Imaging of iatrogenic oesophageal injuries using optimized CT oesophageal leak protocol: pearls and pitfalls

Abstract

Iatrogenic injury to the oesophagus is a serious complication which is increasingly seen in clinical practice secondary to expansion and greater acceptability of surgical and endoscopic oesophageal procedures. Morbidity and mortality following such injury is high. This is mostly due to an inflammatory response to gastric contents in the mediastinum, and the negative intrathoracic pressures that may further draw out oesophageal contents into the mediastinum leading to mediastinitis. Subsequently, pulmonary complications such as pneumonia or abscess may ensue leading to rapid clinical deterioration. Optimized and timely cross-sectional imaging evaluation is necessary for early and aggressive management of these complications. The goal of this review is to make the radiologist aware of the importance of early and accurate identification of postoperative oesophageal injury using optimized CT imaging protocols and use of oral contrast. Specifically, it is critical to differentiate benign post-operative findings, such as herniated viscus or redundant anastomosis, from clinically significant postoperative complications as this helps guide appropriate management. Advantages and drawbacks of other diagnostic methods, such as contrast oesophagogram, are also discussed.

Trans-hiatal repair for Oesophageal and Junctional perforation: a case series

“…However, false negatives may be avoided by optimising CT protocols, as well as the use of oral contrast. This has to be balanced with the risk of aspiration and development of pulmonary complications [25]. Overall, CT is a useful tool in assessment and plays an important role in selecting patients for laparoscopic repair.…”

Iatrogenic oesophageal perforation

“…A risk of aspiration of soluble contrast and consequent necrotizing pneumonia in severely ill patients must be taken into account (1,27). The adoption of ad hoc optimized CT protocols for suspected oesophageal perforation (including lower neck, chest and upper abdomen and scanning both pre-and post-oral contrast administration) can greatly improve the accuracy and efficiency of the diagnostic work-up with a one-stopshop tool (38).…”

Dual-energy CT iodine overlay improves efficiency of oral contrast leak assessment

“…Evaluation for gastrointestinal leak is a common imaging indication that may arise from surgical complications, acute medical conditions (Boerhaave syndrome), or penetrating injuries from trauma (1)(2)(3). The current imaging standard for evaluating leaks and perforations involves the use of oral or rectal contrast for computed tomography (CT) esophagram, CT of the abdomen/pelvis, or fluoroscopy.…”

“…Multiple factors come into play when determining which modality is more appropriate, including availability, access, speed of acquisition, and clinical setting. In most clinical settings, including the emergency department, CT with oral or rectal contrast has become the preferred modality for the diagnostic work-up for viscous leak and hollow viscous perforation largely due to its reduced time of acquisition and overall higher sensitivity when compared to fluoroscopy (2)(3)(4)(5)(6)(7)(8).…”