- Email: [email protected]
Airtraq laryngoscope for difficult intubation during endoscopic band ligation
Correspondence / Digestive and Liver Disease 43 (2011) 580–582
581
[3] Gralnek IM, Adler SN, Yassin K, et al. Detecting esophageal disease with secondgeneration capsule endoscopy: initial evaluation of the PillCam ESO 2. Endoscopy 2008;40:275–9. [4] Gralnek IM, Rabinovitz R, Afik D, et al. A simplified ingestion procedure for esophageal capsule endoscopy: initial evaluation in healthy volunteers. Endoscopy 2006;38:913–8. [5] Oka A, Amano Y, Kusunoki R, et al. A superficial esophageal cancer observed with the PillCam ESO2 in combination with the FICE system: a case report. Digestive Endoscopy 2011; in press.
Yuji Amano ∗ Takafumi Yuki Division of Endoscopy, Shimane University Hospital, Izumo-shi, Shimane 693-8501, Japan Ryusaku Kusunoki Yoshikazu Kinoshita Department of Internal Medicine II, Shimane University School of Medicine, Izumo, Shimane 693-8501, Japan ∗ Corresponding
author. Tel.: +81 853 20 2190; fax: +81 853 20 2187. E-mail address: [email protected] (Y. Amano) Available online 16 February 2011
doi:10.1016/j.dld.2010.12.019
Airtraq laryngoscope for difficult intubation during endoscopic band ligation夽 Sir, Endoscopic band ligation (EBL) became the preferred technique for the endoscopic treatment of esophageal varices when it was proven in several randomized trials to be as effective as endoscopic variceal sclerotherapy but with fewer serious adverse events [1]. The present procedure for EBL includes a complete upper endoscopy performed before placement of the band ligation device onto the endoscope. Occasionally it is difficult to negotiate the endoscope across the upper esophageal sphincter (UES) following the assembly of the ligating unit. We describe the use of the Airtraq laryngoscope (Prodol Meditec S.A., Vizcaya, Spain) for difficult intubation in a 69-year-old woman (BMI 23.4 kg/m2 ) with cirrhosis presented for elective EBL. She suffered from severe cervical kyphosis with very limited cervical range of motion and she was classified as American Society of Anesthesiology (ASA) Physical Status score of III. Sedation was provided by dedicated anaesthetic staff. During the procedure a standard monitor was applied [2,3]. An intravenous (iv) catheter was inserted, and a 0.9% saline infusion started. Oxygen was delivered by a nasal cannula (rate = 3 l/min). Moderate sedation was provided with an iv bolus of 3 mg of midazolam. With the patient in left lateral position a complete upper endoscopy was performed. After the initial endoscopic examination we decide to accomplish EBL for secondary prophylaxis. The ligation device loaded onto the endoscope increased the effective diameter of the endoscope and made it stiff and difficult to negotiate across the UES. It was not possible to perform the usual manoeuvres to intubate the oesophagus (flexing the neck, insufflating air, using limited clockwise–counterclockwise motion of the shaft of the endoscope whilst applying constant intubation pressure) because of the very limited range of motion of the neck.
夽 This work was supported by the Department of Emergency, “G.B. Morgagni-L. Pierantoni” Hospital, viale Forlanini 34, Forlì, Italy.
Fig. 1. A picture of the Airtraq equipped with an endoscope in the canal instead of housing a tracheal tube. In the detail the band ligation unit.
The Airtraq laryngoscope (AL) was designed to provide a clear view of the glottis without altering the normal alignment of the oropharyngeal axes. The anatomically designed blade has both an optical system and a conduit for a tracheal tube. The endoscope can be placed in the conduit instead of the tracheal tube (Fig. 1). Similar to endotracheal intubation, the endoscope can be inserted easily under optical control. That was the case: using the AL as an introducer it was possible to identify through the viewfinder of the scope the esophageal orifice and to direct the endoscope (a standard gastroscope, EG-450WR5 Fujinon, loaded with a 6 Shooter Saeed Multi-Band Ligator, Cook Medical) to the UES quickly and without any assistance. It is possible to advance through AL the standard gastroscope and therapeutic gastroscope. The use of a curvilinear radial EUS and a duodenoscope requires an alternative technique. In this case the AL is positioned in the vallecula, subsequently the endoscope is placed into the oropharynx and advanced through the oesophagus. The procedure was performed providing moderate sedation (midazolam 5 mg iv) and the patient was discharged uneventfully. The EBL is a relatively safe procedure, with very few reported complications. In rare cases it is difficult to pass the banding device through the UES, for this wire-guide intubation techniques have been described [4], however they are time consuming. The combination of the AL and the endoscope has several advantages, indeed the AL can provide an unobstructed airway for the endoscope and place its tip in the immediate proximity of UES. Thus, the AL can be used to monitor the placement of the endoscope and find the cause of any resistance to advancement. This tool helped esophageal introduction of the endoscope and it is a safe and simple alternative method to overcome the difficulty in intubating the oesophagus after assembly of the ligating unit. Conflict of interest statement None declared. References [1] Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 2007;102:2086–102. [2] Cohen LB, Delegge MH, Aisenberg J, et al. Gastroenterology 2007;133: 675–701. [3] American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists. Anesthesiology 2002;96:1004–17. [4] Sang TK, Buto SK. Catheter-guided endoscopic intubation: a new technique for intubating a difficult esophagus. Gastrointest Endosc 1992;38:49–51.
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Correspondence / Digestive and Liver Disease 43 (2011) 580–582
Ruggero Massimo Corso ∗ Anesthesia and Intensive Care Unit, “G.B. Morgagni-L. Pierantoni” Hospital, Forlì, Italy Elena Cavargini Digestive Endoscopy Unit, “G.B. Morgagni-L. Pierantoni” Hospital, Forlì, Italy Emanuele Piraccini Anesthesia and Intensive Care Unit, “G.B. Morgagni-L. Pierantoni” Hospital, Forlì, Italy
Enrico Ricci Digestive Endoscopy Unit, “G.B. Morgagni-L. Pierantoni” Hospital, Forlì, Italy ∗ Corresponding
author. Tel.: +39 0543735011; fax: +39 0543735014. E-mail address: [email protected] (R.M. Corso) Available online 16 February 2011 doi:10.1016/j.dld.2011.02.015
581
[3] Gralnek IM, Adler SN, Yassin K, et al. Detecting esophageal disease with secondgeneration capsule endoscopy: initial evaluation of the PillCam ESO 2. Endoscopy 2008;40:275–9. [4] Gralnek IM, Rabinovitz R, Afik D, et al. A simplified ingestion procedure for esophageal capsule endoscopy: initial evaluation in healthy volunteers. Endoscopy 2006;38:913–8. [5] Oka A, Amano Y, Kusunoki R, et al. A superficial esophageal cancer observed with the PillCam ESO2 in combination with the FICE system: a case report. Digestive Endoscopy 2011; in press.
Yuji Amano ∗ Takafumi Yuki Division of Endoscopy, Shimane University Hospital, Izumo-shi, Shimane 693-8501, Japan Ryusaku Kusunoki Yoshikazu Kinoshita Department of Internal Medicine II, Shimane University School of Medicine, Izumo, Shimane 693-8501, Japan ∗ Corresponding
author. Tel.: +81 853 20 2190; fax: +81 853 20 2187. E-mail address: [email protected] (Y. Amano) Available online 16 February 2011
doi:10.1016/j.dld.2010.12.019
Airtraq laryngoscope for difficult intubation during endoscopic band ligation夽 Sir, Endoscopic band ligation (EBL) became the preferred technique for the endoscopic treatment of esophageal varices when it was proven in several randomized trials to be as effective as endoscopic variceal sclerotherapy but with fewer serious adverse events [1]. The present procedure for EBL includes a complete upper endoscopy performed before placement of the band ligation device onto the endoscope. Occasionally it is difficult to negotiate the endoscope across the upper esophageal sphincter (UES) following the assembly of the ligating unit. We describe the use of the Airtraq laryngoscope (Prodol Meditec S.A., Vizcaya, Spain) for difficult intubation in a 69-year-old woman (BMI 23.4 kg/m2 ) with cirrhosis presented for elective EBL. She suffered from severe cervical kyphosis with very limited cervical range of motion and she was classified as American Society of Anesthesiology (ASA) Physical Status score of III. Sedation was provided by dedicated anaesthetic staff. During the procedure a standard monitor was applied [2,3]. An intravenous (iv) catheter was inserted, and a 0.9% saline infusion started. Oxygen was delivered by a nasal cannula (rate = 3 l/min). Moderate sedation was provided with an iv bolus of 3 mg of midazolam. With the patient in left lateral position a complete upper endoscopy was performed. After the initial endoscopic examination we decide to accomplish EBL for secondary prophylaxis. The ligation device loaded onto the endoscope increased the effective diameter of the endoscope and made it stiff and difficult to negotiate across the UES. It was not possible to perform the usual manoeuvres to intubate the oesophagus (flexing the neck, insufflating air, using limited clockwise–counterclockwise motion of the shaft of the endoscope whilst applying constant intubation pressure) because of the very limited range of motion of the neck.
夽 This work was supported by the Department of Emergency, “G.B. Morgagni-L. Pierantoni” Hospital, viale Forlanini 34, Forlì, Italy.
Fig. 1. A picture of the Airtraq equipped with an endoscope in the canal instead of housing a tracheal tube. In the detail the band ligation unit.
The Airtraq laryngoscope (AL) was designed to provide a clear view of the glottis without altering the normal alignment of the oropharyngeal axes. The anatomically designed blade has both an optical system and a conduit for a tracheal tube. The endoscope can be placed in the conduit instead of the tracheal tube (Fig. 1). Similar to endotracheal intubation, the endoscope can be inserted easily under optical control. That was the case: using the AL as an introducer it was possible to identify through the viewfinder of the scope the esophageal orifice and to direct the endoscope (a standard gastroscope, EG-450WR5 Fujinon, loaded with a 6 Shooter Saeed Multi-Band Ligator, Cook Medical) to the UES quickly and without any assistance. It is possible to advance through AL the standard gastroscope and therapeutic gastroscope. The use of a curvilinear radial EUS and a duodenoscope requires an alternative technique. In this case the AL is positioned in the vallecula, subsequently the endoscope is placed into the oropharynx and advanced through the oesophagus. The procedure was performed providing moderate sedation (midazolam 5 mg iv) and the patient was discharged uneventfully. The EBL is a relatively safe procedure, with very few reported complications. In rare cases it is difficult to pass the banding device through the UES, for this wire-guide intubation techniques have been described [4], however they are time consuming. The combination of the AL and the endoscope has several advantages, indeed the AL can provide an unobstructed airway for the endoscope and place its tip in the immediate proximity of UES. Thus, the AL can be used to monitor the placement of the endoscope and find the cause of any resistance to advancement. This tool helped esophageal introduction of the endoscope and it is a safe and simple alternative method to overcome the difficulty in intubating the oesophagus after assembly of the ligating unit. Conflict of interest statement None declared. References [1] Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol 2007;102:2086–102. [2] Cohen LB, Delegge MH, Aisenberg J, et al. Gastroenterology 2007;133: 675–701. [3] American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists. Anesthesiology 2002;96:1004–17. [4] Sang TK, Buto SK. Catheter-guided endoscopic intubation: a new technique for intubating a difficult esophagus. Gastrointest Endosc 1992;38:49–51.
582
Correspondence / Digestive and Liver Disease 43 (2011) 580–582
Ruggero Massimo Corso ∗ Anesthesia and Intensive Care Unit, “G.B. Morgagni-L. Pierantoni” Hospital, Forlì, Italy Elena Cavargini Digestive Endoscopy Unit, “G.B. Morgagni-L. Pierantoni” Hospital, Forlì, Italy Emanuele Piraccini Anesthesia and Intensive Care Unit, “G.B. Morgagni-L. Pierantoni” Hospital, Forlì, Italy
Enrico Ricci Digestive Endoscopy Unit, “G.B. Morgagni-L. Pierantoni” Hospital, Forlì, Italy ∗ Corresponding
author. Tel.: +39 0543735011; fax: +39 0543735014. E-mail address: [email protected] (R.M. Corso) Available online 16 February 2011 doi:10.1016/j.dld.2011.02.015