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Q1: What abnormality is shown on the barium meal (see 178)?
An abnormal filling defect in close association with a thin C-shaped radio-opaque strip can be seen in the gastric remnant (grey arrow). Radio-opaque clips can also be seen around the cardia (white arrow). These appearances are in keeping with an Angelchik prosthesis which has become detached and eroded into the stomach.
Q2: What are the options for dealing with this complication?
Gastroscopy should be performed not only to confirm the diagnosis but also in an attempt to remove the prosthesis endoscopically.1 At gastroscopy the stomach mucosa appeared normal and the silicon prosthesis, although covered with debris, was easily visualised. However, despite several attempts, it was not possible to retrieve the prosthesis endoscopically. The only other option was to remove the prosthesis surgically and this was performed in this case by carrying out a laparotomy and gastrotomy. The patient made an uncomplicated recovery and was free of symptoms at review three months later.
Q3: What other complications have been reported after insertion of this prosthesis?
The Angelchik prosthesis is no longer widely used because of the high incidence of complications. Intractable dysphagia was common and often required removal of the prosthesis. Free extraluminal migration into the abdominal cavity can occur. The prosthesis usually comes to rest in the pelvis and is usually manifested by chronic lower abdominal pain or urinary symptoms. Migration into the mediastium and distal slippage has also been reported. Erosion of the prosthesis into the oesophagus can lead to abscess formation and intraluminal erosion may even progress to cause small bowel obstruction.
In 1979, Angelchik and Cohen reported a series of 46 patients who had reflux oesophagitis treated surgically with the insertion of an incomplete “doughnut” shaped ring of silicon around the gastro-oesophageal junction: the Angelchik prosthesis. The C-shaped ring was tied around the lower oesophagus with Dacron straps. Insertion of this prosthesis was quick, simple to perform, and standardised and it was hoped that it would become superior to the other surgical antireflux procedures available at the time which were all technically difficult, time consuming, and had variable results which were operator dependent.2
The early short term results for the prosthesis were promising, and objective and subjective outcome measures were similar to other accepted surgical antireflux procedures.3 However the initial enthusiasm has been tempered with experience and when more long term results were analysed up to 20% of prostheses had to be removed for intractable dysphagia and there were other reports of significant problems due to migration and erosion of the prosthesis.4,5
The prosthesis has a tantulum radio-opaque marker encircling its periphery and radio-opaque clips were frequently used to reinforce the knot in the tied Dacron straps making it possible to identify the prosthesis on radiological images as seen in this case.
The continued use of the Angelchik prosthesis was abandoned in most centres over 10 years ago but at least 25 000 have been inserted worldwide. In this case erosion occurred 14 years after insertion, longer than any other case reported. The presentation of new gastrointestinal symptoms should still today arouse suspicion in a patient known to have an Angelchik prosthesis.
Eroded Angelchik prosthesis.
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