Comparison of Radionuclide Scan and Conventional Contrast Study in Detection of Esophageal Anastomotic Leaks: A Prospective Study

Sujith, Varghese Thomas (2007) Comparison of Radionuclide Scan and Conventional Contrast Study in Detection of Esophageal Anastomotic Leaks: A Prospective Study. Masters thesis, Christian Medical College, Vellore.


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INTRODUCTION: Esophageal resection and reconstruction remain a major therapeutic challenge for surgeons involved in the care of patients with benign and malignant disease of esophagus. Despite major advances in postoperative care, operative mortality rates worldwide remain high. Much of the operative mortality is related to complications of anastomotic leak. In a majority of esophageal surgeries, the anastomosis involves another segment of the esophagus, stomach, jejunum or colon. Anastomoses in operations of the stomach like total gastrectomy or proximal gastrectomy also involve the esophagus. One of the commonest complications encountered in patients after the above operations are an anastomotic leak. These leaks can lead to severe morbidity, increased hospital stay and cost and increased mortality. The crucial factors in the management of anastomotic leak are to recognize it earlier even at a sub clinical stage and act accordingly. Conservative management like delaying oral feeds and drainage techniques can be employed. However, rapidly progressing clinical scenario mandates aggressive approach. Contrast esophagography is the investigation of choice for detecting sub clinical anastomotic leaks when done from 7th to 10th postoperative days. Barium or water soluble contrasts are being used for the same. Our institution routinely performs thin barium contrast studies between the 7th to 10th postoperative day. Due to its hygroscopic property, water soluble contrast agents causes dilution of the contrast, thereby decreasing its sensitivity and specificity. Barium is more sensitive than water soluble contrast agents but is known to cause complications such as barium peritonitis and can interfere with repeat scans. Moreover, various studies show that the numbers of false negatives are high. Technetium scans are being used for diagnosis and evaluation of esophageal motility disorders and gastroesophageal reflux disease. There is no data of its use in detection of sub clinical anastomotic leaks in current literature. This study is to evaluate the diagnostic efficacy of technetium scans in detecting sub clinical leaks in comparison to barium contrast studies. It also aims at evaluating the reliability, limitations, disadvantages and complications of a Technetium sulphocolloid scan. AIMS OF THE STUDY: To evaluate the diagnostic efficacy and feasibility of Technetium sulphocolloid scans in comparison to esophageal contrast studies in diagnosis of sub clinical anastomotic leaks following esophageal anastomosis. OBJECTIVES: 1. To prospectively evaluate the feasibility of technetium sulphocolloid studies in the diagnosis of sub clinical anastomotic leaks. 2. To quantify the agreement that technetium sulphocolloid scans have with contrast studies in diagnosis of sub clinical anastomotic leaks. 3. To evaluate advantages and disadvantages of technetium sulphocolloid studies in terms of reliability, patient acceptance and cost in comparison to contrast studies. 4. To characterize Tc-99m sulphocolloid scan findings that would describe a sub clinical anastomotic leak. 5. To correlate patient dependant surgical factors with development of anastomotic leaks. This study aimed at exploring the diagnostic feasibility and efficacy of nuclear images in the detection of postoperative sub clinical anastomotic leak. METHODOLOGY: Patients; Cases for the study were selected according to a set of inclusion and exclusion criteria. They were as follows: Inclusion criteria: All patients undergoing the following operations, irrespective of age or sex, were included for the study. 1. Esophagectomy with reconstruction – Transhiatal, transthoracic (Ivor- Lewis, McKeown’s), en bloc esophagectomy. 2. Substernal colon bypass with or without esophageal resection, 3. Total gastrectomy, 4. Proximal gastrectomy. Exclusion criteria: 1. All patients who are clinically unstable and may not be able to tolerate both the studies as according to the surgeon’s judgment. 2. Patients with clinically obvious leaks. 3. Patients in whom both the studies could not done to completion. All patients who underwent the operations listed in the inclusion criteria were selected for the study after obtaining informed consent. Selected preoperative, intraoperative and postoperative data as mentioned in the proforma were collected for each patient. Patients who satisfied the exclusion criteria during the course of the study were taken off the study. PATIENT PROFILE: 51 cases were enrolled into the study of which 13 cases were excluded from the study due to the various exclusion criteria. The reasons for exclusion form the study were as follows. 1. Patients who were clinically unstable during the time of the tests – 4 patients. 2. Patients who developed clinically detectable leaks prior to the imaging – 5 patients. 3. Patients who could not complete either one of the study due to patient related factors -1 patient (Barium induced vomiting). 4. Patients who could not complete either one of the study due to technical reasons- 2 patients. CONCLUSION: 1. Technetium sulphocolloid esophageal scintigraphy have a good agreement with barium contrast studies in detecting sub clinical anastomotic leaks. 2. The sensitivity of technetium scans could not be assessed due to lack of a proper gold standard. 3. Technetium scintigraphy was found to have detected more sub clinical anastomotic leaks than barium. 4. Technetium sulphocolloid scans are more economical than barium contrast studies. 5. Technetium sulphocolloid imaging does not cause any of the complications of barium such as barium peritonitis or barium inspissation. 6. The amount of radiation exposure to the patient as well as his/her attendants is negligible. 7. Technetium is excreted from the body rapidly and so repeat scans are not confounded by the old technetium.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Radionuclide Scan ; Conventional Contrast Study ; Detection of Esophageal Anastomotic Leaks ; Prospective Study.
Subjects: MEDICAL > General Surgery
Depositing User: Devi S
Date Deposited: 04 May 2018 02:37
Last Modified: 04 May 2018 02:37

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