The historical Angelchik anti‐reflux device: laparoscopic removal for dysphagia

Résumé fourni par la source

We report a now-uncommon cause of dysphagia—the Anglechik anti-reflux device. We highlight the anatomy and radiology of the device, which guides safe and effective laparoscopic removal. A 59-year-old female with longstanding dysphagia had undergone open anti-reflux surgery 30 years prior. Computed tomography (CT) demonstrated an Angelchik device at the gastro-oesophageal junction, without evidence of prolapse, sited in its intended position (Fig. 1). Gastroscopy demonstrated constriction at the gastro-oesophageal junction, which could be passed despite resistance. There were no signs of luminal erosion or oesophagitis. The patient had previously been advised that removal of the Angelchik device carried significant risk, and she thus maintained a pureed diet for many years. After careful workup with imaging and endoscopy, the patient underwent laparoscopic Angelchik device removal. Dense adhesions between the left lobe of the liver and upper stomach were lysed, allowing Nathanson-retraction of the left liver. A fibrous capsule was identified surrounding the Angelchik device, and diathermy was used to open the capsule to expose the device. Further dissection proceeded towards the angle of His, where the Dacron retention ties were identified and divided (Fig. 2) with care taken to preserve the upper pole of the spleen. This allowed the device to be liberated from its fibrous tunnel around the junction and retrieved. The inner layer of the fibrous tunnel was divided with cautery, to release the stricture. No oesophageal injury was identified, at laparoscopy or endoscopy. The patient was upgraded to a puree diet prior to discharge on day four post-operatively. At 3 weeks post-operative review, the patient was tolerating most solid food including steak, without recurrence of reflux. By 18 months, no new symptoms had necessitated imaging or endoscopy. First described as the Angelchik-Cohen ring in 1979,1 the Angelchik device was common in the 1980s as an alternative to fundoplication.2 Over 25,000 prostheses were used worldwide,3 before high rates of dysphagia, migration and erosion were noted.4 The Angelchik device is a C-shaped elastomer shell ring filled with silicone, 6 × 7 cm diameter, with a circumferential tantalum strip, and Dacron retention ties to hold the two ends of the ‘C' together5 (Fig. 3). The device was placed around the gastro-oesophageal junction at open hiatal dissection, with the Dacron straps tied together and sometimes reinforced with Weck clips at the angle of His. On computed tomography (CT), the device appears as a low-density C-shape (Silicone), with a bright outline (elastomer shell and tantalum strip). We find that X-ray and CT scout films (Fig. 1) demonstrate a clear outline of the Angelchik device, helping to determine its location, orientation, and location of the retention point. Further, CT can be used to assess for any gastric prolapse, suspicion of device erosion, and proximity to the spleen. Since the device was historically placed at laparotomy, adhesions to liver and spleen are likely to be encountered at revisional surgery. Similar to contemporary experience with adjustable gastric bands, the prosthesis develops a fibrous capsule formed by foreign body reaction, which needs to be opened to access the Angelchik device. The key to removal is to divide the Dacron retention ties securing the two ends of the ‘C' shaped device—this disconnection allows the device to be pulled from its tunnel. The retention ties are typically found at the posterior aspect of the angle of His, adjacent to the superior pole of the spleen, however can migrate. Imaging should be used as a guide to direct this dissection towards the Dacron ties. The CT scout or X-ray gives a clear view of the device orientation, while CT clarifies the relationship to adjacent structures. Concurrent or staged fundoplication has been described with removal of the Angelchik device6; our patient had no reflux symptoms. The pertinent concern was refractory stricture, however, operative division of the peri-oesophageal scar tissue was adequate to relieve dysphagia. Since the silicone device is soft, it is likely that dysphagia is caused by scar formation from foreign body reaction at the gastro-oesophageal junction, in addition to constriction applied by the device. In severe cases, end-stage pseudo-achalasia has also been described.7 Our experience and literature search suggests that surgeons in Australia may yet encounter patients with symptoms arising from an Angelchik device. This case demonstrates oesophageal obstruction due to chronic scar and extrinsic constriction, which can be relieved with removal of the device and release of the offending scar tissue. Knowledge of the Angelchik device and imaging can direct safe, therapeutic laparoscopic removal. There is no conflict of interest pertaining to the publication of this article from the authors, or institutions. The patient gave consent to publish this case, which is held at the treating institution. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians. Shantanu Joglekar: Conceptualization; data curation; visualization; writing – original draft. Sam Varghese George: Writing – review and editing. Matthew Leong: Writing – review and editing.

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