P-OGC88 Is Routine Contrast Swallow after Ivor-Lewis Oesophagectomy Required or Justified?

Background Traditionally many Upper-GI cancer tertiary centres have carried out contrast swallow fluoroscopic studies as a routine after Ivor-Lewis “Two-Stage” Oesophagectomy. However, more recently studies have demonstrated the limited value of this test as a routine screening study. The primary outcome of our study was to assess the sensitivity of routine contrast swallow in identifying anastomotic leak post oesophagectomy and identify how the study changed management of these patients. Methods This was a single-centre retrospective study involving 2-observer data collection. Data was collected and analysed from clinical notes for all patients who underwent an Ivor-Lewis oesophagectomy for cancer between January 2011 to December 2020. Results A total of 220 patients were identified. Protocol at the centre was to obtain a routine contrast swallow in the Fluoroscopy department on the fifth post-operative day– which occurred in 211 patients (96%). A total of 19 (8.64%) patients were diagnosed with an anastomotic leak (clinically and/or radiologically), with contrast swallow imaging and/or computed tomography (CT). There was no correlation between incidence of leak and T stage (p = 0.38) and N staging (p = 0.22). Only 3 of 19 anastomotic leaks were positively identified on contrast swallow study. All patients with anastomotic leak identified by contrast swallow study were asymptomatic i.e. “subclinical”. 2 patients were managed conservatively; one underwent endoscopic stent insertion. CT scan with oral contrast was the mode of diagnosis for 16 anastomotic leaks; where 10 patients underwent a CT scan following a normal contrast swallow study due to suspicious symptoms and 6 patients underwent expedited CT scans prior to Day-5 contrast swallow study due to presence of symptoms and limitation of fluoroscopy resources. The sensitivity of the Day-5 contrast swallow study was calculated to be 15.8% (CI 3.4, 39.6) with a specificity of 98.0% (CI 95.0, 99.5). Conclusions Our data reflects that routine contrast swallow study on Day-5 post Ivor-Lewis esophagectomy has a poor sensitivity in detecting anastomotic leak and may be falsely reassuring. The vast majority of patients had no change in management as a result of contrast swallow. This adds to the growing body of evidence limiting the role of contrast swallow in this situation. We recommend that clinical judgement and use of CT and endoscopy be the surgeon’s prime tools in the diagnosis of anastomotic leak post oesophagectomy.

Hypopharyngeal perforation caused by blunt trauma during consensual fellatio: an expectant management approach

Perforation of the pharynx is a rare occurrence but has the potential to cause mediastinitis and has an attendant mortality risk. Though numerous mechanisms have been described, we report a unique case of a young woman who presented with a sore throat, odynophagia and subcutaneous emphysema, a short time after performing fellatio. A contrast swallow confirmed hypopharyngeal perforation. She was managed expectantly with nasogastric feeding and empirical antibiotics. The perforation took 4 weeks to heal, but there were no residual swallowing problems at 3-month follow-up. We will explore the incidence and causes of pharyngeal perforation and discuss the options for and risks of surgical repair. This case highlights that non-surgical management of such injuries can be both safe and feasible, and reinforces the importance of ensuring confidentiality and the need for vigilance regarding potential non-consensual injury.

Right Sided Aortic Arch with Aberrant Left Subclavian Artery from Kommerell’s Diverticulum, a Cause of Persistent Dysphagia in an Adult: A Case Report

Congenital variations and anomalies of the aortic arch are important entity in vascular imaging. Most of them are asymptomatic. About 30-40% presents with tracheo-oesophageal symptoms like dyspnea and dysphagia. A 27 year-old female presented with persistent dysphagia for 6 months duration and cause of persistent dysphagia was the right sided aortic arch with aberrant left subcalvian artery from Kommerell’s diverticulum. The diagnosis was made through combination of chest X-Ray, echocardiography, non-ionic contrast swallow and Computed Tomography angiography. Non-invasive modalities (CT and MR Angiography) play an important role in diagnosis and pre-operative surgical planning providing relationship with the surrounding structures especially trachea and esophagus.

Sleeve gastrectomy is the most common cause of Gastro-esophageal Reflux Disease in comparison with other bariatric operations

Introduction GERD is one of the complications of bariatric operations that might affect the quality of life. We aim to perform a retrospective cohort study to determine the incidence of symptomatic GERD following different types of bariatric surgery and which operations are considered a contraindication of GERD. Besides, we are attempting to identify the risk factors of GERD after bariatric surgery. Methods Medical records of 729 patients undergone bariatric operations between January 2010 and June 2019 at Shamir (Assaf Harofeh) Medical Center were reviewed. Results There was a significant difference between the type of bariatric procedure and the incidence of GERD symptoms after the operation. The incidence of symptomatic GERD in patients who underwent SG was 39.9% (p =0.0131). This was significantly higher compared to 16.4% following roux en y gastric bypass, 23.4% following LAGB, and 11% following OAGB. 113 patients out of 718 had a positive swallow test and of these patient 71 developed GERD symptoms post-operatively without correlation to the degree of reflux at the swallow test but with statistically significant correlation to the type of operation especially for SG (P-value <0.001) and to our knowledge this was never reported in the literature. Conclusion SG is a good bariatric procedure option but should be contraindicated in asymptomatic reflux contrast swallow study and symptomatic GERD patients preoperatively because of high levels of symptomatic GERD post-operatively. Asymptomatic reflux at contrast swallow study pre-operatively should be considered a risk factor for GERD after the operation.

Communicating Bronchopulmonary Foregut Malformation Type IB: Diagnostic and Surgical Challenges

Communicating bronchopulmonary foregut malformations (CBPFM) are extremely rare. We present a complex case of type IB CBPFM with esophageal atresia and distal tracheoesophageal fistula (EA/TOF), duodenal atresia/annular pancreas (DA/AP), and intestinal malrotation who underwent primary repair for EA/TOF on day 3. Bilious aspirates on day 8 prompted an upper gastrointestinal (GI) contrast revealing a duodenal obstruction and communication between the right lung lower lobe and the esophagus (T8-T9 level). DA/AP and malrotation were repaired by a gastrojejunostomy and Ladd's procedure. A repeat contrast swallow identified a 2nd communication from the esophagus into the right lower lobe (T5-T6 level) raising the suspicion of a recurrent TOF. Computed tomography (CT) thorax confirmed above findings with an anomalous blood supply to right lung. An exploratory thoracotomy identified a three-lobed lung. However, the lower lobe was enlarged and connected in two separate locations to the esophagus. The child recovered after the disconnection of the esophageal connections and partial right lower lobectomy. CBPFM are extremely rare anomalies requiring a high index of suspicion, use of an upper GI contrast series, and CT scans for diagnosis. The treatment of choice is resection of the affected lung and disconnection of the esophageal communications.

Tissue glue: a potential role in the management of intraoperative oesophageal perforation

An 85-year-old man suffering from oropharyngeal dysphagia due to a pharyngeal pouch and cricopharyngeal spasm underwent endoscopic stapling of the pouch under general anaesthesia. During the procedure, an iatrogenic perforation of the oesophagus was noticed. After considering several options, 5 mL of Tisseel tissue glue was used to seal the perforation intraoperatively. The patient was started on intravenous co-amoxiclav, kept nil by mouth and fed via a nasogastric tube. After 4 days of observation mediastinal collection and any leakage was ruled out with a gastrografin contrast swallow procedure. At this point he was considered safe for oral intake.

Cricopharyngeal myotomy for delayed Cricopharyngeal dysfunction after head and neck surgery – case report

Background Head and neck surgeries can perturb normal structures of neck muscles and nerve innervations, which are supposed to function in harmony to allow complicated process like swallowing. It is still likely that cricopharyngal dysfunction emerges years after the head and neck surgeries. Case presentation We report a case with history of left unilateral vocal cord immobility and development of dysphagia and aspiration 2 years after radical thyroidectomy with neck lymph nodes dissection and medialization thyroplasty. Cricopharyngeal dysfunction was impressed and was confirmed with visualization of cricopharyngeal narrowing segment in radiographic contrast swallow examination. The patient was treated successfully by cricopharyngeal myotomy, achieving long-term relief in our 4 years of follow up. Conclusions Our case of delayed cricopharyngal dysfunction after radical thyroidectomy and medialization thyroplasty shows that it is important to follow up swallowing functions after patients with UVCI undergo medialization thyroplasty. In the event of delayed manifestation of cricopharyngeal function, it can still be treated successfully by cricoharyngeal myotomy, achieving long term relief of dysphagia.

Congenital band adhesion causing a proximal jejunal obstruction: an uncommon presentation and diagnosis

A 20-year-old woman with no medical or surgical history presented with acute onset crampy abdominal pain on a background of uninvestigated similar chronic abdominal pain. She became obstructed during her admission and a contrast swallow showed a complete obstruction at the level of the proximal jejunum. A diagnostic laparoscopy revealed a congenital band adhesion from the greater omentum to the proximal jejunum to be the cause, and dissection of the band relieved her obstruction. This case presents a rare cause of mechanical obstruction, and highlights the seriousness of investigating obstructive symptoms even in atypical patient populations.