Water flush technique: a noninvasive method of optimizing visualization of the distal esophagus in patients with primary achalasia.

OBJECTIVE: The purpose of this study was to assess the use of a water flush technique to optimize visualization of the distal esophageal mucosa during barium esophagography of patients with moderate to severe primary achalasia. The water flush consists of having patients drink tap water at end esophagography in an attempt to clear the standing barium column. CONCLUSION: The water flush technique is a simple, noninvasive maneuver that improves the extent of diagnostic visualization of the distal esophageal mucosa in patients with moderate to severe primary achalasia. It facilitated detection of a tumor in one patient and identification of additional pathologic changes in two other patients in this series.

Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery.

Bariatric surgery dramatically alters the normal stomach anatomy resulting in a significant incidence of hiatal hernia and gastroesophageal reflux disease. Although the majority of patients remain asymptomatic, many complain of severe heartburn refractory to medical management and additional highly atypical symptoms. Here, we describe the diagnosis and treatment regarding four cases of symptomatic hiatal hernia following bariatric surgery presenting with atypical symptoms in the University Hospital, USA. Four patients presented following laparoscopic Roux-en-Y gastric bypass or duodenal switch/pancreaticobiliary bypass (DS) with disabling and intractable midepigastric abdominal pain characterized as severe and radiating to the jaw, left shoulder, and midscapular area. The pain in all cases was described as paroxysmal and not necessarily associated with eating. All four patients also experienced nausea, vomiting, and failure to thrive at various intervals following laparoscopic bariatric surgery. Routine workup failed to produce any clear mechanical cause of these symptoms. However, complimentary use of multidetector CT and upper gastrointestinal contrast studies eventually revealed the diagnosis of hiatal hernia. Exploration identified the presence of a type I hiatal hernia in all four patients, with the stomach staple lines densely adherent to the diaphragm and parietal peritoneum. Operative intervention led to immediate and complete resolution of symptoms. The presence of a hiatal hernia following bariatric surgery can present with highly atypical symptoms that do not resolve without operative intervention. Recognition of this problem should lead to the consideration of surgery in cases where patients are dependent on artificial nutritional support and whose symptoms are poorly controlled with medication alone.

Duodenal switch gastric bypass surgery for morbid obesity: imaging of postsurgical anatomy and postoperative gastrointestinal complications.

OBJECTIVE: The purpose of our study was to evaluate the normal postsurgical findings and appearance of gastrointestinal tract complications in patients who have undergone biliopancreatic diversion with duodenal switch bariatric surgery. We performed a 4-year retrospective review of 218 patients who underwent duodenal switch surgery. CONCLUSION: The most common complications of duodenal switch surgery were bowel obstruction, followed by ventral hernias and anastomotic leaks. Only 2% of cases required repeat surgery for management.

Imaging findings in Roux-en-O and other misconstructions: rare but serious complications of Roux-en-Y gastric bypass surgery.

OBJECTIVE: The purpose of this study was to present the clinical and imaging findings of Roux-en-O and other misconstructions of Roux-en-Y gastric bypass surgery. The more common complications of Roux-en-Y gastric bypass have been described in the literature. Complications secondary to misconstructions are rare and difficult to diagnose. CONCLUSION: Roux-en-O or other misconstruction should be suspected in patients with chronic bilious vomiting after Roux-en-Y gastric bypass when no mechanical basis for obstruction can be identified. Fluoroscopic motility assessment is often critical in the diagnosis of these misconstructions.

Atypical complications of gastric bypass surgery.

Although gastric bypass surgery continues to grow in popularity for weight loss and weight maintenance in the morbidly obese, there has been little attention given to the imaging of complications associated with these surgeries. The purpose of our study is to demonstrate the variety of gastric bypass surgery complications that can be identified radiographically, with attention to the more unusual complications. This study was performed with institutional Internal Review Board approval. We performed a 5-year retrospective review of all patients who had undergone gastric bypass surgery, had complications of the surgery, and had studies performed in our department to image these complications. These studies consisted of contrast fluoroscopy and CT. We identified the more common complications of anastomotic stenoses and anastomotic leaks. We also identified six unusual complications as follow: (1) internal herniation through the small bowel mesentery, (2) internal herniation through the transverse mesocolon, (3) external herniation through the abdominal wall incision, (4) enterocutaneous fistulas, (5) antiperistaltic construction of the Roux-en-Y, and (6) incorrect anstomoses of the Roux limbs resulting in a Roux-en-O configuration. Our findings show that a thorough understanding of expected postoperative bowel configuration is essential in the evaluation of these patients. In addition, fluoroscopic evaluation should assess not only anatomy, but also motility.

Semiquantitative analysis of dynamic contrast enhanced MRI in cancer patients: Variability and changes in tumor tissue over time.

PURPOSE: To evaluate variability of a simplified method for measuring semiquantitative DCE-MRI parameters in patients with cancer and to explore effects of treatment with a putative anti-angiogenic compound. MATERIALS AND METHODS: A total of 19 patients enrolled on treatment trials with the putative anti-angiogenic agent SU5416 underwent contrast enhanced examinations, and 11 had a second examination eight weeks post therapy. Contrast media concentration as a function of time was calculated using changes in signal and literature baseline T(1) values in normal muscle or liver reference tissue. Semiquantitative DCE-MRI parameters, including the area under the contrast concentration vs. time curve (AUC), were calculated for regions-of-interest in normal liver and muscle, and in tumors. RESULTS: The coefficients of variation for pretherapy parameters in normal tissue were 11% to 37%. No significant changes were detected in normal liver over two months of therapy. In tumors and muscle, a significant decrease in the AUC and maximum contrast concentration was observed. CONCLUSION: Variability of semiquantitative DCE-MRI parameters utilizing a method based on known T(1) values in a reference tissue is low enough to detect changes in tumors during therapy. Use of this method as a pharmacodynamic marker should be further investigated.

Update on magnetic resonance cholangiopancreatography.

MRCP is a useful tool in the diagnosis of a wide variety of pathologic entities including congenital anomalies, biliary obstruction and stricture, biliary calculi, pancreatitis, neoplasms, and trauma. ERCP and MRCP both have important roles in the management of patients with suspected pancreaticobiliary disease. Knowledge of the advantages and disadvantages of each technique is needed to determine the appropriate work-up of patients with these pathologies.