Upper Gastrointestinal Studies Research Articles

The performance of ultrasound and upper gastrointestinal study in diagnosing malrotation in children, with or without volvulus.

Rapid diagnosis is crucial for pediatric patients with midgut volvulus and malrotation to prevent serious complications. While the upper gastrointestinal study (UGIS) is the traditional method, the use of ultrasound (US) is gaining prominence. To assess the diagnostic sensitivity and specificity of US compared to UGIS for malrotation and midgut volvulus. A cross-sectional study was performed on 68 pediatric patients who underwent US and/or UGIS before surgery for suspected midgut volvulus or malrotation in Kuala Lumpur (PPUKM and HTA), referencing surgical outcomes as the gold standard. US demonstrated a higher specificity (100%) than UGIS (83%) for diagnosing malrotation, with a slightly lower sensitivity (97% vs. 100%). For midgut volvulus, US surpassed UGIS in sensitivity (92.9% vs. 66.7%) while maintaining comparable specificity. The SMA/SMV criteria showed better sensitivity (91.1%) than the D3 assessment (78.9%) on US, though both had high specificity. US is equivalent to UGIS for identifying malrotation and is more sensitive for detecting midgut volvulus, supporting its use as a primary diagnostic tool. The study advocates for combined US and UGIS when either yields inconclusive results, optimizing diagnostic precision for these conditions.

Understanding the diagnosis of superior mesenteric artery syndrome: analysis of the location of duodenal impression on upper gastrointestinal studies

BackgroundUpper gastrointestinal (GI) contrast studies are frequently requested to aid superior mesenteric artery syndrome diagnosis, a rare entity. Compression of the third duodenal part is expected to be mid-to-left of the midline where the superior mesenteric artery arises from the aorta; however, a duodenal impression to the right of the midline due to normal anatomic impression by the inferior vena cava (IVC) is often encountered and frequently misdiagnosed.ObjectiveThe purpose of this study was to determine the frequencies of (1) normal right-of-midline duodenal impressions and (2) mid-to-left of midline compressions in upper GI studies in a tertiary pediatric referral center.Materials and methodsAll upper GI studies performed at our institution over 2 years were retrospectively evaluated to determine whether the duodenum had vertical duodenal impression to the right of the vertebral midline, mid-to-left of the vertebral midline, or no identifiable duodenal impression at all.ResultsIn total, 538 upper GI studies were included in this analysis. A total of 275 male and 247 female patients between 0 and 17 years of age (median: 6 years, range: 1 month-17 years) were included. Of 538 total upper GI studies, there were 240 studies (44.6%) with a right-of-midline impression. There were only 10 studies (1.9%) with a mid-to-left of midline compression, and 9/10 also showed a concurrent right-sided impression sign.ConclusionRight-of-midline duodenal impression is a normal anatomic finding caused by the IVC and should not be confused with superior mesenteric artery syndrome. In the presence of an appropriate clinical context, proximal duodenal dilation, “to-and-fro” motion of contrast, and duodenal impression at mid-to-left of midline, a diagnosis of superior mesenteric artery syndrome should be considered.Graphical

Comprehensive Manometric Evaluation of Dysphagia in Patients with Down Syndrome.

Dysphagia is a common symptom in children with Down syndrome and is conventionally evaluated with imaging and endoscopy; high-resolution manometry is not routinely utilized. The aim of this study was to describe and correlate pharyngeal and esophageal manometry findings with contrast studies and endoscopy in patients with Down syndrome and dysphagia. Electronic medical records of patients with Down syndrome with dysphagia seen at our center between January 2008 and January 2022 were reviewed. Data collected included demographics, co-morbidities, symptoms, imaging, endoscopy, and manometry. Twenty-four patients with Down syndrome [median age of 14.9years (IQR 7.6, 20.5), 20.8% female] met inclusion criteria. Common presenting symptoms of dysphagia included vomiting or regurgitation in 15 (62.5%) patients, and choking, gagging, or retching in 10 (41.7%) patients. Esophageal manometry was abnormal in 18/22 (81.2%) patients. The most common findings were ineffective esophageal motility in 9 (40.9%) followed by esophageal aperistalsis in 8 (36.4%) patients. Rumination pattern was noted in 5 (22.8%) patients. All 6 (25%) patients who previously had fundoplication had esophageal dysmotility. Strong agreement was noted between upper gastrointestinal studies and high-resolution esophageal manometry (p = 1.0) but no agreement was found between pharyngeal manometry and video fluoroscopic swallow studies (p = 0.041). High-resolution pharyngeal and esophageal manometry provide complementary objective data that may be critical in tailoring therapeutic strategies for managing patients with Down syndrome with dysphagia.

Rare Cause of Arrhythmia and Seizures in a Late-Preterm Newborn

Rare Cause of Arrhythmia and Seizures in a Late-Preterm Newborn

Leak After Sleeve Gastrectomy: A Videoscopic Documentation on Occurrence, Diagnosis, and Treatment

Introduction: Leak after a sleeve gastrectomy varies between 1.1% and 4.7% with a 7% mortality rate.1,2 This video of the primary operation shows a staple line failure coupled with problematic stitching, suggesting an overlooked micro-leak. Methods: In 1163 consecutive sleeve gastrectomies, two leaks (0.17%) occurred, and both were associated with technical failures. Our protocols/technique and changes during the Covid-19 pandemic were reported.3,4 In brief, the protocol includes staple-line reinforcement with full-thickness-continuous-suturing without imbrication, drainage, discharge on postoperative day three, and a selective leak test. The first leak occurred in a patient with a body mass index of 67 kg/m2 with an obstructed distal sleeve at the incisura. This was diagnosed on postoperative day nine and managed by emergency conversion to a gastric bypass. This approach avoided a stent.5 The second patient developed fever on postoperative day three which was attributed to pneumonia. An upper gastrointestinal (UGI) study and computed tomogram (CT) failed to identify a leak. There was no stenosis. A leak was diagnosed ultimately on postoperative day 12 on a repeat UGI study and confirmed with a CT scan. Results: Re-laparoscopy was performed for debridement, stenting, and drainage. A central catheter was inserted for total parenteral nutrition. Subsequent management required repeat hospital admissions, aspirations of abscesses/collections under radiologic guidance, and administration of antibiotics/antifungal agents. Subsequently, the stent was removed on day 54 with resolution of the metabolic syndrome and a 20 kg weight loss. Conclusions: Esophagogastric (EG)-junction encompasses the lower esophageal sphincter and the small “B” formations were unable to provide sufficient closure in this area. Moving the stapler off the EG-junction or using cartridges with larger/deeper “B” formations may have prevented this leak. Full-thickness-continuous-stitching might also have prevented the leak but failed because of technical reasons in this case. A leak test, if performed, may have identified the leak intraoperatively. Overall, leak presentation may be variable and management must be individualized. Leaks that are diagnosed a week after surgery are generally attributed to “non-technical” issues (i.e., ischemia). Our decade-long experience in 1163 consecutive patients contradicts this view and suggests that leaks occur because of technical errors and, therefore, may be preventable. If required, double cuffed stents which can be placed under laparo-endoscopic guidance seems to be a reasonable option provided that the distal cuff is neatly deployed in the duodenal bulb. Since the distal cuff is also fully covered, this must not occlude the pancreatic duct. Migration even a few cm distally will not be tolerable and requires stent re-positioning. No competing financial interests exist. Runtime of video: 9 mins 24 secsPatient Consent: Authors have received and archived patient consent for the video. All individuals appearing in the video also gave written consent to use their footage.

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.

Prospective Employer-Initiated Whole-Body Cancer Screening-Costs and Outcomes of a Cancer Screening Program in Japan.

To determine cancer detection and mortality and its costs associated with employee-initiated, prospective whole-body cancer screening program in an engineering company in Hamamatsu, Japan. The program includes whole-body fluorine-18-2-fluoro-2-deoxy-D-glucose PET/CT, brain and pelvis MR, and abdominal ultrasound, offered every 2 years five consecutive times. Employees are free to opt in or opt out anytime. The subjects were divided into the full (five consecutive screenings), partial (more than once and less than five), and no participation groups. The rate ratio of cancer detection rate and cancer-related mortality and cancer-related costs of care were measured. All employees also received other annual health screenings, including chest radiograph or upper gastrointestinal study. Among 1,213 subjects, 543 employees were under full participation, 318 were under partial participation, and 352 were under no participation. In all, 26, 9, and 19 cancers were detected from the full participation, partial participation, and nonparticipation groups, respectively. No statistical significance was observed in the cancer detection rate ratio. The rate ratio of cancer-related deaths was 0.11 (0.01-0.90) for the full participation group compared with the nonparticipation group, and the difference was statistically significant. The cost of cancer-related care was highest among the nonparticipation group; however, the difference was not statistically significant (P= .108). Whole-body cancer screening can successfully reduce cancer-related mortality and costs of cancer-related care. The cancer detection rate was not significantly improved because of broad implementation of additional annual health screenings offered to all employees at no cost, resulting in the high baseline cancer detection rate.

A scalable database of organ doses for common diagnostic fluoroscopy examinations of children: procedures of current practice at the University of Florida

Of all the medical imaging modalities that utilize ionizing radiation, fluoroscopy proves to be the most difficult to assess values of patient organ dose owing to the dynamic and patient-specific nature of the irradiation geometry and its associated x-ray beam characteristics. With the introduction of the radiation dose structured report (RDSR) in the mid-2000s, however, computational tools have been developed to extract patient and procedure-specific data for each irradiation event of the study, and when coupled to a computational phantom of the patient, values of skin and internal organ dose may be assessed. Unfortunately, many legacy and even current diagnostic fluoroscopy units do not have RDSR reporting capabilities, thus limiting these dosimetry reporting advances. Nevertheless, knowledge of patient organ doses for patient care, as well as for radiation epidemiology studies, remains a research and regulatory priority. In this study, we created procedural outlines which document all radiation exposure information required for organ dose assessment, akin to a reference RDSR, for six common diagnostic fluoroscopy procedures performed at the University of Florida (UF) Shands Pediatric Hospital. These procedures include the voiding cystourethrogram, the gastrostomy-tube placement, the lower gastrointestinal study, the rehabilitation swallow, the upper gastrointestinal study, and the upper gastrointestinal study with follow through. These procedural outlines were used to develop an extensive database of organ doses for the 162-member UF/NCI (National Cancer Institute) library of pediatric hybrid phantoms, with each member varying combinations of sex, height, and weight. The organ dose assessment accounts for the varying x-ray fields, fluoroscopy time, relative concentration of x-ray contrast in the organs, and changes in the fluoroscope output due to patient size. Furthermore, we are also reporting organ doses normalized to total fluoroscopy time, reference point air kerma, and kerma-area product, effectively providing procedure dose coefficients. The extensive organ dose library produced in this study may be used prospectively for patient organ dose reporting or retrospectively in epidemiological studies of radiation-associated health risks.

Duodenal Stenosis with Diaphragmatic Hernia—A Rare Combination—Delayed Diagnoses with Barium Study

AbstractDuodenal stenosis is part of a spectrum of disorders due to non-cannulization of the fetal gut lumen occurring in 11 to 13 weeks of fetal life. The diagnosis is often made in the neonatal period owing to bilious vomiting. The authors present a case of a 9-year-old boy who was diagnosed by an upper gastrointestinal study that showed a hugely dilated stomach filled with food residue and a dilated first part of the duodenum with an abrupt narrowing in the second part of the duodenum in keeping with duodenal stenosis. There was no associated malrotation (a known association), but the delayed images showed a surprising finding of herniation of large bowel loops into the thorax suggestive of a congenital diaphragmatic hernia (Bochdalek type). Both these findings were confirmed on surgery, and the patient underwent duodenoduodenostomy and diaphragmatic hernia repair and is doing well on follow-up. This case is unusual due to the rare association of duodenal stenosis with congenital diaphragmatic hernia and delayed diagnosis. Both these pathologies most often present in the neonatal period, and delayed diagnosis is most often seen with associated trisomy 21 that was not the case in our patient.

Utility of 3-Week Follow-Up of Upper Gastrointestinal Study in Asymptomatic Patients Following Laparoscopic Sleeve Gastrectomy

Rationale and ObjectivesOne day following laparoscopic sleeve gastrectomy (LSG), routine practice has historically dictated that an upper gastrointestinal (UGI) study be performed to assess for staple line leak, clinically significant stenosis, or other complications requiring surgical revision. Recent literature has cast doubt on the utility of performing an UGI immediately following surgery due to its poor sensitivity in detecting leaks and hence referrals for this post-operative study have decreased. However, routine practice at our institution is to perform an UGI study at three weeks following LSG to assess for late complications despite a similar lack of evidence supporting the yield of this exam. The purpose of our study is to assess the utility and cost effectiveness of UGI exams in asymptomatic patients three weeks following LSG. Methods and MaterialsA retrospective chart review of patients who underwent LSG for obesity performed at our institution between January 2014 and October 2018 and subsequently had an UGI within two-four weeks following the surgery was conducted. ResultsA total of seventy three asymptomatic patients underwent an UGI study, of which no clinically significant stricture, leak or other complications were identified. Of the fifteen patients who were symptomatic between two-four weeks after surgery, twelve (80%) were found to have complications ranging from staple line leak or gastric narrowing. ConclusionsThe utility of UGI following LSG in the absence of symptoms is doubtful. Additionally, the added cost and radiation does not add value to the patient's care. We recommend UGI study utilization when there is a clinical suspicion for a complication.

Single-incision laparoscopic gastropexy for mesentero-axial gastric volvulus

BackgroundMesentero-axial gastric volvulus (MAGV) is a rare but critical condition as delay in treatment can lead to lethal situations. Although the report of the surgical treatment with laparoscopic approach for MAGV has recently come to be seen, no standard procedures have been established. We aim to describe our operative technique of single-incision laparoscopic gastropexy (SILG) for MAGV and review the relevant literature to ascertain the most appropriate treatment option in these patients.Case presentationThree patients were referred to our hospital because abdominal pain and vomiting suddenly occurred. Acute MAGV was diagnosed by upper gastrointestinal study. After overnight gastric decompression with a nasal tube, the GV was resolved spontaneously. Elective SILG was planned. Single incision at the umbilicus was made and three 5-mm trocars were inserted. The anterior wall of the body of the stomach was sutured to the peritoneum using 6 × 4-0 non-absorbable sutures for prevention of recurrence of GV and occurrence of internal hernia through the space created between the sutures. Two boys and a girl with mean age 4 ± 2 years underwent SILG. The mean time of the operation was 48 ± 23 min. All of the procedures were completed safely, and there were no postoperative complications. The mean time of postoperative hospitalization was 4 ± 1 days. All patients had good cosmetic and clinical results.ConclusionWe found SILG is a safe, technically feasible, and minimally invasive approach with low incidence of postoperative complication and the best cosmetic result for the patients with MAGV.

Esophageal Diameters in Children Correlated to Body Weight.

The development of stenoses after correction of an esophageal atresia or acid and lye burn of the esophagus are well-known problems in pediatric surgery. Currently, stenoses are treated in the majority of cases by repeated balloon dilatations. The diameter of the balloons used is not standardized; standard curves do not exist. The aim of this study was to evaluate the diameter of the esophagus correlated to the body weight of the children as measured in upper gastrointestinal (GI) studies to answer the important question to what extent a stenosis should be dilated. Within the time period from 2011 through 2016, 60 patients with upper GI studies were selected. Evaluations were blinded to two different examiners. The diameters were measured under maximum contrast filling between the second and third rib (cranial point of measurement) and between the seventh and eighth rib (caudal point of measurement). For both, the anteroposterior and lateral aspect was examined. The diameter was calculated as the arithmetic average of both measurements within one level. The diameters were correlated to the weight of the children. All children (n = 38) within the 3rd to 97th weight percentile were analyzed. Linear correlation and coefficients of 0.67 at the cranial point and 0.70 at the caudal point were found. Mean diameter at the cranial point of measurement was 6.75 mm at the lowest weight (2.6 kg) and 14 mm at 74 kg. Mean weight of these children (standard deviation [SD]) was 25.3 (18.8) kg and median age was 7 years. Within weight groups (0-10 kg; 10-20 kg; 20-35 kg; 35-50 kg; >50 kg), we calculated SD and two side tested critical 95% confidence interval for all measurements (n = 74). Although the variation in measurements is considerable, this evaluation gives a reliable hint to which extent esophageal stenoses should be dilated in relation to the body weight. To the best of our knowledge, this is the first investigation to evaluate the diameter of the esophagus in children in relation to the body weight.

RA06.04: THE DEVELOPMENT AND NATURAL HISTORY OF A HIATA HERNIA

Abstract Background Little is known about the initial development and natural history of a hiatal hernia. Methods A database containing 12,050 upper gastrointestinal (UGI) studies dating from 1991 to 2013 was queried to identify patients that had more than one study a minimum of 5 years apart showing a hernia. The x-ray films or digital images were reviewed and the type and size of any hernia determined. Results There were 56 patients with 133 UGI studies. On initial UGI; 13 patients had no hernia, 35 patients had a sliding hernia (SH), and 8 patients had a paraesophageal hernia (PEH). Follow-up UGI results are shown in the Figure. A third or fourth UGI study was available for 17 patients. Over a median of 41 months, the most recent UGI showed that the majority (78%) of SH increased in size, with 1 changing to PEH. Among patients with PEH, 2 were already completely intrathoracic stomachs and on most recent UGI 4 of the remaining 6 increased in size with 1 turning into complete intrathoracic stomach. Conclusion Most PEHs (77%) started out as a SH. Over time the majority of both SH and PEH increase in size, with many PEH becoming completely intrathoracic stomachs. Given the risks associated with a PEH, patients with SH should be re-evaluated for progression of their hernia. Disclosure All authors have declared no conflicts of interest.

Specialty Article: so You Think You Got a Bypass? A Case Series of Adventures in Bariatric Surgery.

To raise awareness for surgeons encountering bariatric patients with anatomy that deviates from the standard Roux-en-Y gastric bypass (RYGB). This is a single-institution retrospective case series over 12years (2003-2014) involving patients who believed they received RYGBs, but actually did not. Data was obtained reviewing physician encounters, imaging, and operative reports. There were six cases with confusing clinical pictures, found to have aberrant RYGB anatomy: (1) gastric bypass with jejuno-jejunostomy only without gastrojejunostomy, (2) distal partial vertical gastrectomy without expected prosthetic band, (3) inverse vertical banded gastroplasty, (4) non-divided gastric bypass with no gastrojejunostomy, (5) 20-cm Roux limb, with gastro-gastric fistula, and (6) 200-cm bilio-pancreatic limb similar to the traditional Scopinaro procedure. There are cases of "Roux-en-Y gastric bypasses" that have no resemblance to the named procedure at all. Adjunctive upper gastrointestinal studies and upper endoscopies help surgeons make diagnoses that are incongruent with the surgical history. It is important to keep in mind that there could be anatomic or surgical variations which were born out of necessity or based on other surgeons' creativities.

Routine contrast imaging after bariatric surgery and the effect on hospital length of stay

BackgroundAlthough multiple studies demonstrate that routine postoperative contrast studies have a low yield in diagnosing patients with early gastrointestinal (GI) leak after bariatric surgery, the practice pattern is unknown. Additionally, routine imaging may hinder procedural pathways that lead to accelerated postoperative discharge. ObjectivesTo report on the nationwide use of routine upper GI studies (UGI) and evaluate the effect on hospital resource utilization. SettingNationwide analysis of accredited centers. MethodsThe Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file for 2015 was used to identify patients who underwent routine UGI after nonrevisional Roux-en-Y gastric bypass or sleeve gastrectomy. Multivariable logistic regression models were developed to identify risk factors for early hospital discharge. ResultsBariatric surgery was performed on 130,686 patients. Routine UGI was performed in 30.9% of Roux-en-Y gastric bypass and 43% of sleeve gastrectomy patients (P<.0001). Patients undergoing routine UGI were less likely to be discharged by postoperative day 1 (odds ratio .7, 95%; confidence interval .69–0.72). There was no difference in postoperative leak rate between the routine UGI versus nonroutine UGI group (.7% versus .8%, P = .208). Among patients who developed a GI leak, there was no significant difference in the rate of reoperation, readmission, and reintervention between the 2 groups. The time interval between index operation and any further management for the leak was longer in the routine UGI group. ConclusionsRoutine UGI evaluation after bariatric surgery remains a common practice in accredited centers. This practice is associated with prolonged hospital length of stay, with no effect on the diagnosis of leak rate.

Simultaneous laparoscopic repair of intestinal malrotation and ileal duplication

Abstract An 8-year old boy was referred for chronic, frequent bilious vomiting and intermittent abdominal pain. Intestinal malrotation was diagnosed by upper gastrointestinal study (UGI) and laparoscopic Ladd's procedure was performed. Ladd's bands were laparoscopically dissected out, and the mesentery was dissected to be broaden. After performing Ladd's procedure, an ileal duplication cyst was found 30 cm proximal to the terminal ileum, which was extracted through the umbilical port site and was totally resected. Three years postoperatively, the patient has had no further symptoms.

“Candy cane syndrome:” an underappreciated cause of abdominal pain and nausea after Roux-en-Y gastric bypass surgery

Background“Candy cane” syndrome (a blind afferent Roux limb at the gastrojejunostomy) has been implicated as a cause of abdominal pain, nausea, and emesis after Roux-n-Y gastric bypass (RYGB) but remains poorly described. ObjectivesTo report that “candy cane” syndrome is real and can be treated effectively with revisional bariatric surgery SettingAll patients underwent “candy cane” resection at University Hospitals of Cleveland. MethodsAll patients who underwent resection of the “candy cane” between January 2011 and July 2015 were included. All had preoperative workup to identify “candy cane” syndrome. Demographic data; pre-, peri-, and postoperative symptoms; data regarding hospitalization; and postoperative weight loss were assessed through retrospective chart review. Data were analyzed using Student’s t test and χ2 analysis where appropriate. ResultsNineteen patients had resection of the “candy cane” (94% female, mean age 50±11 yr), within 3 to 11 years after initial RYGB. Primary presenting symptoms were epigastric abdominal pain (68%) and nausea/vomiting (32%), particularly with fibrous foods and meats. On upper gastrointestinal study and endoscopy, the afferent blind limb was the most direct outlet from the gastrojejunostomy. Only patients with these preoperative findings were deemed to have “candy cane” syndrome. Eighteen (94%) cases were completed laparoscopically. Length of the “candy cane” ranged from 3 to 22 cm. Median length of stay was 1 day. After resection, 18 (94%) patients had complete resolution of their symptoms (P<.001). Mean body mass index decreased from 33.9±6.1 kg/m2 preoperatively to 31.7±5.6 kg/m2 at 6 months (17.4% excess weight loss) and 30.5±6.9 kg/m2 at 1 year (25.7% excess weight loss). The average length of latest follow-up was 20.7 months. Conclusion“Candy cane” syndrome is a real phenomenon that can be managed safely with excellent outcomes with resection of the blind afferent limb. A thorough diagnostic workup is paramount to proper identification of this syndrome. Surgeons should minimize the size of the blind afferent loop left at the time of initial RYGB.

Value of routine upper gastrointestinal swallow study after laparoscopic sleeve gastrectomy

BackgroundGastric leak (GL) is one of the main early-onset postoperative complications of sleeve gastrectomy (SG). Many institutions perform routine upper gastrointestinal (UGI) contrast studies within 24 hours of surgery, looking for GL or gastric stenosis and to determine the need for urgent re-exploration, but this examination delays oral feeding, can cause side effects and is responsible for systematic and probably unnecessary irradiation of the patient. ObjectiveDetermine the efficacy of routine UGI contrast studies to predict postoperative complications after SG in a large population. SettingUniversity hospital, France, public practice. Material and methodsThis study consisted of retrospective review of a prospective database of a cohort of patients who underwent primary SG between January 2007 and August 2013 (n = 1137). Routine UGI contrast studies, performed on postoperative day 1, were independently reviewed by 2 radiologists. The primary endpoint of the study was the effect of routine UGI contrast study on detecting postoperative complications. The secondary endpoints were comparison of the findings of routine UGI contrast study and abdominal computed tomography (CT) scan, sensitivity, and specificity of different imaging signs on abdominal CT scan in the presence of GL, evaluation of the SG learning curve based on the findings of routine UGI contrast studies. ResultsA total of 1137 patients underwent primary SG and 30 GL (2.6%) with a mean time to diagnosis of 23.4 days (1–245) and 15 cases of gastric stenosis (1.3%) were observed during the study period. Routine UGI study was performed in 1108 patients, whereas 29 patients were assessed by first-line CT scan. None of the 1108 UGI studies found a GL or gastric stenosis. In the 30 cases of GL, the most sensitive and specific sign was the presence of perigastric abscess without contrast material leak (sensitivity: 56.6%; specificity: 95%). The mean time interval between routine postoperative UGI contrast study and abdominal CT scan was 12.9 days (0–86). Uniform gastric shape was acquired after 30–32 SG procedures. ConclusionRoutine postoperative UGI on postoperative day 1 is of limited value after SG. Abdominal CT scan should be preferred in the presence of clinical suspicion of postoperative complications. Selective UGI contrast study remains indicated when gastric stenosis is suspected and at the beginning of the SG learning curve.

Spontaneous Choledochoduodenal Fistula with Purulent Discharge Treated Endoscopically

A 93 year-old female presented with abdominal pain, nausea and vomiting that began 2 hours after eating. She had a history of gallstone-induced pancreatitis 2 weeks earlier with unsuccessful ERCP at that time secondary to ampullary edema. Examination revealed right upper quadrant tenderness with positive murphy's sign, no generalized abdominal tenderness and no jaundice was noted. Laboratory analysis revealed WBC of 25bil/l, ALT 179U/L, AST 390U/L and ALK phos.173 U/L and total bilirubin is 2.4mg/dl with 1.4mg/dl being direct portion. Right upper quadrant abdominalultrasound showed intra and extra hepatic biliary dilatation. Intravenous antibiotics and fluids for ascending cholangitis were given. Same day ERCP revealed bulging and edematous major papilla, bile and pus extruding from an opening near the ampulla (Figure 1A, 1B) suggesting Choledochoduodenal fistula (CDF), injected contrast demonstrated dilated common bile duct and multiple filling defects (Figure 2). Sphincterotomy connecting the CDF and the major papilla with balloon dilatation was performed and the stone was extracted. Biliary enteric fistula (BEF) can occur between any segment of the biliary system and the intestine, the most common between gall bladder and duodenum (62%). Li et al. showed that 50 cases out of 1200 patients with biliary disease had CDF with incidence of 4.2%. Spontaneous BEF occur secondary to stones, malignancy, crohn's, trauma, tuberculosis or metallic biliary stent. Wu et al showed the most common presenting symptom is epigastric pain (80%), cholangitis (54%) and vomiting (10%). This case had typical presentation but subacute despite pus formation as the pus was discharging through the CDF and not from common nile duct due (CBD) to its obstruction by stone. Plain films show pneumobilia (30%), ectopic stone is diagnostic if seen (3%), ERCP is the most common and effective method for diagnosis, CT can be helpful in determining the location of the fistula, upper gastrointestinal study with barium is very specific if positive as it shows the fistulous tract and ultrasound can be helpful. Distal CDF connects any segment of the intestine with distal 2 cm of CBD can be managed endoscopically but the proximal CDF, which drains elsewhere 2 cm and above the junction of CBD to the papilla will be treated surgically only.Figure 1Figure 2Figure 3

Evaluation of a pediatric fluoroscopy training module to improve performance of upper gastrointestinal procedures in neonates with bilious emesis.

Life-threatening midgut volvulus usually occurs in infants with malrotation and requires rapid diagnosis and surgical treatment to prevent bowel necrosis and death. However, because of the low frequency of upper gastrointestinal studies performed in infants younger than 1month, many diagnostic radiology residents finish their residency training having limited or no opportunity to perform or observe an upper gastrointestinal (GI) series for evaluation of bilious emesis in a neonate. To determine whether adding simulated upper GI series on neonates with bilious emesis to the curriculum improves residents' skill and accuracy in diagnosing midgut volvulus. We assessed the performance of 12 residents in training whose curriculum included simulated upper GI series (study group) and 10 traditionally trained residents (control group) using a multiple-choice test, checklist procedure evaluation and diagnostic accuracy scores for 3 randomly selected simulated upper GI series. We then compared the results from the study group that had simulation curriculum to the scores for the control group using the Mann-Whitney test. We also analyzed the scores for the study group obtained prior to and after simulation curriculum using Wilcoxon signed rank test. There was a significant difference in test scores (study group median = 84.5%, control group median = 67.2%, P=0.001), overall diagnostic accuracy (study group median = 100%, control group median = 50%, P=0.011) and checklist evaluation (study group median = 83.3%, control group median = 70.8%, P=0.025) for the residents in the study group who completed simulation curriculum compared with the control group. There was also a significant difference in multiple-choice test scores for the study group before and after completion of simulation curriculum (before simulation curriculum median = 56.9%, after simulation curriculum median = 84.5%, P=0.002), checklist evaluation (before simulation curriculum median = 58.3%, after simulation curriculum median = 83.3%, P=0.002) and overall diagnostic accuracy scores (before simulation curriculum median = 50%, after simulation curriculum median = 100%, P=0.024). Radiology residents had significantly higher scores on a multiple-choice test, checklist procedure evaluation and overall diagnostic accuracy after completing a structured pediatric fluoroscopy curriculum that included simulated neonatal upper GI series and when compared to a control group of traditionally trained residents.