Post-fundoplication contrast studies: is there room for improvement?

Quantification of fluoroscopic fundoplication anatomy: inter- and intraobserver reliability

The etiology of postfundoplication dysphagia remains incompletely understood. Subtle changes of gastroesophageal junction (GEJ) anatomy may be contributory. Barium swallows have potential for standardization to evaluate postsurgical anatomical features. Using structured barium swallows, we aim to identify reproducible, objectively measured postfundoplication anatomical features that will permit future comparison between patients with/without dysphagia. At 6-12 months of postfundoplication, 31 patients underwent structured barium swallow with video-fluoroscopy recording: standing anteroposterior; standing oblique (×2); prone oblique (×2); and prone oblique with continuous free drinking. A primary observer recorded 11 variables of GEJ anatomy for each view, repeated 3 months later, forming two datasets to assess intraobserver consistency. Interobserver reliability was determined using a dataset each from the primary observer and two medical students (after training). Intraclass correlation coefficients (ICC) were based on two-way mixed-effects model (ICC agreement: 0.40-0.59 'fair'; 0.60-0.74 'good'; 0.75-1.00 'excellent'). Interobserver reliability was good-excellent for 47 of 66 measurements. Measures of maximal esophageal diameter cf. wrap opening diameter and posterior esophageal angle showed high interobserver reproducibility on all views (ICC range 0.84-0.91; 0.68-0.80, respectively). Interobserver agreement was good-excellent for 5/6 views when measuring anterior GEJ displacement and axis deviation (ICC range 0.56-0.79; 0.41-0.77, respectively). Measures of wrap length showed lower reproducibility. Prone oblique measurements showed highest reproducibility (good-excellent agreement in 19/22 measurements). Intraobserver consistency was excellent for 98% of measurements (ICC range 0.74-0.99). Objective measurements of postfundoplication GEJ anatomy using structured barium swallow are reproducible and may allow further interrogation of anatomical features contributing to postfundoplication dysphagia.

Variability in endoscopic assessment of Nissen fundoplication wrap integrity and hiatus herniation

BACKGROUND

Upper endoscopy (EGD) is frequently performed in patients with esophageal complaints following anti-reflux surgery such as fundoplication. Endoscopic evaluation of fundoplication wrap integrity can be challenging. Our primary aim in this pilot study was to evaluate the accuracy and confidence of assessing Nissen fundoplication integrity and hiatus herniation among gastroenterology (GI) fellows, subspecialists, and foregut surgeons.

METHODS

Five variations of post-Nissen fundoplication anatomy were included in a survey of 20 sets of EGD images that was completed by GI fellows, general GI attendings, esophagologists, and foregut surgeons. Accuracy, diagnostic confidence, and inter-rater agreement across providers were evaluated.

RESULTS

There were 31 respondents in the final cohort. Confidence in pre-survey diagnostics significantly differed by provider type (mean confidence out of 5 was 1.8 for GI fellows, 2.7 for general GI attendings, 3.6 for esophagologists, and 3.6 for foregut surgeons, P = 0.01). The mean overall accuracy was 45.9%, which significantly differed by provider type with the lowest rate among GI fellows (37%) and highest among esophagologists (53%; P = 0.01). The accuracy was highest among esophagologists across all wrap integrity variations. Inter-rater agreement was low across wrap integrity variations (Krippendorf's alpha <0.30), indicating low to no agreement between providers.

CONCLUSION

In this multi-center survey study, GI fellows had the lowest accuracy and confidence in assessing EGD images after Nissen fundoplication, whereas esophagologists had the highest. Diagnostic confidence varied considerably and inter-rater agreement was poor. These findings suggest experience may improve confidence, but highlight the need to improve the evaluation of fundoplication wraps.

Utility of routine oral contrast study for detecting postesophagectomy anastomotic leak - a systematic review and meta-analysis

Oral contrast studies are used to detect anastomotic leak (AL) postesophagectomy. However, recent evidence suggests oral contrast studies have low sensitivity in detecting ALs, and their false positive results can lead to unnecessary prolonged hospital stay. The objective of this study was to determine if oral contrast studies should be used routinely post-esophagectomy for cancer. A systematic literature search was conducted for studies published between January 1990 and June 2018. Data extracted for analyses included type of esophagectomy, operative morbidity (such as AL and pneumonia), mortality rates, timing of contrast study, and type of oral contrast used. The sensitivity, specificity, and positive and negative predictive values of routine oral contrast studies to detect AL were calculated using the aforementioned variables. Two hundred and forty-seven studies were reviewed with 16 studies included in the meta-analysis. Postoperative oral contrast study was performed in 94.0% of cases between day 5 and 7. The rates of early and delayed leaks were 2.4% (1.8%-3.3%) and 2.8% (1.8%-4.4%), respectively. Routine contrast studies have a sensitivity and specificity of 0.44 (0.32-0.57) and 0.98 (0.95-0.99), respectively. Analysis of covariates revealed that sensitivity is reduced in centers with a higher volume of cases (greater than 15 per year: 0.50 [0.34-0.75; p = 0.0008]) and specificity was higher in centers with a lower leak rate. Given its poor sensitivity and inability to detect early/delayed AL, oral contrast study should be used selectively with endoscopy and/or computerized tomography scan to assess surgical anastomoses following esophagectomy.

Anti-reflux procedures: complications, radiologic findings, and surgical and gastroenterologic perspectives

This article provides an overview of the current surgical anti-reflux procedures and their imaging findings, as well as the surgical complications. Accurate and timely clinical assessment requires an engaged radiologist fluoroscopist who understands the perspectives of their interdisciplinary colleagues, including the surgeon and gastroenterologist. The complex pathophysiology calls for an interdisciplinary approach, and the radiologist needs to tailor their evaluation to answer the specific questions posed by their clinical colleagues and by the presenting symptomatology.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

What is the role of radiological testing of lower esophageal sphincter function?

Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.

Routine versus selective contrast imaging to identify the need for early re-intervention following laparoscopic fundoplication: A retrospective cohort study

BACKGROUND

The prompt recognition of complications is essential in reducing morbidity following anti-reflux surgery. Consequently, many centres employ a policy of routine post-operative contrast studies. The study aimed to examine whether routine contrast studies more effectively recognised early post-operative complications following anti-reflux surgery compared with selective use.

METHODS

This was a retrospective analysis of 240 adults who had undergone primary anti-reflux surgery. Selective use of water-soluble contrast swallows was employed for 115 patients (Group 1) while 125 patients (Group 2) had routine studies.

RESULTS

10 (0.9%) patients from Group 1 underwent contrast studies, four (40%) of which were abnormal. Routine studies in Group 2 identified thirty-two abnormalities (27%) however the inter-group difference was not significant (p = 0.32). Only one case from group 2 required immediate re-intervention. This was not statistically significant (p = 0.78). Multivariate analysis found no significant association between selective or routine imaging and re-intervention rates. One patient from group 2 presented three days following discharge with wrap migration requiring reoperation despite a normal post-operative study.

CONCLUSION

Routine use of contrast imaging following anti-reflux and hiatus hernia surgery is not necessary. It does not identify a significantly greater number of post-operative complications in comparison to selective use. Additionally, routine use of contrast studies does not ensure the diagnosis of all complications in the post-operative period.

MRI patterns of Nissen fundoplication: normal appearance and mechanisms of failure

PURPOSE

The purpose of the study was to assess the role of MR fluoroscopy in the evaluation of post-surgical conditions of Nissen fundoplication due to gastro-oesophageal reflux disease (GERD).

METHODS

A total of 29 patients (21 patients with recurrent/persistent symptoms and eight asymptomatic patients as the control group) underwent MRI of the oesophagus and gastro-oesophageal junction (GEJ) at 1.5 T. Bolus transit of a buttermilk-spiked gadolinium mixture was evaluated with T2-weighted half-Fourier acquisition single-shot turbo spin-echo (HASTE) and dynamic gradient echo sequences (B-FFE) in three planes. The results of MRI were compared with intraoperative findings, or, if the patients were treated conservatively, with endoscopy, manometry, pH-metry and barium swallow.

RESULTS

MRI was able to determine the position of fundoplication wrap in 27/29 cases (93% overall accuracy) and to correctly identify 4/6 malpositions (67%), as well as all four wrap disruptions. All five stenoses in the GEJ were identified and could be confirmed intraoperatively or during dilatation. MRI correctly visualized three cases with motility disorders, which were manometrically confirmed as secondary achalasia. Three patients showed signs of recurrent reflux without anatomical failure.

CONCLUSION

MRI is a promising diagnostic method to evaluate morphologic integrity of Nissen fundoplication and functional disorders after surgery.

KEY POINTS

MRI offers simultaneous morphological and functional imaging in one diagnostic method. MR fluoroscopy offers the possibility to identify the wrap position. MRI enables a non-invasive diagnosis, providing detailed information for the surgeon.