Diagnostic imaging of delayed complications after antireflux surgery

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1 Diagnostic imaging of delayed complications after antireflux surgery Poster No.: C-862 Congress: ECR 27 Type: Scientific Exhibit Authors: M. V. Pavlov, N. V. Orlova, A. Abduraimov, K. A. Lesko, J. V. Kuleznewa; Moscow/RU Keywords: Abdomen, Gastrointestinal tract, Fluoroscopy, Digital radiography, Contrast agent-oral, Barium meal, Dilatation, Motility DOI:.594/ecr27/C-862 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page of 25

2 Aims and objectives Aim and objectives According to some authors, the complication rate after ARS is sufficiently high [-4]. Barium videofluoroscopic examination of the upper gastrointestinal tract (UGT) plays an important role in ARS complication diagnosis. It is a part of ARS complication diagnosis as well as endoscopy and esophageal manometry [5]. Underestimation of radiological patterns of ARS complications due to wide variation of ARS types leads to decrease quality of diagnosis. Evaluation of the esophageal shortening, features of hiatal hernia (HH) and the width of the esophageal aperture of diaphragm are crucial to planning of surgical correction of ARS complications [3, 6-8]. Moreover anamnestic information about type of ARS is also very important (fig. ). Aim: clarify the range of radiographic signs of delayed complications after different types of ARS barium videofluoroscopic examination of the UGT. Page 2 of 25

3 Images for this section: Fig. : Schematic diagram of the most frequently performed ARS: a - Nissen, Nissen Rosetti; b - Chernousov; c - Toupet; d - Dor (author of the article pictures MV Pavlov). Page 3 of 25

4 Methods and materials Methods and materials In we examined 67 patients aged years (38 (56.7%) females and 29 (43.3%) males) after different types of ARS, in a period of 6 months to 5 years after surgery (table ). All patients underwent barium videofluoroscopic examination of the UGT. All patients had complaints typical for ARS complications, including nausea, eructation, vomiting eaten food, hearthburn and epigastric pain. We used X-ray system "Raffine", liquid and dense suspension of barium sulfate for filling the esophagus. In videofluoroscopy examination intact wrap length was 3-4 mm, the lumen was < mm, passage of the contrast medium through the esophagus - < 5 seconds. Table. The number of patients after the ARS in (N = 67, %) View Nissen ARS (autors) abs. % Number 22 of patients Nissen - Chernousov Dor Rosetti Toupet Belsey Total abs. % abs. % abs. % abs. % 32,8 5 abs. % 22,4 4 abs. % 2, ,4,5 67 Page 4 of 25

5 Results Results We revealed wide range of delayed ARS complications in patients with equal complaints. Radiographic patterns of organic complications were determined in 53 (79%) cases, in (6.5%) cases only functional disorders were revealed, in 3 (4.4%) cases false-positive results were obtained (Tabl. 2). Table2. Types of radiography patterns of ARS delayed complications ARS Nissen type Nissen Rosetti - Cherousov Dor Toupet Total Abs. % Complications Abs. % Abs. % Abs. % Abs. % Abs. % «Slipped 3 Nissen» 6, ,4 Wrap 5 migration 27, ,5 9 28,3 Disorder of esophagus and / or stomach emptying, as a result of migration or slipping wrap 4 2, 5 7,5 Complete wrap reverse 5,5 5 6, Recurrent HH (the 5,5 5 6, ,4 Page 5 of 25

6 complete wrap reverse) Wrap failure 5, Ulcers 2, or esophageal strictures 6,7 3 4,5 Stomach deformation 2 2 3,3 4 6 False- 2, positive conclusion of ARS complication, 3 4,5 Esophageal 3 6,7 dysmotility without wrap function disorder 2 2 3,3 7,4 Wrap hyperfunction,,5 Disorder of the evacuation of the stomach: <24 hours,,5 >24 hours 2 3,3 2 3 Total In all cases, patient's complaints were typical: chest pain, dysphagia and heartburn. Page 6 of 25

7 Complete wrap reverse is the simplest sigh to reveal. It is due to superficial sutures tearing. A special case of Nissen ARS complications is a wrap failure, so-called «missing Nissen». Typical «missing Nissen» radiography patterns are recurrent gastroesophageal reflux, HH, shortening of the esophagus, peptic strictures and ulcers of the esophagus (Fig. 2). Wrap failure relates to ineffective formed wrap or stretching. It is one of the reasons for subsequent complete reverse wrap. Typical Nissen-Rosetti ARS complication wrap failure due to circular wrap formation (Fig. 3). Frequent ARS complication is wrap migration, which subdivides into type I - wrap locates in the posterior mediastinum, cardia located in the abdomen (Fig. 4 a- c); and type II - cardia and wrap located in the posterior mediastinum (Fig. 5a - c). A typical complication after Nissen ARS is slipped Nissen, which occurs when cardia, fundus and terminal part of esophagus slip from wrap (Fig. 6). Radiographic pattern of slippage useally appears in hourglass phenomenon (Fig. 7). Wpar slippage due to tearing sutures between wrap and esophagus, crural suturing in patients with esophagus shortening. Simultaneous surgical intervention at ARS, such as selective proximal or truncal vagotomy, as well as nerve vagus damage during surgery can lead to slowdown gastric emptying, which causes symptoms such as eructation, feeling of fullness in the stomach, nausea, vomiting. In the present study, this complication occurred at the ARS on Chernousov in 2 (3.3%) cases (in both cases was carried proximal vagotomy) complete emptying of the stomach after 24 hours did not occur in both cases. When ARS on Tupe in (.%) cases of intraoperative damage to the vagus nerve, gastric emptying occurred after 2 hours from the time of the study (Fig. 8, a, b). As a result of wrap migration or slipping we observed disorders of esophageal and/or stomach emptying due to narrowing of the lumen of the stomach or esophagus wrap (Figure 9, a - c). Type I migration did not always lead to a wrap failure. It happens because only a small portion of the wrap slipped to the posterior mediastinum, it had no effect on function. This phenomenon confirmed by manometry and esophagogastroscopy. Disorders of esophageal emptying occur in sequent cases: tight formed (hyperfunction) wrap (Fig. ), over-extended wrap and an esophageal dysmotility, denervation abdominal part of esiphagus. These complications can arise both early and delay. Stomach pseudodiverticulum deformation caused by the sutures eruption on one of the sides of the wrap and its subsequent torsion around the axis, confirmed at the time of surgical intervention in 2 (%) patients after ARS Nissen-Rosetti and 2 (3.3%) cases after the ARS on Chernousov (Fig. ). Page 7 of 25

8 In cases insufficiency of esophageal propulsive force or uncoordinated peristalsis diagnosed by preoperative esophageal manometry, the food passing through the Nissen neovalve can be difficult. In such cases, some authors recommend Toupet operation with the formation of the wrap is not circular. Esophageal spasm or esophageal hypomotility without breaking the wrap function were observed in 7 (.4%) patients and were the cause of dysphagia (Fig. 2). When cardiospasm or achalasia perform same ARS as in patients with RE, without myotomy (Fig. 3). False-positive results of videofluorographic examination occurred when there were no anamnestic data about previous surgery. Fixed HH with initial shortening of the esophagus with placing wrap in the posterior mediastinum and suturing to hiatal misinterpreted as wrap migration in 3 (4.5%) cases (Fig. 4). Page 8 of 25

9 Images for this section: Fig. 2: Barium swallow of a Nissen fundoplication. Complete reverse wrap. Peptic stricture of the esophagus (white arrow), peptic ulcer (dotter arrow). Esophagus shortened. Fixed axial hiatal hernia (black arrow). Page 9 of 25

10 Fig. 3: Barium swallow of a Nissen ARS. Insufficiency wrap. Lumen of the esophagus at the level of the wrap not narrowed (white arrow). Gastroesophageal reflux (dotter arrow). Insufficiency Nissen wrap regarded as full reversal. Page of 25

11 Fig. 4: Barium swallow in patient with type I migration of a Toupet wrap. Portion of the wrap has herniated above the diaphragm (white arrow) but the gastroesophageal junction remains below the diaphragm (black arrow). Page of 25

12 Fig. 5: Barium swallow, of a type II migration of a Toupet wrap. Whole wrap including gastroesophageal junction has herniated above the diaphragm (black arrow). Esophagus shortened. Transit on the esophagus is correct. Page 2 of 25

13 Fig. 6: Barium swallow after Nissen-Rosetti fundoplication. «Slipped» Nissen - slipping cardia and the fundus of the stomach with terminal esophagus in relation to the wrap. Wrap compresses the upper third of the body stomach (white arrow). Slipping cardia distension and is located above diaphragm (black arrow). Esophagus shortened. Page 3 of 25

14 Fig. 7: Barium swallow of a Nissen-Rosetti fundoplication. «Slipped» Nissen. Wrap compresses the upper third of the stomach (black arrow). Slipping cardia distension and is located below diaphragm (black arrow). Page 4 of 25

15 Fig. 8: Barium swallow of a Chernousov fundoplication. Full reversal of wrap. Fixed axial hiatal hernia (white arrow - a). Shortening of the esophagus. Tonus on the stomach reduced. After 24 hours - gastrostasis (b). The cause of the complications is the vagotomy and/or damage to the vagus nerves during surgery. Page 5 of 25

16 Fig. 9: Barium swallow in patient after Toupet ARS (23). There is type I wrap migration (white arrow) and slowdown of stomach evacuation (black arrow). Page 6 of 25

17 Fig. : Barium swallow of a Toupet fundoplication. Wrap hyperfunction. Wrap located below the diaphragm. Lumen of the esophagus at the level of the wrap narrowed (white arrow). Lumen of the esophagus above the diaphragm distended (black arrow). Page 7 of 25

18 Fig. : Barium swallow in patient after Chernousov fundoplication. Pseudodiverticulum deformation stomach (black arrow). Wrap at the level of the upper thirds of the body of the stomach (white arrow). The cause of the complications is the eruption seams with one of the parties wrap and followed by its torsion. Page 8 of 25

19 Fig. 2: Barium swallow in patient after Nissen fundoplication. Function wrap is not broken (white arrow). Diffuse esophageal spasm (black arrow). Page 9 of 25

20 Fig. 3: Barium swallow. Complication after fundoplication Toupet in 2 combined with achalasia. Vomiting eaten a few hours before the meal. Esophageal achalasia (black arrow) is an undiagnosed pathology before the operation. Low wrap formed on the cardia# esophagus (white arrow). Page 2 of 25

21 Fig. 4: Barium swallow. Complication after Nissen-Rossetti ARS (24). Wrap function is satisfactory. Transit through wrap and cardiac esophagus is correct (white arrow), ae well as transit through gastro-esophageal junction (black arrow). Page 2 of 25

22 Conclusion Conclusion The most frequent complications for each ARS revealed. Inappropriate surgery procedures performed because of incomplete or incorrect preoperative diagnosis verification. Those procedures were leading to severe complications. The dominant radiographic patterns of ARS complications are gastric wrap migration - 9 (28.3%) cases and gastric dysmotility - 7 (.4%) cases. Barium videofluoroscopic examination of the UGT is one of the main methods of investigation to identify ARS complications. Page 22 of 25

23 Personal information Pavlov Mikhail Vladimirovich, Radiologist, Radiology Department, Moscow Clinical Scientific Center, Moscow Healthcare Department. Address: 86, sh. Enthusiastov, Moscow, 23, Russia. Phone number: +7 (495) Orlova Natalija Vladimirovna, Head of the Radiology Department, Moscow Clinical Scientific Center, Moscow Healthcare Department. Address: 23, Russia, Moscow, sh. Enthusiastov, 86 Phone number. 8 (495) n.orlova@mknc.ru Abduraimov Adhamzhon Bahtierovich, #. D. Med., Head of Mammology Development Project, Deputy Director, Moscow Clinical Scientific Center, Moscow Healthcare Department. Address: 86, sh. Enthusiastov, Moscow, 23, Russia. Phone number: +7 (495) a.abduraimov@mknc.ru Lesko Konstantin Alexandrovich, Ph. D. Med, Senior Researcher, Department of Radiological Techniques of Diagnosis And Treatment, Head of Educational and Scientific Department, Moscow Clinical Scientific Center, Moscow Healthcare Department. Address: 86, sh. Enthusiastov, Moscow, 23, Russia. Phone number: +7 (495) k.lesko@mknc.ru Kulezneva Julija Valer'evna, #. D. Med, Head of radiological techniques of diagnosis and treatment, head of educational and scientific department, Moscow Clinical Scientific Center, Moscow Healthcare Department. Address: 86, sh. Enthusiastov, Moscow, 23, Russia. Phone number: +7 (495) y.kulezneva@mknc.ru Page 23 of 25

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