Keywords:
Gastrointestinal tract, Stomach (incl. Oesophagus)
Authors:
S. Canovetti, P. Giusti, A. Sibilla, S. Giusti, C. Bartolozzi; Pisa/IT
DOI:
10.1594/ecr2010/C-1511
Conclusion
Digital fluoroscopy swallow study is a fast, well tolerated and reliable diagnostic procedure which plays a foundamental role in post surgical follow up of patients treated for numerous gastro-esophageal diseases, such as giant paraesophageal hiatal hernias. Obviously the radiologist must be aware of the surgical tecniques in order to evaluate the images correctly. In Nissen fundoplication, the fundus is wrapped posteriorly around the distal esophagus and the lower esophageal sphincter, then sutured anteriorly thus making a complete 360° wrap. Digital fluoroscopy reveals a typical subdiaphragmatic
circumferential defect of the stomach fundus, which causes a smooth narrowing of the contrast column passing through distal esophagus, extending for approximately 2–3 cm. Like Nissen fundoplication, Toupet fundoplication involves wrapping the fundus posterior to the esophagus; however, the result is not a complete 360° wrap but an approximately 270° wrap, anchored to the crus and the esophagus(4). DF demonstrates a partial posterior wrap filled with contrast media, finding that does not necessarily indicate wrap dehiscence. At radiography also if is not so immediate a clear differentiation between Nissen and Toupet fundoplication, an expert radiologist can highlight the typical circumferential wrapping in case of Nissen fundoplication. Moreover, contrast examination can rule out eventual complications as complete o partal wrap dislocation inside of the chest, leaks , excessive wrap narrowing causing transit obstruction ( in the early post-operative period mainly due to local edema rather than a surgeon mistake, in late period mainly as a result of cicatrization), gastro-esophageal reflux disease and slipped wrap. A recurrent hernia should not be confused with a slipped fundoplication, which occurs when the fundoplication slips distally and encircles the stomach rather than the GEJ. Obstruction appears as a distal esophagus emptying delay with possible air-fluid level proximally to the fundoplication: in the early post-operative period it is usually due to local edema, and a second look after 2 weeks can be useful to prove a normal acquired canalization. In the late period it is rather related to local cicatrization: the patient can refer abdominal distension and impossibility to erupt (gas bloat syndrome). Esophagogram can show excessive constriction and fixity of the organ passing through the fundoplication with proximal distension. Leak is a typical early post operative complication: it appears as the passage of contrast material out of the lumen. It is an emergency and requires immediate re-operation. In order to avoid peritonitis, early post-operative swallow controls must be conducted using hydrosoluble iodinated contrast media. A complete dehiscence consists of a complete rupture of suture line stitchies and is radiographically visualized as hernia and gastroesophageal reflux disease recurrence, in absence of fundoplication signs. A partial dehiscence appears as a partially complete fundoplication associated with gastric fundus extroflession and gastroesophageal reflux disease.
In conclusion it is necessary to remember that a collaboration between the surgeon and the radiologist is necessary to guarantee a good management of the patient's health, since the improvement of surgery technique permitted a reduction of the complication rate, and DF study represents a fundamental exam to evaluate possible complications.