Contrast Esophagram Research Articles

Patient-Friendly Summary of the ACR Appropriateness Criteria®: Dysphagia

Dysphagia is a term used to describe the awareness of swallowing difficulties or perception of blockage during swallowing. It is a swallowing disorder commonly caused by structural and functional abnormalities of the mouth, throat, esophagus, and other organs involved with swallowing. For oropharyngeal dysphagia with known causes, fluoroscopy barium swallow modified (x-rays taken as individual swallows barium liquid) is usually appropriate. Fluoroscopy pharynx dynamic and static imaging, fluoroscopy biphasic esophagram, or fluoroscopy single contrast esophagram may also be appropriate. For oropharyngeal dysphagia with unknown causes, fluoroscopy biphasic esophagram is usually appropriate. Fluoroscopy barium swallow modified, fluoroscopy single contrast esophagram, or esophageal transit nuclear medicine scan (imaging after drinking radioactive water) may also be appropriate. For retrosternal dysphagia (blockage or discomfort behind sternum while swallowing) in persons with functioning immune systems, fluoroscopy biphasic esophagram is usually appropriate. Fluoroscopy single contrast esophagram, esophageal transit nuclear medicine scan, or fluoroscopy barium swallow modified may also be appropriate. For retrosternal dysphagia in persons with compromised immune systems, fluoroscopy biphasic esophagram is usually appropriate. Fluoroscopy single contrast esophagram or barium swallow modified may also be appropriate. For oropharyngeal and retrosternal dysphagia after surgery, fluoroscopy single contrast esophagram or CT neck/chest with contrast are usually appropriate. CT neck/chest without contrast may also be appropriate. For oropharyngeal and retrosternal dysphagia more than a month after surgery, CT neck/chest with contrast or fluoroscopy single contrast esophagram are usually appropriate. Fluoroscopy barium swallow modified, fluoroscopy biphasic esophagram, or esophageal transit nuclear medicine scan may also be appropriate. See the full appropriateness criteria for dysphagia at: https://acsearch.acr.org/docs/69471/Narrative/.

Clinical value of routine contrast esophagram in the diagnosis of anastomotic leakage for three-incision esophagectomy with cervical anastomosis

Objective: To examine the clinical value of routine contrast esophagram (RCE) for the diagnosis of anastomotic leakage (AL) after three-incision esophagectomy with cervical anastomosis. Methods: Clinical data of 1 022 patients with esophageal cancer who underwent McKeown three-incision esophagectomy with cervical anastomosis from January 2015 to December 2019 at Department of Minimally Invasive Esophageal Surgery, Tianjin Medical University Cancer Hospital and Institute were analyzed retrospectively. There were 876 males and 146 females, aging(M(IQR)) 48(16) years (range: 36 to 84 years). There were 253 patients (24.8%) with neoadjuvant therapy, and 817 patients (79.9%) with minimally invasive esophagectomy. According to the diagnosis and treatment habits of the attending surgeons, 333 patients were included in the RCE group, and RCE was performed on the 7th day postoperative, while 689 patients were included in the non-RCE group, and RCE was performed when the patients had suspicious symptoms. Taking clinical symptoms, RCE, CT, endoscopy and other methods as reference to the diagnosis of AL, the sensitivity and specificity were used to analyze and evaluate the efficacy of RCE for the diagnosis of AL. The data were compared by U test or χ² test between groups. Results: The incidence rate of AL after three-incision esophagectomy was 7.34% (75/1 022), including 30 cases in the RCE group and 45 cases in the non-RCE group (9.0%(30/333) vs. 6.5%(45/689), χ²=2.027, P=0.155). The diagnostic time of AL was 9(5) days postoperative (range: 4 to 30 days). Among them, 23 cases showed cervical leakages, 50 cases showed intro-thoracic leakages, and 2 cases both cervical and intro-thoracic leakages. The diagnostic time of patients with intro-thoracic leakages was longer than that of cervical leakages (10(4) days vs. 6(3) days, Z=-2.517, P=0.012). Among the 333 patients in the RCE group, 16 cases of RCE indicated leakages including 11 cases of true positive and 5 cases determined to be false positive, while 317 cases indicated no abnormalities including 19 cases developed leakages. The sensitivity and specificity of RCE to detect AL were 36.7%(11/30) and 98.3%(298/333), respectively. The Youden-index was 0.35, and the diagnostic accuracy was 92.8%(309/333). The positive and negative predictive value were 11/16 and 94.0%(298/317), respectively. Conclusions: Routine contrast esophagram after three-incision esophagectomy with cervical anastomosis has low sensitivity and high specificity in the diagnosis of AL. The diagnostic time of AL is the 9th day after surgery. It is necessary to prolong the observation time clinically, and combine RCE with CT, endoscopy and other inspection methods for diagnosis.

Endoscopic Removal of an Eroded LINX® Device Using a Mechanical Biliary Lithotriptor

Background: Magnetic sphincter augmentation (MSA) via the surgical placement of a LINX® device (LINX® Reflux Management System, Torax Medical, Shoreview, MN, USA) is an increasingly performed minimally invasive outpatient anti-reflux procedure with a low erosion rate. The most common initial approach to eroded LINX® devices is endoscopic removal. Often endoscopy centers do not have specialized devices to cut through the newer, more durable LINX® systems. In this paper we describe a unique approach for removal of a LINX® with intraluminal erosion using a commonly stocked mechanical biliary lithotripsy device. Case description: A 63-year-old male with a history of GERD and symptomatic type III paraesophageal hernia (PEH) underwent a robotic PEH repair with magnetic sphincter augmentation (1.5T, 17 bead) at an outside hospital. He developed an acute recurrence of his PEH, and subsequent upper endoscopy and contrast esophagram four weeks postoperatively revealed a gastric erosion of the LINX device, which had migrated 6 cm onto the stomach. Attempted endoscopic LINX® removal using the OVESCO remove DC Cutter device was unsuccessful. Using principles of prior endoscopic bariatric lap band foreign body removal, the entire LINX® device was successfully removed with the described biliary lithotriptor technique. Conclusion: Using a common biliary mechanical lithotriptor device and a guidewire to transect the newer 1.5T LINX® Reflux Management System is a safe, effective and familiar technique for endoscopic removal of an eroded MSA device.

S1997 Spontaneous Pneumomediastinum Secondary to Cannabinoid Hyperemesis Syndrome

INTRODUCTION: Marijuana use has been infrequently identified as a potential risk factor for the development of spontaneous pneumomediastinum, a rare condition characterized by free air in the mediastinum not preceded by medical or surgical trauma. We present the case of cannabinoid hyperemesis syndrome causing spontaneous pneumomediastinum. CASE DESCRIPTION/METHODS: A 23-year-old female with a history of cannabinoid hyperemesis syndrome presented to the emergency room with a 3-day history of chest pain associated with nausea and multiple episodes of vomiting. She confirmed a three-year history of daily inhaled marijuana use. A CT Chest revealed extensive pneumomediastinum with air tracking along the left hilum/bronchovascular sheath of an unclear source with no radiographic evidence of chest trauma. The patient was admitted to the intensive care unit for continued management. Subsequent water-soluble contrast esophageal revealed findings consistent with pneumomediastinum and no evidence of esophageal perforation, hence Boerhaave’s syndrome was excluded. Given her recurring cyclic vomiting in the setting of cannabis the patient was diagnosed with cannabinoid hyperemesis syndrome (CHS) with spontaneous pneumomediastinum. The patient was managed conservatively, with complete recovery and extensively counseled on cannabis cessation. DISCUSSION: Inhaled marijuana use has been infrequently identified as a potential risk factor for the development of spontaneous pneumomediastinum. Spontaneous pneumomediastinum is a rare clinical entity defined as the presence of free air within the mediastinal structures in the absence of thoracic trauma, surgery, or medical procedure. It is a self-limiting condition resulting from alveolar rupture secondary to an acute increase in intrathoracic pressure subsequently leading to dissection of air along the bronchovascular sheath towards the mediastinum. The hypothesized pathophysiology of marijuana related pneumomediastinum is barotrauma occurring during breathing movements. SPM is managed conservatively with analgesia and treatment of the underlying etiology. Long term prognosis depends on the etiology of the SPM and involves lifestyle modification especially in the setting CHS. Diagnosis of a SPM can often be overlooked as its presenting symptoms remains non-specific. A comprehensive history should be obtained including a detailed history of tobacco and cannabinoid use in patients with intractable nausea and vomiting with a low threshold for chest imaging.Image 1.: Air within the mediastinal structures with no evidence of perforation.Image 2.: Water-soluble contrast esophagram with no evidence of contrast extravasation into the mediastinum.

Laparoscopic Heller Myotomy and Roux-en-Y Gastric Bypass as Treatment for Patients with Achalasia and Morbid Obesity: Outcomes in a Short Series of Patients.

Background: The association between morbid obesity and esophageal achalasia is very infrequent. However, over the last decade, these cases started to increase because of the disturbing rise of morbid obesity worldwide. Heller myotomy (HM) and laparoscopic fundoplication represent the best treatment option for esophageal achalasia. However, in morbidly obese patients with achalasia, the best treatment option is not established. We present laparoscopic HM and Roux-en-Y gastric bypass (RYGB) as an alternative treatment for morbidly obese patients with achalasia. Materials and Methods: We analyzed the course of patients with achalasia and morbid obesity in our institution undergoing a laparoscopic HM and RYGB, with at least 1 year of follow-up. Symptoms questionnaire, body mass index (BMI), and minuted esophagogram before and after treatment were performed in all patients. Results: Seven patients underwent laparoscopic HM and RYGB. All patients had dysphagia. The mean BMI before the onset of symptoms was 42 kg/m2 (range 40 to 50). In 5 patients, preoperative contrast esophagram showed mild or marked dilated esophagus, and in 2, one esophageal curve and severe dilation. Manometry confirmed the diagnosis. At a mean follow-up of 38 months (range 14-69), all patients reported a marked improvement in dysphagia, with median overall satisfaction rating of 10 (range 9-10), and no symptom of gastroesophageal reflux disease (GERD). The mean percentage excess weight loss (%EWL) was 77.1% (range 70.1-98.1) and the mean BMI was 25.7 kg/m2 (range 23-31). Conclusion: HM and RYGB are an excellent treatment for morbidly obese patients with achalasia. All patients reported a marked improvement of their dysphagia and no symptoms of GERD. The %EWL and BMI descent was very good and maintained through time, showing also an excellent control for morbid obesity.

Clinical impact of routine esophagram after peroral endoscopic myotomy

It is unclear whether the common practice of postoperative day (POD) 1 esophagram impacts clinical care or reliably identifies significant adverse events (AEs) related to peroral endoscopic myotomy (POEM). Therefore, we aimed to correlate the most clinically relevant esophagram findings with postoperative outcomes after POEM. Patients were retrospectively reviewed and included if they underwent POEM at 1 of the 3 study institutions between 2014 and 2018. Patient outcomes were assessed in relation to relevant POD 1 esophagram findings such as esophageal dissection or leak. One hundred seventy post-POEM contrast esophagrams (139 fluoroscopy-based vs 31 CT-based) performed on POD 1 were included. Most esophagrams (n= 98) contained abnormal findings but only 5 showed esophageal leak or dissection. Confirmed postoperative AEs of leak or dissection occurred in 4 patients. In 2 patients, POD 1 esophagram appropriately identified the leak or dissection, but in the other 2 patients the initial esophagram was negative, and the AEs were not recognized before clinical deterioration. One patient had a false-positive leak and dissection noted on esophagram leading to an unremarkable endoscopy. Despite the low AE rate after POEM, follow-up esophagram on POD 1 frequently shows expected, unremarkable postprocedural findings and occasionally fails to diagnose serious AEs. This results in pitfalls in accuracy regarding agreement between esophagram versus clinical and endoscopic findings. Relying exclusively on esophagram for post-POEM clinical decision-making can lead to unnecessary additional testing or missed AEs.

PV isolation guided by esophageal visualization with a tailored ablation strategy for the avoidance of esophageal thermal injury: a randomized trial.

Radiofrequency ablation along the posterior wall of the left atrium may lead to atrioesophageal fistula due to esophageal thermal injury. The purpose of our study was to prospectively investigate whether ablation guided by soluble contrast esophageal visualization (SCEV) reduces injury during atrial fibrillation (AF) ablation. Seventy-eight patients with paroxysmal AF undergoing circumferential pulmonary vein isolation (PVI) were randomized to a SCEV group (n = 39) and control group without visualization (n = 39). Cine imaging of the esophagus was performed during soluble contrast swallowing at the beginning of ablation, after adjacent ipsilateral PVI and at the end of the procedure. The ablation lesion set was modified to avoid radiofrequency delivery within the contrast esophagram boundaries. In the control group, a single final ingestion was performed at the end of the procedure. Esophageal injury was assessed by esophagogastroscopy within 24h in all patients. In the control group, the ablation lesion crossed over the esophagus in 46.2% of patients, whereas in SCEV group, the ablation line violated the boundaries of the esophagus unavoidably in 15.4% of patients (confidence interval (CI); 1.61-13.98, p = 0.003). The incidence of esophageal injury was significantly lower in patients that underwent ablation with SCEV (5.1% vs. 20.5%, CI; 0.04-1.06, p = 0.042). Regardless of randomization group, patients who received ablation which overlapped the esophagus had a higher incidence of esophageal injury compared with those without overlap (37.5 vs. 1.9%, CI; 3.73-271.37, p = 0.000). Esophageal contrast visualization helps to reduce the potential for esophageal injury during paroxysmal AF ablation. This simple procedural adjunct has important implications to improve safety of paroxysmal AF ablation procedures globally.

Resection of the Gastroesophageal Junction and Roux-en-Y Reconstruction as a New Alternative for the Treatment of Recurrent Achalasia: Outcomes in a Short Series of Patients.

Background: Heller myotomy and laparoscopic fundoplication represents the best treatment option for esophageal achalasia, with effective short- and long-term success. However, treatment options in patients in whom primary surgery failed represent a real challenge. We present the resection of the gastroesophageal junction (GEJ) along with a Roux-en-Y reconstruction as a treatment alternative. Materials and Methods: We analyzed the course of 5 patients with achalasia undergoing the resection of the GEJ along with a Roux-en-Y reconstruction for recurrent dysphagia after Heller myotomy and fundoplication, with at least 1 year of follow-up. Symptoms questionnaire and minuted esophagogram before and after treatment were performed in all the patients. Results: Five patients underwent resection of the GEJ along with a Roux-en-Y reconstruction. All the patients had dysphagia and 60% had regurgitations. Eighty percent of the patients had more than one previous redo surgery and 100% had had multiple dilations. Preoperative contrast esophagram of 3 patients show Stage II disease (mild and mark dilated esophagus) and 2 patients with Stage III disease (one esophageal curve and severe dilation). Manometry confirmed the diagnosis. At a mean follow-up of 34 months, all the patients reported a marked improvement in dysphagia, with median overall satisfaction rating of 9 (range 7-10), no symptom of gastroesophageal reflux disease (GERD), and good esophageal emptying in the postoperative contrast esophagram. Conclusions: The resection of the GEJ and Roux-en-Y reconstruction is an excellent treatment for recurrent dysphagia after Heller myotomy. All the patients reported a marked improvement of their dysphagia. No symptoms of GERD were documented after the surgery. This procedure should be taken into account as an alternative to esophagectomy for recurrent dysphagia.

Sa1276 UTILITY OF ESOPHAGRAM AFTER PER-ORAL ENDOSCOPIC MYOTOMY (POEM)

Per-oral endoscopic myotomy (POEM) is an endoscopic treatment for achalasia with a clinical success rate of >90%. A contrast esophagram is often performed on post-operative day #1 (POD #1) to assess for esophageal leak; however, limited data exist demonstrating the benefit of this evaluation. We hypothesized that POD #1 esophagram findings alone do not accurately predict presence or absence of post-POEM adverse events (AE).

DOZ047.113: Outcome of routine esophagogastroduodenoscopy, high-resolution manometry (HRM), and pH-(impedance) measurement in esophageal atresia patients according to international guidelines

Abstract Background Evidence-based guideline recommendations for follow-up of patients with esophageal atresia (EA) include regular surveillance esophagogastroduodenoscopy (EGD) with biopsies and a pH(-impedance) measurement (pH-MII) to evaluate gastroesophageal reflux disease (GERD) in asymptomatic patients. In addition, high-resolution manometry (HRM) is considered useful to assess esophageal dysmotility. Additional testing is recommended when symptoms are present. Our aim was to evaluate the diagnostic and clinical yield of these tests. Methods All EA patients who underwent EGD, pH-MII, and HRM according to EA guideline recommendations in 2017 and 2018 were included. Results Seventy-eight patients (53% male, 78% type C, median age 5 (0–17) years) were included. Thirty-one patients had EGD (n = 30), pH-MII (n = 11), and/or HRM (n = 7) as part of a routine surveillance program. Forty-seven patients had EGD (n = 47), pH-MII (n = 26), and HRM (n = 9) for symptom evaluation. Symptoms at the time of testing included dysphagia (51%), regurgitation (41%), and heartburn (24%). Results and consequences of the surveillance and clinically indicated tests are shown in Tables 1 and 2, respectively. Macroscopic EGD findings included stricture (21%), signs of eosinophilic esophagitis (EoE, 3%), and signs of reflux esophagitis (3%). Histological findings included EoE (13%) and reflux esophagitis (17%). Clinical implications of EGD results included medication alteration (GERD/EoE), esophageal dilation, antireflux surgery, or diet change. MII-pH was performed in 37 patients; 15 (41%) were on acid suppressive medication during measurement. Clinical implications of MII-pH results were: start or adjustment of acid suppressive therapy (30%), start or increase of other medication (22%), ceasing of acid suppressive therapy (14%), and referral for fundoplication (3%). HRM was performed in 16 patients (21%, n = 2 uninterpretable due to continuous crying) and showed absent peristalsis in 8/14 (50%), ineffective peristalsis in 4/14 (25%), and fragmented peristalsis in 2/14 patients (12.5%). Clinical implications of manometry results included referral for contrast esophagram (n = 1), increased gastrostomy feeding (n = 1), and gastrostomy placement (n = 1). Conclusion EGD, MII-pH, and HRM reveal multiple abnormalities that have clinical consequences when performed as per recommended surveillance guidelines, which highlights their importance. In most symptomatic patients, additional testing demonstrates underlying pathology. Abnormal diagnostic tests can help guide clinical management in asymptomatic and symptomatic EA patients.

An experimental study on magnetic esophageal compression anastomosis in piglets

IntroductionFashioning a patent, watertight anastomosis in patients with esophageal atresia is a challenging task in pediatric surgery, particularly when performed under tension. A reproducible suture-less alternative would decrease operative time. We evaluated magnetic esophageal compression anastomoses in a novel bypass-loop swine model. MethodsEight-week-old piglets underwent thoracotomy to mobilize the esophagus at the carina to create a U-shaped loop. Custom-made 8 mm diameter Neodymium Magnets were inserted into the esophagus proximal and distal to the loop, then mated side-to-side at the future anastomosis site. Pigs were observed for 8 (n = 4), 10 (n = 6), and 12 (n = 2) days and then sacrificed. The magnetic compression anastomosis was evaluated macroscopically, by radiography, burst pressure testing, and histology. ResultsAll 12 pigs survived until the endpoint. Separation of the magnets occurred at a median of 9 days. Contrast esophagrams showed patency and no leak. All anastomoses withstood pressures well over 13 kPa without leak. Histopathology showed epithelialized circular scar tissue. ConclusionMagnetic compression anastomoses of the esophagus using our specially-designed magnets are formed between the 8th and 10th postoperative day, are patent and mechanically resistant to supraphysiologic intraluminal pressures. These data lay the basis for a potential clinical application in patients born with esophageal atresia. Level of evidenceNot applicable (experimental animal study).

Air Bubble Sign: ANew Screening Method for Anastomotic Leakage After Esophagectomy for Esophageal Cancer.

Contrast esophagography often is performed to screen for anastomotic leakage (AL) after esophagectomy. However, its sensitivity remains low. Adverse events also have been reported. This report describes a new screening method to detect AL on computed tomography (CT) after esophagectomy. From January 2012 to December 2015, 185 patients with esophageal cancer underwent surgical resection at the authors’ institution. The study comparatively reviewed patient characteristics, surgical outcomes, and findings from postoperative CT images and contrast esophagrams of 142 patients who underwent esophagectomy followed by primary gastric conduit reconstruction through a posterior mediastinum route. In this study, 24 patients (15.5%) had AL (leakage-positive group), and 120 patients (84.5%) did not (leakage-negative group). Both groups had comparable backgrounds. The number of air bubbles around the anastomotic site and the mediastinal space on postoperative CT images were significantly greater in the leakage-positive group than in the leakage-negative group. The cutoff value for the number of air bubbles required for a positive diagnosis of AL (“air bubble sign”) was calculated to be 3 by receiver operating characteristic curve. Compared with contrast esophagography, the air bubble sign on CT demonstrated a significantly higher sensitivity (86.4 vs. 50.0%) and an equivalent specificity (95.8 vs. 100.0%). Contrast esophagography altered the postoperative management of only five patients (3.5%). A positive air bubble sign on CT is an objective and noninvasive screening method for AL after esophagectomy for esophageal cancer and may replace contrast esophagography as a screening test for AL.

PS01.076: LAPAROSCOPIC REMOVAL OF A SLIPPED ANGELCHIK ANTIREFLUX PROSTHESIS

Abstract Background The Angelchik prosthesis is c-shaped silicone ring designed to prevent acid reflux. The device, which is fitted around the gastroesophageal junction, was popular in 1980s and over 25,000 devices were placed in patients worldwide. However, follow-up showed a high frequency of undesirable results, including device migration and esophageal erosion. The use of this device was therefore abandoned in the early 1990s. Methods A 70-year-old man with a body mass index of 36 kg/m2 presented to us with persistent dysphagia and progressively increasing heartburn. He had undergone placement of an Angelchik prosthesis 37 years earlier. He said that he had experienced dysphagia since it was implanted, but had accepted it. His past medical history included hypertension, hyperlipidemia, sleep apnea, atrial fibrillation, cerebrovascular accident, and benign prostatic hypertrophy. Upper gastrointestinal endoscopy, contrast esophagram, and high-resolution manometry showed a slipped Angelchik device on the stomach with moderately impaired esophageal body motility. Results The patient underwent laparoscopic removal of the Angelchik prosthesis, followed by a Roux-en-Y gastric bypass for antireflux. After laparoscopic access, adhesions from previous laparotomy were taken down and standard laparoscopic foregut surgery ports were placed. A fibrous calcified capsule encircling the Angelchik prosthesis was noted around the proximal stomach. The anterior wall of the capsule was peeled off using a Harmonic scalpel, and the Angelchik prosthesis was removed in one piece. Given the patient's esophageal dysmotility and scarring around the fundus, we proceeded with Roux-en-Y gastric bypass. The alimentary and biliary limbs were tailored to 80 cm and 30 cm in length, respectively. Using linear staplers, the gastric pouch was created by dividing the proximal stomach just below the level of the scarred tissue created by the Angelchik device. The distal stomach was left in situ. The operation lasted 160 minutes, and the intraoperative blood loss was 150 mL. Barium swallow on postoperative day 1 showed no leakage, and a liquid diet was initiated. The patient was discharged on postoperative day 2. The patient now reports resolved dysphagia and reflux. Conclusion Laparoscopic removal of the Angelchik prosthesis and Roux-en-Y gastric bypass was performed safely with good outcomes. Disclosure All authors have declared no conflicts of interest.

Air Bubble Sign: A New Screening Method for Anastomotic Leakage After Esophagectomy for Esophageal Cancer.

Contrast esophagography often is performed to screen for anastomotic leakage (AL) after esophagectomy. However, its sensitivity remains low. Adverse events also have been reported. This report describes a new screening method to detect AL on computed tomography (CT) after esophagectomy. From January 2012 to December 2015, 185 patients with esophageal cancer underwent surgical resection at the authors' institution. The study comparatively reviewed patient characteristics, surgical outcomes, and findings from postoperative CT images and contrast esophagrams of 142 patients who underwent esophagectomy followed by primary gastric conduit reconstruction through a posterior mediastinum route. In this study, 24 patients (15.5%) had AL (leakage-positive group), and 120 patients (84.5%) did not (leakage-negative group). Both groups had comparable backgrounds. The number of air bubbles around the anastomotic site and the mediastinal space on postoperative CT images were significantly greater in the leakage-positive group than in the leakage-negative group. The cutoff value for the number of air bubbles required for a positive diagnosis of AL ("air bubble sign") was calculated to be 3 by receiver operating characteristic curve. Compared with contrast esophagography, the air bubble sign on CT demonstrated a significantly higher sensitivity (86.4 vs. 50.0%) and an equivalent specificity (95.8 vs. 100.0%). Contrast esophagography altered the postoperative management of only five patients (3.5%). A positive air bubble sign on CT is an objective and noninvasive screening method for AL after esophagectomy for esophageal cancer and may replace contrast esophagography as a screening test for AL.

Endoscopic Fundoplication: Effectiveness for Controlling Symptoms of Gastroesophageal Reflux Disease.

Transoral incisionless fundoplication (TIF) is a completely endoscopic approach to treat gastroesophageal reflux disease (GERD). We previously reported our initial results demonstrating safety and early effectiveness. We now present an updated experience describing outcomes with longer follow-up. For a three-year period, TIF procedures were performed on 80 patients. Preoperative workup routinely consisted of contrast esophagram and manometry. PH testing was reserved for patients with either atypical symptoms or typical symptoms unresponsive to proton-pump inhibitors (PPIs). Heartburn severity was longitudinally assessed using the GERD health-related quality of life index. Safety analysis was performed on all 80 patients, and an effectiveness analysis was performed on patients with at least 6-month follow-up. Mean procedure time was 75 minutes. There were seven (8.75%) grade 2 complications and one (1.25%) grade 3 complication (aspiration pneumonia). The median length of stay was 1 day (mean, 1.4). Forty-one patients had a minimum of 6-month of follow-up (mean, 24 months; range, 6-68 months). The mean satisfaction scores at follow-up improved significantly from baseline (P < 0.001). Sixty-three percent of patients had completely stopped or reduced their PPI dose. Results were not impacted by impaired motility; however, the presence of a small hiatal hernia or a Hill grade 2/4 valve was associated with reduced GERD health-related quality of life scores postoperatively. At a mean follow-up of 24 months, TIF is effective. Although symptoms and satisfaction improved significantly, many patients continued to take PPIs. Future studies should focus on longer-term durability and comparisons with laparoscopic techniques.

Hydropneumothorax Due to Esophageal Rupture

BackgroundA brief review of the historical aspects of esophageal rupture is presented along with a case and current recommendations for diagnostic evaluation and treatment. Case ReportA 97-year-old woman complained of acute dyspnea without prior vomiting. Chest x-ray study showed a large right pneumothorax with associated effusion. A thoracostomy tube was placed with return of > 1 L turbid fluid with polymicrobial culture and elevated pleural fluid amylase level. Chest computed tomography (CT) scan demonstrated overt leakage of oral contrast into the right pleural space. She was treated with ongoing pleural evacuation, antibiotics, antifungals, and total parenteral nutrition. The patient and family declined surgical resection as well as endoscopic stent placement. In 1724, Boerhaave described spontaneous rupture of the esophagus postmortem; Boerhaave syndrome remains the name for complete disruption of the esophageal wall in the absence of pre-existing pathology typically occurring after vomiting. It most commonly occurs in the distal left posterolateral thoracic esophagus. Contrast esophagram is considered the “gold standard” for diagnosing esophageal rupture although CT esophagography also shows good diagnostic performance. Treatment includes nil per os status, broad-spectrum antibiotics, and drainage of the pleural space. Surgical repair of the esophageal perforation should be done early if the patient is deemed a good candidate, and esophageal stenting is also an option. Why Should an Emergency Physician Be Aware of This?Esophageal perforation should be suspected in patients with new pleural effusion, often with overt pneumothorax, that is polymicrobial with elevated amylase.

The Diagnostic Value of Routine Contrast Esophagram in Anastomotic Leaks After Esophagectomy.

Routine contrast esophagram has been shown to be increasingly limited in diagnosing anastomotic leaks after esophagectomy. Patients undergoing esophagectomy from 2013 to 2014 at Huai'an First Peoples' Hospital were identified. We retrospectively analyzed patients who underwent routine contrast esophagram on postoperative day 7 (range 6-10) to preclude anastomotic leaks after esophagectomy. In 846 patients who underwent esophagectomy, a cervical anastomosis was performed in 286 patients and an intrathoracic anastomosis in 560 patients. There were 57 (6.73%) cases with anastomotic leaks, including cervical leaks in 36 and intrathoracic leaks in 21 patients. In the cervical anastomotic leak patients, 13 were diagnosed by early local clinical symptoms and 23 underwent routine contrast esophagram. There were 7 (30.4%) true-positive, 11 (47.8%) false-negative, and five (21.8%) equivocal cases. In the intrathoracic anastomotic leak patients, four (19%) were diagnosed by clinical symptoms, 16 (76.2%) were true positives, and one (4.8%) was a false negative. Aspiration occurred in five patients with cervical anastomoses and in eight patients with intrathoracic anastomoses; aspiration pneumonitis did not occur in these cases. Gastrografin and barium are safe contrast agents to use in post-esophagectomy contrast esophagram. Because of the low sensitivity in detecting cervical anastomotic leaks, routine contrast esophagram is not advised. For patients with intrathoracic anastomoses, it is still an effective method for detecting anastomotic leaks.

Spontaneous pneumomediastinum: Is elaborate workup chasing shadows for a known benign condition?

Background: Spontaneous pneumomediastinum (SPM) because of its relative rarity frequently causes apprehension when encountered in the emergency department (ED) leading often to unnecessary investigative workups. Methods: The medical records of patients admitted at a level 1 trauma center ED from January 2012 to June 2017 with SPM were retrospectively reviewed. Results: There were 8 patients with 50.0% females, mean age 26.7 ± 11.5 years and body mass index 22.8 ± 3.6. Chest pain (87.5%), shortness of breath (62.5%), and neck pain (50.0%) were the most common symptoms. Known predisposing or precipitating factors were present in 50.0% and leukocytosis in 75.0%. Although chest X-ray was diagnostic, all patients also had electrocardiogram, chest computed tomography scan, and contrast esophagram. In addition, 3 (37.5%) patients with pneumopericardium associated with tachyarrhythmia had transthoracic echocardiogram, while 1 (12.5%) presenting with persistent vomiting had esophagogastroscopy. There were no significant abnormalities found in these additional studies. All patients were treated conservatively without any complications, and mean hospital length of stay was 1.7 ± 0.8 days. Conclusion: SPM is a benign condition rarely requiring any surgical intervention. Chest X-ray is usually diagnostic, and additional investigations are therefore seldom necessary unless the diagnosis is questionable or there is a high index of suspicion for esophageal injury. Discharge from the ED or 23 h observation disposition should be sufficient for most patients.

A Penny's Worth of Advice

A healthy 15-month-old Hispanic boy presented with dysphagia. The symptoms began without fever, rhinorrhea, or cough. He was immediately taken to the local Urgent Care and diagnosed with an upper respiratory infection. Four days later he returned for persistent symptoms without hematemesis or fever. A chest radiograph noted a round object at the carina (A). Emergent esophagogastroduodenoscopy (EGD) was performed. The coin was removed using rat tooth forceps. Upon inspection of the esophagus the area was noted to have a significant mucosal erosion (B). The patient was admitted for observation. A water-soluble contrast esophagram noted a large mucosal irregularity without perforation (C). After observation the patient was discharged home on a liquid and soft diet. Follow-up demonstrated a significantly improved but ongoing mucosal diverticulum and absence of dysphagia. While complications from esophageal coins are rare, patients with retained esophageal coins are at risk for strictures, perforation, fistula to the great vessels, and respiratory distress.1 This case highlights the importance of prompt removal of retained esophageal foreign bodies.2 Although mucosal injury can be seen on EGD the injury may be greater and longer lasting than visualized. Subsequent imaging after removal may be warranted.3

Early esophagram in per-oral endoscopic myotomy (POEM) for achalasia does not predict long-term outcomes

In the recently reported international survey of centers performing per-oral endoscopic myotomy (POEM), 88% of operators reported obtaining routinely an early postoperative contrast esophagram. To date, there have been no studies to assess the prognostic value of early esophagram in POEM. A retrospective review of a prospectively maintained, single-institution database of patients who underwent POEM for treatment of achalasia was conducted. Patients were evaluated with a routine contrast esophagram on the first postoperative day (POD#1) to assess for perforation. The finding of delayed esophageal emptying, as determined by an attending radiologist, was compared with the patients' symptomatic outcomes and functional parameters at one year follow-up. Contrast esophagram was obtained on POD#1 for 72 patients undergoing POEM; 26 patients (36%) were observed to have a delay in esophageal emptying. Both groups of patients, those with a delay and those without a delay in esophageal emptying on POD#1, had similar preoperative Eckardt scores (7 ± 2 vs 7 ± 2, P = ns) and column height at 5 minutes on preoperative timed barium esophagram (12.1 ± 8 cm vs 14.1 ± 8 cm, P = ns). At a mean follow-up of 1 year, there was no difference in Eckardt scores between patients with and those without a delay in emptying on POD#1 esophagram (1 ± 2 vs 1 ± 1, P = ns), nor was there a difference between the 2 groups in column height at 5 minutes on TBE (5.5 ± 5 cm for delay vs 4.2 ± 4 cm for no delay; P = ns). Rates of treatment failure, as measured by Eckardt score >3 or need for subsequent treatment, also did not differ between the 2 groups (3 patients with delay vs 4 patients without delay in emptying, P = ns). Delay in passage of contrast on POD#1 esophagram did not predict symptomatic or physiologic outcomes at 1-year follow-up in patients undergoing POEM for treatment of achalasia.