Niveditha, Shama Viswanathan (2016) Study to assess the requirement of a routine upper GI contrast study post-operatively in patients undergoing an oesophageal anastomosis: A Randomized control trial. Masters thesis, Christian Medical College, Vellore.
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Abstract
INTRODUCTION: In patients undergoing an oesophageal anastomosis, post-operatively, a routine upper GI fluoroscopic imaging with thin Barium Sulfate/ Gastrografin has been employed to assess the integrity of the anastomosis, prior to initiation of feeding orally. However, this modality is plagued by a low sensitivity, and its routine use has been questioned in the last decade. The aim of this study was to assess outcomes between a group who had the routine upper GI contrast study and a group where a routine contrast was not performed. . BACKGROUND DATA: A number of retrospective studies have been carried out to assess the need of doing a routine upper GI contrast study on the 7th postoperative day following an oesophageal anastomosis. In most of the studies published, only 70% of anastomotic leaks were detected within the first five days. Moreover, even if the upper GI contrast study done on day 7 was normal, this did not preclude a delayed leak occurring as late as one month after surgery (maximum period). This resulted in delayed leaks being missed out and a consequent delay in intervention. OBJECTIVES: 1. To compare the delay in starting oral feeds, liquids and solids, duration of post-operative hospital stay and to compare readmission and re-surgery rates. 2. To evaluate the overall morbidity and 30 day mortality in the two groups. METHODS: A prospective randomized control study was carried out to assess the need of a routine upper GI contrast study after an oesophageal anastomosis. All patients undergoing an oesophageal anastomosis were randomized into 2 groups. The patients from Group A underwent a routine upper GI contrast study between post-operative day 5 to day 7. None of the patients from Group B underwent a routine upper GI contrast study. However, they underwent an appropriate radiological assessment post operatively, if a leak was suspected. The outcomes were assessed as per objectives. RESULTS: Among the 40 patients recruited, it was found that there were no significant differences in length of hospital stay and the time to starting liquid feeds orally between the 2 groups. However, there is a probable statistically significant delay of 1 day in starting solid feeds. There was no added morbidity in the non-contrast study group. Thus, it can be concluded that the practice of doing a routine upper GI contrast study after an oesophageal anastomosis may not be necessary unless there are strong indicators to perform it. Instead, monitoring the patient’s clinical parameters to look out for clinical evidence of a leak, followed by performance of an appropriate investigation to confirm or rule out a leak may be a more appropriate practice. CONCLUSIONS: There was no increase in rate of morbidity or mortality in patients who did not routinely have a contrast swallow prior to initiation of feeds (Group B). • Routine upper GI contrast studies after an oesophageal anastomosis did not offer any additional clinical benefit. In fact, two patients had aspiration of the contrast medium although there were no untoward consequences as a result of this. • The use of an upper GI contrast study has a low sensitivity (13.60%) and hence it may not be of value as a screening test to detect a post-operative leak. • The negative predictive value of this study is 45.70%. Hence, relying on this test to rule out a leak may give a false sense of security and may lead to missed leaks. • Scheduling an upper GI contrast study on the 7th post-operative day delayed the initiation of solid feeds by a day, adding to the length of hospital stay and therefore the cost incurred by the patient. • In this study, the 2 patients with a neck anastomotic leak were not picked up by the contrast study. This therefore proves that a contrast study is not of much value in cervical oesophageal anastomosis. • One patient had an abdominal anastomotic leak confirmed on contrast study. But this leak would have been clinically picked up even without a study. Therefore this underlines the fact that selective use of contrast study is more appropriate. • Hence, the routine use of contrast study to rule out a post-operative oesophageal anastomotic leak can probably be abandoned. The need for an appropriate study can be made by the treating clinician, based on the level of clinical suspicion and the local expertise available.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Oesophageal ; anastomosis ; upper GI contrast study ; routine ; anastomotic leaks ; ivor-Lewis ; McKeown’s Oesophagectomy ; total gastrectomy ; corrosive strictures ; colon pull through ; gastric pull through ; bypass ; conduit ; barium sulphate ; gastrografin. |
| Subjects: | MEDICAL > General Surgery |
| Depositing User: | Subramani R |
| Date Deposited: | 12 Oct 2017 01:03 |
| Last Modified: | 12 Oct 2017 01:03 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/3556 |
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