Residual Barium Research Articles

Case Report: Two-year consequences of barium sulfate aspiration

Aspiration of barium contrast is a rare, but well-known, event occurring during examinations of the upper gastrointestinal system using contrast media. We present a case of large-volume high-concentration barium sulfate aspiration in an 88-year-old male diagnosed with dysphagia, during the swallowing study. He rapidly developed difficulty in breathing, hypoxemia and chemical pneumonitis. The chest radiograph showed the infiltration of barium contrast at both sides with left lower lung predominance. His lowest oxygen saturation by pulse oximetry was 91%. His condition improved with supportive care including oxygen therapy. The patient was finally discharged a few days later with normal oxygen saturation by pulse oximetry. The follow-up chest radiograph at 2 years after the aspiration showed considerable interval clearing of the aspirated contrast material. The plasma and urine barium concentrations at 2 years after the aspiration were <0.5 μg/L and 13.6 μg/L, respectively. Currently, there is no reference urine barium level in the Thai population. These finding may be partially explained by our patient’s exposure of barium from food or water or might be gradually absorbed systemically from the residual barium in lungs.

Esophageal Motility Disorders in Patients With Esophageal Barium Residue After Videofluoroscopic Swallowing Study

To investigate esophageal motility disorders in patients with esophageal residual barium on chest x-rays after videofluoroscopic swallowing studies (VFSS) through high-resolution esophageal manometry (HREM). We reviewed the records of 432 patients who underwent VFSS from September 2019 to May 2021, and 85 patients (19.7%) with large residual barium (diameter ≥1 cm) were included. As a result of HREM, motility disorders were classified as major or minor motility disorders according. Esophagogastroduodenoscopy and chest computed tomography results available were also reviewed. Among 85 patients with large residual barium in the esophagus, 16 patients (18.8%) underwent HREM. Abnormal esophageal motilities were identified in 68.8% patient: three patients (18.8%) had major motility disorders-achalasia (n=1), esophagogastric junction (EGJ) outflow obstruction (n=2)-and eight patients (50%) had minor motility disorders-ineffective esophageal motility (n=7), fragmented peristalsis (n=1). In those with normal esophageal motility, three patients of esophageal structure disorders (18.8%)-esophageal cancer (n=1), cardiogenic dysphagia (n=1), slight narrowing without obstruction of EGJ (n=1)-and two patients (12.5%) with chronic atrophic gastritis (n=2) were confirmed. Esophageal motility disorders were identified in 68.8% of 16 patients with large esophageal residual barium with three patients in the major and eight patients in the minor categories. Residual barium in the esophagus was not rare and can be a sign of significant esophageal motility disorders.

582. REPORT ON A 42 YEAR EXPERIENCE WITH THE LAPAROTOMIC/LAPAROSCOPIC HELLER-DOR OPERATION PERFORMED WITH INTRAOPERATIVE MANOMETRY FOR ESOPHAGEAL ACHALASIA

Abstract In 1979 our surgical group proposed the Heller-Dor operation (HD) to accomplish new concepts of surgical pathophysiology: to abolish the lower esophageal sphincter with the division of the U-and sling fibers of the lesser gastric curvature, to prevent GER with an effective but not too effective partial fundoplication which protects the myotomy surface. Aim is to report very long-term results of the treatment of esophageal achalasia with the Heller-Dor operation performed with intra operative manometry. In the period 1979-2021 HD was in first instance adopted in 202 patients (97 men; median age 45 years; IQR 31–59) in laparotomy (L-HD) and in 162 (79 men; age 48 years; IQR 35–63) in laparoscopy (V-HD). At intraoperative manometry, the complete abolition of the high-pressure zone was always obtained and the Dor length and pressure were trimmed according to reference values. Follow-up consisted of interview, endoscopy and barium swallow performed every 3 years. The overall outcome was graded from excellent to poor according to the severity of symptoms and esophagitis. Median follow-up was 14.8 years in HD, 7.5 years in V-HD (p<0.001). Esophageal diameter and residual barium column decreased substantially during the first 3 years after the operation, but not successively. In the L-HD group poor results were 22 (10.9%): due to esophagitis in 17 (8.4%) and to recurrent dysphagia in 5 (2.5%). In V-HD, 4 (2.5%) had esophagitis and 2 (1.2%) severe dysphagia. Outcome was satisfactory in 89% of L-HD and in 96% of V-HD (p<0.001). Postoperatively, according to the Kaplan Mayer curve, dysphagia, reflux symptoms and esophagitis occurred within 60-65 months after surgery. Timing of dysphagia relapse and post-myotomy reflux occurrence indicate that after five years, surgical results can be considered definitive. The 96% of satisfactory results we achieved with VL-HD, at a median follow-up time of 8 years, shows the potentiality of this surgical technique. In our experience, the learning process, not the follow-up length or the laparotomy/laparoscopy method is the cause of improved results of the laparoscopy HD.

579. LONG TERM RESULTS OF THE PULL-DOWN HELLER-DOR TECHNIQUE FOR ACHALASIA PATIENTS WITH SIGMOID ESOPHAGUS

Abstract The outcome of achalasia treatment in patients with sigmoid esophagus is worse than that achieved for fusiform achalasia. We compared two groups of sigmoid achalasia patients, in which we performed the standard Heller-Dor procedure (HD) and the Heller-Dor plus a technique aimed to restore the vertical axis of the intraabdominal portion of the esophagus pull-down Heller-Dor (PD-HD). Long-term results were evaluated. We considered 48 patients affected by primitive esophageal sigmoid achalasia operated upon consecutively (1979-2021) in first instance. After 1987, we routinely isolated 360° of the gastro-esophageal junction and the lower esophagus and applied U stitches at the right side of the lower esophagus to pull down and rotate the gastro-esophageal junction toward the right. Twenty-five patients underwent the standard HD and 23 patients underwent the PD-HD technique. Postoperative follow-up included barium swallow, clinical interview investigating dysphagia and reflux symptoms and endoscopy. The overall outcome was graded from excellent to poor according to the severity of symptoms and esophagitis. The median follow-up period was 11 years (IQR 6-22) for HD group and 9 (IQR 6-14) for PD-HD (p=0.22). At postoperative barium swallow, patients in the PD-DH group had smaller esophageal diameter [4 cm (IQR 4-4.7) vs 4.7 cm (IQR 4-5), p=0.04] and lower residual barium column [10 cm (IQR 6-13) vs 6 cm (IQR 0-8), p=0.001] than those in the HD group. Postoperative moderate-severe (D2-D3) dysphagia rates were 40% for HD and 13% for PD-HD group (p=0.003). The outcome of treatment revealed satisfactory (excellent, good, fair) results in 68% and 91.4% of HD and PD-HD group patients, respectively. The Heller-Dor operation is effective in the presence of sigmoid achalasia. The clinical and instrumental evaluations showed better results with the PD-HD technique. This technique may be the first choice for end-stage achalasia with null or low risk for cancer.

Dysphagia Secondary to Esophageal Compression in a Patient with Decompensated Heart Failure

Cardiogenic dysphagia is a rare type of esophageal dysphagia caused by external compression of the esophagus by an enlarged left atrium. Long-term comparisons between the degree of cardiogenic dysphagia and heart failure have not been reported due to its low incidence. We hereby report the case of a 74-year-old woman with valvular heart disease, suspected of having oropharyngeal dysphagia following a recent intracerebral hemorrhage, who performed a swallowing function test. Videofluoroscopic swallowing study (VFSS) revealed a supraglottic penetration, confirming the oropharyngeal dysphagia. Furthermore, post-VFSS chest radiograph revealed esophageal residual barium, suggestive of reduced esophageal food transition secondary to external compression, at the level of the T6 vertebral body. Chest computed tomography showed mid-esophageal compression caused by left atrial enlargement. She had pulmonary edema which was managed with diuretics. Post-VFSS chest radiographs also revealed a direct association between the diameter of the esophageal barium residue and body weight. A reduction in body weight led to the resolution of the barium residue and vice versa. Development of cardiac dysphagia may be one of the signs of acute exacerbation of heart failure.

Elevated average maximum intrabolus pressure on high-resolution manometry is associated with esophageal dysmotility and delayed esophageal emptying on timed barium esophagram

BackgroundIntrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE.MethodsA retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015–03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure < 17 mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 min or as tablet retention after 5 min.ResultsAM-IBP was significantly related to liquid barium retention (p = 0.003) and tablet arrest on timed barium esophagram (p = 0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p < 0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p = 0.002).ConclusionsOur findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0.

Timed barium swallow: Esophageal stasis varies markedly across subtypes of esophagogastric junction obstruction.

Timed barium swallow (TBS) is a recommended ancillary investigation in evaluation of esophagogastric junction (EGJ) obstruction, yet there are little data comparing esophageal stasis across subtypes. A retrospective cohort study was performed. All type III achalasia diagnosed between November 2016 and November 2020 were included, along with matched numbers of consecutive types I and II and conclusive EGJOO cases with concurrent TBS evaluation. Co-primary outcomes were TBS retention at 1 and 5min. Secondary outcomes were symptoms and manometric metrics of EGJ function and peristaltic integrity. One hundred patients were included (25 each of types I-III and conclusive EGJOO). TBS retention measured by height and width at 1 and 5min differed significantly across the four subtypes (p<0.0001 all comparisons), with esophageal stasis tending to be significantly greater for types I and II achalasia (88% and 84% with >5cm column at 5min) compared to type III and EGJOO (24% and 8% with >5cm column; p<0.0001). Eckardt symptom severity was similar across subtypes (p=0.30). Magnitude of esophageal stasis and integrated relaxation pressure (IRP) were uncorrelated (R=0.21). In EGJOO, the number of swallows with intact peristalsis inversely correlated with barium column height (R=-0.49) and those with disordered peristalsis were more likely to have any residual barium at 5min compared to those without disordered peristalsis (43% vs. 0%; p=0.02). Timed barium swallow findings differed markedly with significantly less esophageal stasis in type III achalasia and EGJOO, despite similar symptom severity and no correlation between degree of emptying and IRP. Preservation of peristalsis may underlie this finding in EGJOO.

Intraperitoneal Barium From Gastrointestinal Perforations: Reassessment of the Prognosis and Long-Term Effects.

OBJECTIVE. The purpose of this study was to reassess the outcome and potential consequences of intraperitoneal barium leakage during radiologic evaluation of the gastrointestinal tract. MATERIALS AND METHODS. This retrospective study included 18 patients who had significant intraperitoneal leakage of barium from gastrointestinal perforations that were not suspected or diagnosed before the radiologic procedures. This complication occurred during a barium enema examination in nine patients, an upper gastrointestinal study in seven, and a small bowel series in two patients. All patients underwent urgent laparotomy for repair of perforation, with vigorous peritoneal lavage and antibiotic therapy. RESULTS. All patients had an uneventful recovery and were followed for 4-17 years (mean, 8.5 years). Radiographs obtained during this interval showed that a significant amount of residual barium was retained in the abdominal cavity. Six patients had a total of 10 subsequent abdominal operations for unrelated conditions, and some had developed barium granulomas and peritoneal adhesions. However, none of the patients in this series experienced intestinal obstruction or any clinical symptoms related to barium deposits in the abdominal cavity. CONCLUSION. Intraperitoneal leakage of barium is a rare complication of radiologic gastrointestinal examinations, and this series of 18 cases reflects 3 decades of experience at two major medical centers. The presented data indicate that the commonly held and perpetuated concept about the high rate of morbidity and mortality of this complication would not be valid in the modern era of medical and surgical management.

Templated grain growth of high coercive field CuO‐doped textured PYN‐PMN‐PT ceramics

AbstractThis paper explores the templated grain growth and texturing of Pb(Yb1/2Nb1/2)O3‐Pb(Mg1/3Nb2/3)O3‐PbTiO3 (PYN‐PMN‐PT) ceramics. A PbO‐CuO liquid phase was determined to substantially increase the growth of PYN‐PMN‐PT on barium titanate template particles. Texturing resulted in an 83% enhancement in strain behavior (754 pm/V) compared with random PYN‐PMN‐PT ceramics (413 pm/V). The increased Pb(Yb1/2Nb1/2)O3 (PYN) content of textured 21PYN‐41PMN‐38PT resulted in a high coercive field of 13.9 kV/cm. Residual barium titanate templates reduced the polarization from 33.7 to 26.2 µC/cm2 and slightly decreased the Curie temperature (236‐224°C). These results show that textured PYN‐PMN‐PT is a promising material for high strain and coercive field transducers.

The timed barium swallow and its relationship to symptoms in achalasia: Analysis of surface area and emptying rate.

Timed barium swallow (TBS) is used to objectively measure response following achalasia therapy; however, findings can be discordant with symptoms. We hypothesized that measurement of surface area of the residual barium column would improve its utility in measuring outcome. In a single-center cohort, achalasia patients undergoing therapy between September 2015-2016 who had TBS were included. Four metrics of emptying were studied: Post-therapy residual barium (a) absolute height and (b) surface area and percentage reduction in (c) residual height (%H) and (d) surface area (%SA) compared to pretherapy. Metrics were evaluated against symptom response (Eckardt score). Twenty-four achalasics (median age 43year; 13 males) were included; 14 received pneumatic dilatation, and 10 had peroral endoscopic myotomy. Treatment resulted in significant reduction in median Eckardt score (7 to 1; P=.03), mean residual barium column height (14.7±8.7 to 7.9±6.0cm; P=.01) and surface area (52.7±43.5 to 24.5±23.6cm2 ; P=.02). There were 4 (17%) initial non-responders (Eckardt>3). % SA was best at discriminating between responders and non-responders (area under curve 0.85±0.08; sensitivity 100%, specificity 80%). Concordance with symptomatic response following therapy was 83% when using 45% as the cutoff for surface area reduction compared to pretherapy. Eight patients whose static barium height was discordant with symptoms became concordant when % SA was used as a measure of response. Change in barium surface area is a superior measure of esophageal emptying and better correlates with treatment response than the conventional 5-minute barium height in defining objective response to achalasia therapy.

Characteristics of Patients With Esophageal Dysphagia Assessed by Chest X-Ray Imaging After Videofluoroscopic Swallowing Study.

ObjectiveTo evaluate the prevalence rate, types, characteristics, and associated factors of esophageal dysphagia detected on chest X-ray images after videofluoroscopic swallowing study (VFSS).MethodsThe medical records of 535 adults were reviewed retrospectively. Chest X-ray images taken after barium swallow study were analyzed and presence of any residual barium in the esophagus was considered as esophageal dysphagia. Esophageal dysphagia was classified based on the largest width of barium deposit (mild, <2 cm; severe ≥2 cm) and the anatomic level at which it was located (upper and lower esophagus).ResultsEsophageal residual barium on chest X-ray images was identified in 40 patients (7.5%, 40/535). Esophageal dysphagia was more frequent in individuals aged 65–79 years (odds ratio=4.78, p<0.05) than in those aged <65 years. Mild esophageal dysphagia was more frequent (n=32) than its severe form (n=8). Lower esophageal dysphagia was more frequent (n=31) than upper esophageal dysphagia (n=9). Esophageal residual barium in patients diagnosed with esophageal cancer or lung cancer was significantly associated with severe esophageal dysphagia (p<0.05) and at the upper esophagus level (p<0.01).ConclusionEsophageal residual barium was observed on chest X-ray imaging after VFSS. Esophageal barium in the upper esophagus with a diameter of ≥2 cm is an important indicator of malignancy, and chest X-ray image taken after VFSS is an important step to evaluate the presence of esophageal disorder.

Imaging individual barium atoms in solid xenon for barium tagging in nEXO.

Double-β-decay involves the simultaneous conversion of two neutrons into two protons, and the emission of two electrons and two neutrinos; the neutrinoless process, although not yet observed, is thought to involve the emission of the two electrons but no neutrinos. The search for neutrinoless-double-β-decay probes fundamental properties of neutrinos, including whether or not the neutrino and antineutrino are distinct particles. Double-β-decay detectors are large and expensive, so it is essential to achieve the highest possible sensitivity with each study, and removing spurious contributions ('background') from detected signals is crucial. In the nEXO neutrinoless-double-β-decay experiment, the identification, or 'tagging', of the 136Ba daughter atom resulting from the double-β decay of 136Xeprovides a technique for discriminating background. The tagging scheme studied here uses a cryogenic probe to trap the barium atom in a solid xenon matrix, where the barium atom is tagged through fluorescence imaging. Here we demonstrate the imaging and counting of individual barium atoms in solid xenon by scanning a focused laser across a solid xenon matrix deposited on a sapphire window. When the laser irradiates an individual atom, the fluorescence persists for about 30 seconds before dropping abruptly to the background level-a clear confirmation of one-atom imaging. Following evaporation of a barium deposit, the residual barium fluorescence is 0.16 per cent or less. Our technique achieves the imaging of single atoms in a solid noble element, establishing the basic principle of barium tagging for nEXO.

A Case of a Gastric Cancer Patient who Developed Gastric Perforation due to Residual Barium Sulfate after X-ray Gastrography

A Case of a Gastric Cancer Patient who Developed Gastric Perforation due to Residual Barium Sulfate after X-ray Gastrography

Incidence and risk factors for the development of epidermoid carcinoma in oesophageal achalasia†.

The risk factors for oesophageal achalasia, a precancerous condition that can lead to epidermoid carcinoma, are unknown. The aim of this study was to determine these factors. Beginning in 1973, patients presenting with achalasia from 1955 to 2016 periodically underwent clinical assessment, the barium swallow test (the oesophageal diameter and residual barium column were measured) and endoscopy according to a prospective protocol. We included patients with the minimum follow-up duration of 12 months. Of 681 cases, 583 patients were considered. The median follow-up time was 147.13 months (interquartile range 70.42-257.82 months), and 17 epidermoid carcinomas and 1 carcinosarcoma were diagnosed. After excluding 4 achalasia patients admitted with a cancer diagnosis, the incidence rate of epidermoid carcinomas was 1.61/1000 persons-year, and the cumulative probability of developing cancer at 56.34 years of follow-up was 13%. Risk factors for cancer were a sigmoid oesophagus [risk ratio (RR) = 17.64, 95% confidence interval (CI) 4.13-75.43], duration of achalasia symptoms >280 months (RR = 19.62, 95% CI 4.59-83.80), duration of follow-up >353 months (RR = 5.96, 95% CI 2.50-14.18), oesophageal diameter at diagnosis >71 mm (RR = 21.07, 95% CI 9.29-47.82), residual barium column at diagnosis >23 cm (RR = 24.27, 95% CI 6.93-85.01) and residual barium column at the last follow-up >10 cm (RR = 8.15, 95% CI 2.40-27.62). Conversely, the risk of epidermoid carcinoma was lower when the residual barium swallow decreased by >57% (RR = 0.10, 95% CI 0.03-0.34). Patients with achalasia carry a substantial risk of developing epidermoid carcinoma. Several factors, such as sigmoid achalasia and dysphagia lasting more than 23 years, are associated with an increased risk of cancer. An effective Heller myotomy may positively influence the carcinogenetic process.

Oropharyngeal Dysphagia With Pyriform Sinus Dilatation Mimicking Zenkerʼs Diverticulum

Dysphagia is a common complaint amongst the elderly, affecting approximately 16 to 22 percent of individuals over the age of 50, with oropharyngeal dysphagia accounting for the majority of cases. Common causes of oropharyngeal dysphagia include stroke, neuromuscular disease, and obstruction (e.g. malignancy). Abnormalities of the upper esophageal sphincter may lead to high hypopharyngeal pressure, causing Zenker's diverticulum. Here we present a case of oropharyngeal dysphagia secondary to lower motor neuron disease, which resulted in pyriform sinus dilatation mimicking Zenker's diverticulum on video fluorescent swallow study. An 82-year-old lady with a history of type 2 diabetes presented with aspiration pneumonia, which was treated with intravenous antibiotics. On review of systems, she reported progressive dysphagia to solids and liquids for 4 years, and workup for dysphagia was initiated. Video fluorescent swallow study showed premature spillage to level of pyriform recesses and delayed pharyngeal response with a large pouch around the level of the pharyngoesophageal segment, suspected to be Zenker's diverticulum. Subsequent EGD was normal. An esophagram with barium contrast was then attempted, however patient aspirated a large volume of contrast during initial phase of the examination, complicated by acute hypoxic respiratory failure requiring intubation and transfer to the intensive care unit. Bronchoscopy was performed with aspiration of about 5 mL of contrast material. The patient was later successfully extubated without complication, however a follow-up CXR showed residual contrast persisting in the hypopharynx. Laryngoscopy was performed, which visualized pooling of material in bilateral pyriform sinuses, which was successfully suctioned. EMG of bilateral genioglossus muscles were done showing chronic bilateral reinnervation, suspicious of possible lower motor neuron disease. Patient recovered on general medical floor with no further hypoxic episodes. PEG tube was placed for long-term feeding and patient was discharged in stable condition with close follow up with neurology for further workup. This patient posed a diagnostic challenge given symptoms of oropharyngeal dysphagia with evidence of hypopharyngeal pooling on video fluorescent swallow study. While hypopharyngeal contrast extravasation would typically elicit a diagnosis of Zenker's diverticulum, in our patient this was a manifestation of dilated pyriform recesses.1749_A Figure 1. Video fluorescent swallow study (left) showing premature contrast spillage to level of pyriforms with delayed pharyngeal response. Large pouch noted around the level of pharyngoesophageal segment, suspected to be Zenker's diverticulum (red arrow). Subsequent barium esophagram (right) showing markedly dilated bilateral symmetric pyriform sinuses (blue arrow) with no evidence of Zenker's diverticulum.1749_B Figure 2. Computed tomography of the neck without contrast (left) delineating retained residual barium within piriform sinuses (red arrows). Chest X-ray (right) showing retained barium within bilateral pyriform sinuses (blue arrows) and bilateral lower lung fields (green arrows).

PS01.001: CARCINOMA IN ESOPHAGEAL ACHALASIA: WHO, WHEN AND HOW

Abstract Background Esophageal achalasia is a precancerous condition for epidermoid carcinoma; prevalence and risk factors for cancer development are not defined. Aim of the study was to determine these parameters. Methods Achalasia patients observed in the period 1955-2016, since 1973 were periodically submitted to clinical assessment, barium swallow (esophageal diameter and residual barium column were measured), endoscopy, according to a prospective protocol. In this study we included patients with a minimum 12 months follow-up, endoscopy or radiology at the last control. Follow up was discontinued for decision or death of patients. Results Five hundred and eighty-three of 681 cases were considered. The median follow-up was 147.13 months (IQR 70.42-257.82 months); 17 epidermoid, 1 carcinosarcoma were diagnosed (30.8/1000 cases). At multivariate analysis esophageal diameter (p &lt; 0.001), residual barium column (p &lt; 0.05) and duration of dysphagia (p &lt; 0.001) were independent risk factors. Conversely, the risk of epidermoid carcinoma development decreased after residual barium swallow decrease (p &lt; 0.05), consequent to efficacious therapy. According to classification tree (Figure), patients with severe dysphagia at the last clinical-radiological control and sigmoid esophagus experienced a risk of epidermoid carcinoma development equal to 48.6%. classification tree for squamous cell carcinoma. o outcome; se sigmoid esophagus.jpg Conclusion End-stage achalasia and dysphagia lasting longer than 22 years are risk factors for development of epidermoid cancer. Effective Heller myotomy can interrupt the carcinogenetic process in the presence of end-stage achalasia. Patients who overcome the risk parameters, should be offered esophagectomy or conservative surgery followed by strict endoscopic surveillance. Disclosure All authors have declared no conflicts of interest.

Treatment of reverse osmosis brine by direct contact membrane distillation: Chemical pretreatment approach

Different chemical pretreatment strategies followed by direct contact membrane distillation (DCMD) process were adopted for the processing of reverse osmosis (RO) brine. CPT with Na2CO3+NaOH allowed scale reduction, removing both permanent calcium hardness and temporary calcium hardness whereas the chemical pretreatment with BaCl2 permitted to remove sulfate ions from RO brine. This last chemical pretreatment was found to be the most efficient pretreatment improving the DCMD performance because of the corresponding highest permeate flux, lowest permeate flux decline and best permeate quality. However, it is relatively an expensive pretreatment not recommended for consumption because of the toxic residual barium. The brine was concentrated up to 37wt% of salts in water, which is above the limiting salt (NaCl) saturation concentration. Therefore, the volume of discharged RO brine can be reduced considerably facilitating its efficient management.

Sa1658 - The Timed Barium Esophagram Surface Area Correlates with Symptom Improvement Better than Column Height Following Treatment in Achalasia

Introduction Timed barium esophagram (TBE) is an objective measurement of esophageal emptying in achalasia. Post-therapy reduction of residual barium column height correlates imperfectly with short term symptomatic outcomes. We hypothesise that surface area (SA) of the barium column may be more accurate than height; firstly, by incorporating improvement in esophageal width that often occurs post-therapy, but also by correcting for artificially higher height values due to esophageal contraction occurring. We aimed to compare the correlation of TBE outcome measures of height and SA with symptom improvement post-therapy. Method Achalasia patients who underwent therapy between 2015–6 and had TBE and Eckardt score (ES) performed at baseline as well as within 6 months post-therapy were included. TBE images were acquired 5 mins following ingestion of 200 mL barium. Barium height was measured between the gastro-esophageal junction and the superior extent of any residual barium column. After manually defining column boundaries, software was used to calculate SA. Adequate symptom relief was defined as ES reduction to ≤3. On TBE, metrics of adequate emptying evaluated were i) post-therapy column height 50% reduction in column height from pre to post-therapy and iii)>50% reduction in column SA from pre to post-therapy. Results Of 18 patients, 11 had dilatation and 7 POEM. Reductions with therapy of both 5 min barium column height (14.7±8.7 to 7.9±6.0 cm; p=0.01) and SA (52.7±43.5 to 24.5±26.0cm2; p=0.02) were noted. Symptoms also improved; median baseline ES 7 (IQR 5.25–8) improved to 0 (IQR 0–1) post-therapy. However there was poor concordance between post-therapy barium height and symptomatic relief (i.e. post-therapy column >5 cm despite ES ≤3 or vice versa), and the correlation (R) between these two variables was poor. Similar poor concordance was seen when adequate emptying was defined by >50% reduction in column height, but >50% reduction in SA paralleled symptom relief most closely. Conclusion In TBE performed on achalasia patients post-therapy, reduction in SA of the residual barium column compared with baseline values parallels symptomatic relief more closely than reduction of column height. Disclosure of Interest None Declared

Laryngeal Elevation Velocity and Aspiration in Acute Ischemic Stroke Patients.

ObjectivesAspiration after stroke has been associated with aspiration pneumonia, which contributes to increased mortality of stroke. Laryngeal elevation is a core mechanism for protection from aspiration. Few studies have explored the predictive value of laryngeal elevation velocity for aspiration after stroke. This study aimed to explore the ability of laryngeal elevation velocity to predict aspiration in patients with acute ischemic stroke.MethodsThis was a prospective cohort study that included consecutive acute ischemic stroke patients treated at a teaching hospital during a 10-month period. Patients underwent magnetic resonance imaging (MRI) to confirm the diagnosis of acute ischemic stroke. Patients who were at risk of aspiration and could swallow 5 ml of diluted barium (40%, w/v) for a videofluoroscopic swallowing (VFS) study were included. The association between abnormal indices in the oral and pharyngeal phase of the VFS study and aspiration was examined using univariate analyses. These indices included the lip closure, tongue movement and control, laryngeal elevation velocity and range, the latency of pharyngeal swallowing, pharyngeal transit time (PTT), abnormal epiglottis tilt, residual barium in the pharynx, and the duration of upper esophageal sphincter (UES) opening. The laryngeal elevation velocity (%/s) was calculated as the range of laryngeal elevation (%) from the resting position to the maximum superior position or to the position where the laryngeal vestibule is fully closed divided by the corresponding duration of laryngeal elevation. The range of laryngeal elevation (%) was the percentage calculated as the distance between the resting laryngeal position and the maximum superior excursion position or position where the laryngeal vestibule is fully closed divided by the distance between the resting laryngeal position and the lowest edge of the mandible. A logistic regression analysis was used to determine the predictive value for aspiration secondary to reduced laryngeal elevation velocity after adjusting for the effects of other indices. Intrarater and interrater reliability were calculated using Pearson’s correlation coefficients.ResultsData from 89 patients were analyzed. This cohort included 71 males and 18 females with a mean age of 59.31±11.46 years. The mean time from stroke onset to the VFS study was 3 days (1–7). Twenty one (23%) patients aspirated while swallowing 5 ml of diluted barium (40%, w/v). Aspiration was associated with age, the velocity (%/s) of laryngeal elevation and duration, delayed pharyngeal phase, pharyngeal transit time, abnormal epiglottic tilt, and invalid laryngeal elevation before true swallowing, and duration of upper esophageal sphincter (UES) opening. After adjusting for the effects of the indices mentioned above, logistic regression analysis revealed that a reduced of laryngeal elevation velocity before vestibule closure was predictive of aspiration independently (OR, 0.993; 95% CI, 0.987–1.000).DiscussionsReduced laryngeal elevation velocity for laryngeal elevated to position where laryngeal vestibule is fully closed was an independent predictor of aspiration in patients with acute ischemic stroke. This may be related to a decreased contraction velocity of the muscles involved in hyolaryngeal elevation. Therapeutic methods aimed at improving laryngeal elevation velocity may decrease aspiration events and pneumonias after stroke.

The role of the defaecating pouchogram in the assessment of evacuation difficulty after restorative proctocolectomy and pouch-anal anastomosis.

Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is the most frequently performed operation for intractable ulcerative colitis (UC) and for many patients with familial adenomatous polyposis (FAP). It can be complicated by a functional evacuation difficulty, which is not well understood. We aimed to evaluate the role of defaecating pouchography in an attempt to assess the mechanism of evacuation difficulty in pouch patients. All RPC patients who had had a defaecating pouchogram for evacuation difficulty at one hospital between 2006 and 2014 were retrospectively reviewed. The findings and features were correlated with the symptoms. Demographic, clinical and radiological variables were analysed. Eighty-seven [55 (63%) female] patients aged 47.6±12.5years (mean standard±SD) were identified. Thirty-five had a mechanical outlet obstruction and 52 had no identified mechanical cause to explain the evacuation difficulty. The mean age of these 52 [33 (63%) female] patients was 48.2±13years. Of these 52 patients, significantly more used anti-diarrhoeal medication (P=0.029), complained of a high frequency of defaecation (P=0.005), experienced a longer time to the initiation of defaecation (P=0.049) and underwent pouchoscopy (P=0.003). Biofeedback appeared to improve the symptoms in 7 of 16 patients with a nonmechanical defaecatory difficulty. The most common findings on defaecating pouchography included residual barium of more than 33% after an attempted evacuation (46%, n=24), slow evacuation (35%, n=18) and mucosal irregularity (33%, n=17). Correlation between radiological features and symptoms showed a statistically significant relationship between straining, anal pain, incontinence and urgency with patterns of anismus or pelvic floor descent or weakness seen on the defaecating pouchogram. Symptoms of incomplete evacuation, difficulty in the initiation of defaecation, high defaecatory frequency and abdominal pain were not correlated with the radiological features of the pouchogram. Defaecating pouchography may be useful for identifying anismus and pelvic floor disorders in pouch patients who have symptoms of straining, anal pain or incontinence. In patients with a high frequency of defaecation and abdominal pain it does not provide clinically meaningful information. Patients who complain of straining, incontinence, anal pain or urgency and have anismus or pelvic floor disorders may benefit from behavioural therapy.