Esophageal intubation over a guide wire

Letters to the Editor Esophageal intubation over a guide wire To the Editor: Anatomic abnormalities of the hypopharynx are known to increase the difficulty and risk of UGI endoscopy.! In this situation Peura and Johnson 2 have advocated passage of the endoscope over a guide wire previously placed under fluoroscopic guidance. Recently Tsang and Buto 3 described a method of intubating such patients with the use of a washing pipe inserted under direct endoscopic control through the cricopharyngeus. This method can be used at the time of the initial attempt at endoscopy, and passage of the catheter under direct vision obviates the need for fluoroscopy. For the past several years I have been using a similar technique with a standard 0.035-inch ERCP guide wire instead of a washing pipe, although I have generally also used fluoroscopy because it is available in our endoscopy unit. This technique has allowed me to successfully perform endoscopy in "un-endoscopable" patients with disorders of the hypopharynx who were referred to us after failed attempts at endoscopy by experienced endoscopists elsewhere. In every case I have been able to safely intubate the patient and no complications have developed. Despite the flexibility of the wire, bowing or kinking has not posed a problem. This guide-wire method has several advantages. Standard guide wires are readily available to most endoscopists. No fluoroscopic control is required because the floppy tip ofthe wire is unlikely to traumatize the mucosa of the esophagus or to induce a perforation. As opposed to the method of Peura. and Johnson, 2 a separate session for guide-wire placement IS not necessary. Tsang and But0 3 describe removal of t~e endoscope from the hypopharynx to load the washing pipe, but the narrow-caliber wire can be pre-loaded into the endoscope without loss of suction when a difficult intubation is anticipated. For these reasons, I believe that this method may be preferable to those previously described. Marta A. Dabezies, MD

with corrosive esophageal strictures. Chen reported that esophageal dilation with through-the-scope balloons is a safe, effective, and easy method for treatment of corrosive esophageal strictures. Our experience, however, differs from his observations. Caustic injury to the UGI tract is a common cause of benign esophageal strictures in India. 2 , 3 During the last 7 years, of 123 patients with benign esophageal strictures in adults treated by us, strictures were due to caustic ingestion in 52 patients. 3 Similarly, of 25 children and adolescents, caustic ingestion was a cause of benign esophageal stricture in 15 patients. 4 Since 1986, we have been treating all patients who have corrosive and other benign esophageal strictures with endoscopic dilation. Surgery is advised only when dilation fails. However, our experience with balloons for treatment of corrosive strictures has not been satisfactory (unpublished observations). The main drawbacks of balloons are as follows: (1) balloons do not produce true-to-size dilation; (2) corrosive strictures at times are very long (15 to 20 cm) and thus not easily amenable to balloon dilation; (3) balloon dilation carries a high risk of perforation; and (4) balloons are delicate and costly as compared to bougies. In view of these reasons, we have been using bougies such as Savary Gilliard, Eder Puestow, or advanced Key Med dilators with very good results. 2-4 Despite the fact that corrosive strictures are difficult to dilate, we had good response (dilation to 45F size lumen with complete relief of dysphagia) in 93 % of patients. Balloon dilation may be helpful initially in patients who have extremely narrow, tortouous, and angular strictures where it is not easy to pass a guide wire. It may be noted that despite having short strictures in his series, none of Chen's patients had "good" response and two of eight patients had no response at all to through-the-scope dilation. Previous reports 5- 7 of balloons (over the guide wire) in corrosive esophageal strictures have included too small a number of cases to draw any firm conclusions. In another report, balloon dilation was found to be effective for treatment of corrosive esophageal strictures but was associated with an unacceptably high incidence of perforation (30 %). 8 Thus, we b~lieve that in the absence of a large prospective study it is dIfficult to conclude that the balloons are safe and effective for dilation of corrosive esophageal strictures.

Temple University School of Medicine Philadelphia, Pennsylvania

REFERENCES 1. Benjamin SB. Procedure-related complications. In: Yamada T, ed. Textbook of gastroenterology. Philadelphia: JB Lippincott 1991:2679. ' 2. P.eura DA, Joh~son LF. Esophageal motility and miscellaneous disord~rs. In: SIvak M, ed. Gastroenterologic endoscopy. PhiladelphIa: WB Saunders, 1987:339. 3. Tsang T-K, Buto SK. Catheter-guided endoscopic intubation: a ~ew technique for intubating a difficult esophagus. Gastromtest Endosc 1992;38:49-51.

Balloon dilation of corrosive esophageal strictures To the Editor: We read with great interest the report by Chen i on the effectiveness of through-the-scope balloon dilation in patients VOLUME 39, NO.4, 1993

Sohan L. Broor, MD Deepak Lahoti, MD Department of Gastroenterology G.B. Pant Hospital New Delhi, India

REFERENCES 1. Chen ~C. En~oscopic balloon dilation of esophageal strictures followmg surgical anastomoses, endoscopic variceal sclerotherapy and corrosive ingestion. Gastrointest Endosc 1992;38:586-9. 2. Broor SL, K,umar .A, .Chari.ST, et at. Corrosive esophageal strictures followmg aCid mgestIOn: clinical profile and results of endoscopic dilation. J Gastroenterol Hepatol 1989;4:55-61. 3. Bro?r SL, Basu PP, Raju GS, Lahoti D, Ramesh GN, Kumar A. Bemgn esophageal strictures: Long term results of endoscopic dilatation. Indian J Gastroenerol 1992;11(suppl 1):B3. 4. Broor S.L, Ram~sh C:N, Sood GK, Raju GS, Basu PP. Esophageal strictures m chIldren: clinical profile and result of endoscopic dilatation [Abstract]. Am J Gastroenterol 1991;86:A6. 5. Shemesh E, Czerniak A. Comparision between Savary-Gilliard and balloon dilatation of benign esophageal strictures. World J Surg 1990;14:518-22.

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