P1.016. Routine Esophagram After Surgery for Benign Esophageal Diseases: What Is Its Utility?

Topic Benign Disease: Esophageal Surgery Background Reflex testing with routine esophagram after benign esophageal surgeries has traditionally been upheld as surgical dogma around the world. However, this standard practice contributes to higher healthcare costs and unintended consequences for patients. Therefore, we aim to assess its utility in detecting abnormalities after surgery for benign esophageal diseases. Methods From January 1, 2000 to December 31, 2023, 1,022 routine esophagrams were performed after myotomy for achalasia (662 Heller, 360 peroral endoscopic myotomy [POEM]), and from January 1, 2018 to December 31, 2023, 359 after hiatal hernia repair. Demographic factors, operative details, imaging results and postoperative outcomes were assessed. Our institution’s standard practice involves obtaining an esophagram on postoperative day one or two with subsequent initiation of a clear liquid diet and discharge on the same day if the test is normal. The results of routine esophagram, immediate postoperative clinical outcomes, and any re-interventions were evaluated. Results A total of 1,375 (99.6%) routine esophagrams were negative for leak. After myotomy, 5 patients had a positive leak test. Four had confirmed clinical leaks, and one was a false positive. All 4 patients with a confirmed leak on routine testing showed clinical evidence of a leak at the time of the study. Three patients with normal routine postoperative esophagram had delayed leaks, later presenting with clinical signs requiring re-interventions. After hiatal hernia repair, one patient had a false positive test (Figure 1). Four patients had recurrence of hiatal hernia on routine esophagram. All 4 patients were re-intervened on due to the imaging abnormality but remained asymptomatic given their nil-per-os (NPO) status. Conclusion The results from this study suggest that routine screening with postoperative contrast imaging to detect leak has little clinical value and is not recommended for postoperative management of benign esophageal diseases. Clinically significant radiographic findings after surgery are almost always associated with concerning clinical abnormalities. Routine postoperative contrast imaging is not indicated unless it is used as a confirmatory test for patients with suspicious clinical signs or in those at high risk of complications.