Angelchik Prosthesis

In 1979 Angelchik and Cohen described a new and novel approach for the prevention of gastroesophageal reflux [136]. They designed a C-shaped prosthesis made out of silicone and filled with a silicone gel. The inner diameter was 2.5 x 3.1cm with an outer diameter of 6 x 7 cm2. The device was anchored in place by a Dacron fiber strap and had a tantalum-filled marker for radiographic localization. Originally the device had a 1 cm gap in the radiopaque marker that sometimes led to the diagnosis of a nonexistent fracture in the device. The gap was closed in 1982. The device was inserted via an abdominal incision in which the collar of the prosthesis is wrapped around the distal esophagus and held in place anteriorly by the Dacron straps [137,138].

The Angelchik prosthesis has had a checkered history and has generally fallen out of favor [137-146]. Many complications have been described, including migration, displacement, and erosion. Migration due to breaks in the Dacron tapes was eliminated by the change in design in 1982. Displacement occurred either into the mediastinum through a widened esophageal hiatus [139,140] or into the abdomen because of an excessive mobilization of the cardia at the time of surgery [139]. Even a fatal case of suppurative pericarditis was reported [141]. Erosion may be due to placement near a preexisting suture line in the stomach, or accidental entry into the gastric lumen may occur during surgery. In the absence of development of an acute abdomen, however, the slow and insidious movement of the prosthesis may also suggest a chronic form of migration, with the formation of surrounding adhesions [142,143].

The prosthesis appears as a doughnut encircled by an opaque tantalum band 2 mm wide [138]. When properly positioned, it should be at the gastroesophageal junction [137]. It may cause a nipplelike protrusion in the center of the gastric fundus [137]. On CT images the ring has attenuation similar to the liver or spleen [144]. It may be obliquely oriented and not completely imaged on any single section through the gastroesophageal junction. The tantalum strap is easily visible, and the prosthesis should not be difficult to recognize. When either intra- or extraluminal dislodgment has occurred, the radiopaque marker should make the CT or even plain film diagnosis of the complication easy.

The Angelchik prosthesis may cause dysmotility, and many patients will have prolonged esophageal transit times as measured by a marsh-mallow swallow [145]. However, the absence of abnormal motility does not mean that a complication is not present [146]. Gas bloat, usually indicative of an overly tight gastroesophageal junction, has also been reported in patients with this prosthesis.

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