Presentation
Nursing home patient with worsening cough and dyspnea
Patient Data
Doughnut-shaped surgical device (Angelchik prosthesis) visible on CXR as well. The prosthesis is rotated vertically, rather than laying horizontally under the diaphragm.
Likely incidental finding of malpositioned Angelchik antireflux prosthesis with a moderate hiatus hernia
Other findings:
- No PE
- Left upper lobe apical nodule concerning for a primary lung malignancy
- Small left pleural effusion, tiny right pleural effusion and interstitial
thickening most in keeping with pulmonary edema
- Partially imaged 4.2cm AAA
- Cholelithiasis and features of chronic cholecystitis
Case Discussion
As per Burhenne et al1, the Angelchik Antireflux device was a commonly used simpler surgical alternative to gastropexy and fundoplication in the 1980s. It is a doughnut shaped prosthesis made of silicone with a radio-opaque outer margin. Post-operatively, it should sit sub-diaphragmatically around the abdominal part of the esophagus. Ideally, above the hepatic branch of the anterior vagus nerve.1 Unfortunately, dislodgment of the device into the chest or abdominal cavity over time has been reported1-3 and many patients have required removal of these devices as a result. By 1990 the use of the Angelchik prosthesis was uncommon as the Open Nissen's fundoplication became the accepted technique for the treatment of GERD, followed by laparoscopic surgery.3
On first inspection of these images, a gastric lap band device had been a differential. However, the patient was known to have had an Angelchik procedure done over 20 years ago.
Although the Angelchik prosthesis is mispositioned in this patient, it is likely an incidental finding. The likely cause for the patient's symptoms are likely related to an exacerbation of his COPD and heart failure.
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