E5011. Functional Use of the Marshmallow/Bagel Barium Esophagram in Assessing Patient Candidacy for Novel Biomedical Devices Treating GERD
  1. Emily Gonzalez; Baylor University Medical Center
  2. Kiera Mason; Baylor University Medical Center
  3. Michelle Thieu; Texas A&M School of Medicine
  4. Cory Pfeifer; Phoenix Children's
The LINX device is a new biomedical device used for gastroesophageal reflux refractory to medical management. The surgically placed circular magnetic device is seated external to the lower esophageal sphincter. The LINX device artificially increases the lower esophageal sphincter tone, while allowing for the passage of food from the esophagus to the stomach, reducing gastroesophageal reflux. However, overcompensation of lower esophageal sphincter tone can result in dysphagia and difficulty swallowing food. We perform a modified fluoroscopic esophagram to determine if the patient is a suitable candidate for the device and can overcome the 15-mmHg pressure that the magnetic LINX device exerts at the gastroesophageal junction.

Educational Goals / Teaching Points
The LINX device, a new surgical treatment for medically resistant gastroesophageal reflux, is described. The importance of preoperatively utilizing a targeted or modified examination to determine patient’s eligibility for the LINX device is detailed. Normal and abnormal findings of the marshmallow/bagel esophagram are depicted. Necessary elements of the report are included.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The marshmallow/bagel protocol consists of two steps that can occur during a comprehensive esophagram. In the decubitus lateral anterior oblique position, the patient eats a barium-coated marshmallow and barium-coated bagel. The radiologist assesses the clearance of the solid-phase swallows, with primary attention to whether the substance is cleared within a single peristaltic wave. This process assesses the patient’s candidacy for the LINX device. Pertinent preoperative findings necessary to convey to gastroenterologists are highlighted, in particular, patients who are poor surgical candidates. Lastly, evaluation of postoperative outcomes in patients who were evaluated using the fluoroscopic study prior to surgery are discussed. The patient is allowed to take barium to swallow the bite, which should pass completely with up to two swallows. Any additional swallows are considered abnormal. If the patient can pass the barium through the GE junction, the patient is considered to have enough contractile force to pass through the LINX device.

With new and emerging surgical interventions for esophageal motility diseases, such as LINX device for the treatment of gastroesophageal reflux, radiologists have an important role in determining functionality and preoperative eligibility. Modifying traditional esophagrams to include semisolid and solid phases improves preoperative evaluations. This presentation demonstrates how to perform and evaluate a patient using a marshmallow/bagel esophagram and highlights relevant information required for gastroenterologists.