Letters to the Editor
Laryngeal jack-assisted endoscopic management of postcricoid esophageal obstruction To the Editor: I read with great interest the paper by Baumgart et al1 on recanalization of completely obliterated esophageal stricture by using an endoscopic rendezvous maneuver, and I admire their novel approach in the management of this challenging problem. Adequate visualization of postcricoid esophageal stricture is a major limiting factor, because of its proximity to the upper esophageal sphincter. The ‘‘laryngeal jack technique’’ (a Dedo laryngoscope is placed behind the larynx, and the larynx is lifted anteriorly and suspended in a Leevy suspender to open up the postcricoid area for clear visualization with a small-caliber endoscope while the patient is under general anesthesia) offers an opportunity to see the obstruction clearly and to plan appropriate management. Severe postcricoid esophageal stricture can be successfully dilated by using the laryngeal jack technique under direct visualization.2 Complete esophageal obstruction requires an endoscopic rendezvous maneuver. A thin esophageal membranous obstruction, confirmed by a positive diaphanoscopy, can be opened up by retrograde membranotomy,3 whereas, a thick septum may require forceful puncture with a wide-bore needle inserted through the laryngoscope, under close observation of the whole procedure through the endoscope stationed below the septum by using the endoscopic rendezvous maneuver (personal experience). Placement of a large-bore PEG tube (minimum 24F), instead of a small-bore PEG, before chemoradiation of patients with head and neck cancer, allows endoscopic rendezvous maneuvers without the need for dilation of a small PEG tract. In cases where there is no PEG available for retrograde access, the dilation procedure potentially could be completed in a single setting by laparoscopy, retrograde intubation through a gastrostomy with a camera drape (to maintain sterility of the surgical field), dilation of the stricture, and placement of a PEG tube for subsequent access if need be.4 In summary, collaboration with otorhinolaryngologists and general surgeons is required to manage patients with postcricoid esophageal strictures. Gottumukkala S. Raju, MD, FRCP, FACP, FACG Department of Internal Medicine Center for Endoscopic Research, Training, and Innovation University of Texas Medical Branch Galveston, Texas, USA
using an endoscopic rendezvous maneuver. Gastrointest Endosc 2005; 61:473-5. 2. Raju GS, Ahmed I, Bunting E, Tsue TT. A novel approach to radiationinduced post-cricoid esophageal stricture: the ‘‘laryngeal jack’’ to facilitate dilatation. Gastrointest Endosc 2000;52:282-5. 3. Raju GS, Hershberger J, Crawford G, Girod D, Tsue T, Merati A. Laryngeal jack-assisted retrograde esophageal membranotomy through a gastrostomy. Gastrointest Endosc 2001;53:239-41. 4. Torres F, Moncure M, Krout J, Merati A, Raju GS. Endoscopic drape to avoid contamination of the operative field during laparotomy-assisted endoscopy. Gastrointest Endosc 2001;54:401-2. doi:10.1016/j.gie.2005.04.007
Successful recanalization of a completely obliterated esophageal stricture by using an endoscopic rendezvous maneuver To the Editor: We appreciate the interest and comments of Dr. Raju regarding our report.1 We agree that adequate visualization is paramount when performing challenging endoscopic maneuvers. Optimal visualization is elegantly accomplished with cutting edge, small-caliber endoscopes and high-illumination optical processors as described in our paper.1 We admire the inventive ‘‘laryngeal jack technique’’ proposed by Dr. Raju and colleagues but see no particular advantage in it.2,3 In the hands of a skilled endoscopist, it is uncritical whether rigid or flexible endoscopes are used. In our opinion the ‘‘laryngeal jack’’ approach requires a more complicated setup, exposes the already injured tissue to greater forces, and potentially causes more trauma. With regard to the suggestion of placing large-bore PEG tubes (minimum 24F) in all patients who are undergoing chemoradiation, we disagree with Dr. Raju. Fortunately, radiation-induced complete esophageal obstruction is a rare complication, which would not justify that. A standard 15F PEG tract is easily dilated if necessary. Alternatively, percutaneous gastrostomies can be placed with fluoroscopic or abdominal ultrasound guidance (percutaneous sonographic gastrostomy).4,5 Daniel C. Baumgart, MD Wilfried Veltzke-Schlieker, MD Bertram Wiedenmann, MD Department of Medicine Division of Hepatology and Gastroenterology Charite´ Medical Center – Virchow Hospital Medical School of the Humboldt-University of Berlin Berlin, Germany
REFERENCES
REFERENCES
1. Baumgart DC, Veltzke-Schlieker W, Wiedenmann B, Hintze RE. Successful recanalization of a completely obliterated esophageal stricture by
1. Baumgart DC, Veltzke-Schlieker W, Wiedenmann B, Hintze RE. Successful recanalization of a completely obliterated esophageal stricture by
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Volume 62, No. 3 : 2005 GASTROINTESTINAL ENDOSCOPY 473