Postoperative Esophagus

General Principles

Radiologic evaluation of the postoperative esophagus requires an understanding of the operative procedures and normal postoperative findings. Radiographic studies are performed in these patients for three general purposes: (1) to define the postoperative anatomy and establish a baseline; (2) to assess the efficacy of the procedure; and (3) to detect complications during the early (<4 weeks after surgery) or late (>4 weeks after surgery) postoperative periods. During the early postoperative period, the most common complications include stasis from postoperative ileus or vagotomy, obstruction from anastomotic edema, and perforation from anastomotic or staple line breakdown ( Box 16.1 ). During the late postoperative period, the most common complications include aspiration, gastroesophageal reflux (GER), anastomotic strictures, and recurrent tumor (see Box 16.1 ).

Depending on the type of surgery and status of the patient, postoperative fluoroscopic studies should be tailored to optimize detection of suspected complications. Barium and water-soluble contrast agents each have advantages and disadvantages for evaluating patients during the early postoperative period. This subject is discussed in detail in Chapter 14. Briefly, water-soluble contrast agents should be used to rule out perforation or anastomotic leak into the mediastinum or pleural space. If no water-soluble contrast medium is seen to extravasate from the esophagus on the initial spot images, high-density barium should then be given for a more detailed study. If aspiration or an esophageal-airway fistula is suspected, however, barium should be used as the primary contrast agent. Knowledge of the surgical technique is important for performing and interpreting these studies.

Gastroesophageal Reflux and Hiatal Hernia

Patients with gastroesophageal reflux disease who develop intractable reflux esophagitis, peptic strictures, or Barrett’s esophagus may undergo a laparoscopic or open surgical fundoplication to prevent GER. The surgery usually entails dissecting the diaphragmatic crura, mobilizing the esophagus, reducing the hiatal hernia, and repairing the diaphragm (while preserving the vagus nerves). A gastropexy may also be performed.

NORMAL POSTOPERATIVE APPEARANCES

During a fundoplication, a portion of the gastric fundus is wrapped around a variable length of the distalmost esophagus and gastric cardia to create an antireflux valve. A 360-degree Nissen fundoplication wrap normally appears as a 2- to 3-cm fundal mass that has a smooth contour and surface ( Fig. 16.1 ). If the patient drinks barium in a recumbent, steep oblique, or lateral position, the distal esophageal lumen is shown to pass through the center of the fundoplication wrap. A smooth, symmetric wrap and its consistent relationship with the lumen readily differentiates the wrap from a true tumor in the fundus.

Patients with esophageal dysmotility and poor esophageal clearance are more likely to have partial wraps (usually anterior or posterior) to avoid problems with esophageal emptying. These partial wraps produce smaller radiolucent defects than a circumferential Nissen fundoplication. Loose wraps are more often created in patients who undergo laparoscopic surgery ( Fig. 16.2 ).

COMPLICATIONS

Obstruction

During the early postoperative period, edema of the fundoplication wrap may cause transient dysphagia. Esophagrams may show the wrap as a large, smooth fundal mass with tapered narrowing of the lumen through the wrap and delayed emptying of contrast material into the stomach ( Fig. 16.3 ). This edema usually subsides within 1 to 2 weeks after surgery.

Some patients have persistent narrowing at the fundoplication that causes recurrent dysphagia or the “gas bloat” syndrome characterized by upper abdominal fullness and an inability to belch after meals. Esophagrams may show fixed narrowing of the lumen by a tight fundoplication wrap ( Fig. 16.4 ). Comparison with preoperative barium studies may be helpful for patients in whom it is difficult to differentiate a distal peptic stricture from a tight fundoplication wrap.

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