analysis showed higher rs-FC values for NA-DMV and NA-NTS connections in achalasia patients. Achalasia patients exhibited decreased fALFF values in the NA, DMV, and NTS regions, as well as increased ReHo values in the NA and DMV regions. A positive correlation was observed between fALFF values in all six ROIs and the width of the barium meal. The NTS fALFF value and NA ReHo value displayed a positive correlation with integrated relaxation pressure (IRP), while the ReHo value in the right precentral gyrus showed an inverse correlation with the height of the barium meal. ConclusionsAbnormal rs-FC and regional brain activity was found in patients with achalasia. Our study provides new insights into the pathophysiology of achalasia and highlights the potential of rs-fMRI in improving the diagnosis and treatment of this condition.

Esophageal Radiography Interpretation: a Primer for the Gastroenterologist.

Radiological studies can be helpful when evaluating patients with suspect esophageal disorders. From benign strictures to malignancy and motility disorders such as achalasia, imaging modalities play a significant role in diagnosis. This review explores the role of different imaging modalities in the most frequently encountered esophageal pathologies. Conventional barium esophagram has long been considered the primary imaging modality of the esophagus. In the same fashion, a timed barium esophagram is a valuable tool in the evaluation of achalasia and esophagogastric junction outlet obstruction. Over the last few decades there has been an increase in CT and MRI studies, which also play a role in the evaluation of esophageal pathologies. However, not infrequently, these newer imaging techniques can result in incidental esophageal findings. It is important that gastroenterologists appreciate the value of different modalities and recognize key imaging features. The diagnosis and management of esophageal disorders is evolving. A basic understanding of esophageal radiology is essential to any gastroenterologist caring for patients with esophageal complaints.