- Email: [email protected]
Reflections on “Reflections on retroflexions” and “flexi-rigid” esophagoscopes
39
Reflections on "Reflections on retroflexions" and "f1exi-rigid" esophagoscopes In the February, 1971, issue of this journal, Drs. Burke and Roling suggest that the hazard of impacting a retroflexed endoscope may be increased by performing the U-turn with the patient in the left lateral decubitus position rather than supine, and make the assumption that the 3 impactions we encountered and mentioned in the February, 1970, issue were all performed in the supine position. This thought had not occurred to us, but it was possible to recall the 3 situations, and we feel it should be stated that the 1 apparent impaction which resulted in perforation occurred when the retroflexion was done with the patient supine. We have made no survey of how many retroflexions have been done in what position, but a significant number in this area are still done routinely with the patient supine. Therefore, although Drs. Burke and Roling may be correct that the supine position allows for a safer retroflexion, our experience cannot be used to prove the point, as we have had trouble in either position and have not kept statistics on incidence of problems versus incidence of positions. (This begins to sound like a marriage manual.) Simply to express an opinion, it seems to us that retroflexion can be done in either position, and our feeling is that if it doesn't occur smoothly and easily with the patient in the decubitus position, or if the gastric pool presents problems, the supine position with or without tilting the patient "head up" may be useful. To keep the retroflexion pot simmering, we would like to report another retroflexion problem encountered only last month. The patient was one known to use large amounts of alcohol, responded poorly to sedation, and was somewhat uncooperative. The trainee endoscopist, however, thought that the LoPresti-ACMI esophagoscope had been introduced without undue difficulty, although he had not had his index finger as deep in the pharynx as he would like, not wanting to be bitten. He was quite surprised to note that the scope was nicely in the esophagus, but the tip was retroflexed 180 and the shaft of the scope was in clear view. Manipulation of the controls or of the instrument accomplished nothing, so it was decided to gently withdraw it, hoping it would exit as readily as it had entered. To our relief, it did pass the upper sphincter without undue force, and there was no apparent damage to patient or instrument. 0
VOLUME 18. NO.1. 1971
As Hermon Taylor pointed out about 13 years ago, 1 the finger of a trained endoscopist inserted deep in the pharynx can avoid the pitfalls of pharyngeal injuries and could no doubt have prevented this impaction. Turning to injuries with rigid esophagoscopes, the same issue of this bulletin contains an editorial by Dr. Dagradi pointing out the inherent advantages of the "flexi-rigid" Hufford esophagoscope. While we have not kept as complete statistics as some endoscopy units, we have a reasonably complete record of perforations and other injuries. It seems significant that in this area there have been 5 perforations of the body of the esophagus with this instrument, 3 "crush" injuries to the posterior pharynx, 3 perforations when Jackson dilators were used through the "flexi-rigid" scope, and 1 perforation with the small cup biopsy forceps. Although we have used fiberoptic esophagoscopes fewer years, we have done more procedures per year, and in the Seattle area we have yet to hear of a perforation with this type of instrument or with its biopsy forceps. That doesn't mean we may not have one tomorrow or that nation-wide statistics suggesting that similar injury rates occur with fiberoptic instruments are incorrect. A problem facing anyone responsible for training endoscopists today is obtaining enough cases where the unique capabilities of an open esophagoscope require its use. Many of our trainees may spend 2 years and encounter no such patient. This problem is increased in a community where ENT or thoracic surgery specialists do most of the foreignbody removals and pediatric endoscopy. As a practical matter, our trainees will probably have to rely on others to do endoscopies which require the use of an open lumen esophagoscope. Such is the price of progress. I. TAYLOR, H.: Difficulties and dangers in gastroscopy. Gastroenterology
35:79,1958
Beach Barrett, M.D. Division of Gastroenterology Department of Medicine University of Washington Seattle, Washington 98105
Was it really murder? More on the marvelous GT-V The late lament for the gastrocamera (GT-V) struck, as it must in all enthusiastic gastrophotographers, a sympathetic note. Why, indeed, is it not more generally used in the United States? Is it really dead, or alive and well in certain clinics where its loyal supporters employ it regularly and enthusiastically with appropriate ceremony? The recent admission by its most enthusiastic protagonist that the Olympus Fiberesophagoscope (EF) has led to the almost complete eclipse of the GT-V in his clinic would seem to indicate that the main bulwark had fallen, although it is difficult to understand exactly why this should be SO.1 Certainly, the EF is a relatively poor instrument for viewing the entire stomach, especially the lower half, and the G T-V was highly touted as valuable for this purpose.
Reflections on "Reflections on retroflexions" and "f1exi-rigid" esophagoscopes In the February, 1971, issue of this journal, Drs. Burke and Roling suggest that the hazard of impacting a retroflexed endoscope may be increased by performing the U-turn with the patient in the left lateral decubitus position rather than supine, and make the assumption that the 3 impactions we encountered and mentioned in the February, 1970, issue were all performed in the supine position. This thought had not occurred to us, but it was possible to recall the 3 situations, and we feel it should be stated that the 1 apparent impaction which resulted in perforation occurred when the retroflexion was done with the patient supine. We have made no survey of how many retroflexions have been done in what position, but a significant number in this area are still done routinely with the patient supine. Therefore, although Drs. Burke and Roling may be correct that the supine position allows for a safer retroflexion, our experience cannot be used to prove the point, as we have had trouble in either position and have not kept statistics on incidence of problems versus incidence of positions. (This begins to sound like a marriage manual.) Simply to express an opinion, it seems to us that retroflexion can be done in either position, and our feeling is that if it doesn't occur smoothly and easily with the patient in the decubitus position, or if the gastric pool presents problems, the supine position with or without tilting the patient "head up" may be useful. To keep the retroflexion pot simmering, we would like to report another retroflexion problem encountered only last month. The patient was one known to use large amounts of alcohol, responded poorly to sedation, and was somewhat uncooperative. The trainee endoscopist, however, thought that the LoPresti-ACMI esophagoscope had been introduced without undue difficulty, although he had not had his index finger as deep in the pharynx as he would like, not wanting to be bitten. He was quite surprised to note that the scope was nicely in the esophagus, but the tip was retroflexed 180 and the shaft of the scope was in clear view. Manipulation of the controls or of the instrument accomplished nothing, so it was decided to gently withdraw it, hoping it would exit as readily as it had entered. To our relief, it did pass the upper sphincter without undue force, and there was no apparent damage to patient or instrument. 0
VOLUME 18. NO.1. 1971
As Hermon Taylor pointed out about 13 years ago, 1 the finger of a trained endoscopist inserted deep in the pharynx can avoid the pitfalls of pharyngeal injuries and could no doubt have prevented this impaction. Turning to injuries with rigid esophagoscopes, the same issue of this bulletin contains an editorial by Dr. Dagradi pointing out the inherent advantages of the "flexi-rigid" Hufford esophagoscope. While we have not kept as complete statistics as some endoscopy units, we have a reasonably complete record of perforations and other injuries. It seems significant that in this area there have been 5 perforations of the body of the esophagus with this instrument, 3 "crush" injuries to the posterior pharynx, 3 perforations when Jackson dilators were used through the "flexi-rigid" scope, and 1 perforation with the small cup biopsy forceps. Although we have used fiberoptic esophagoscopes fewer years, we have done more procedures per year, and in the Seattle area we have yet to hear of a perforation with this type of instrument or with its biopsy forceps. That doesn't mean we may not have one tomorrow or that nation-wide statistics suggesting that similar injury rates occur with fiberoptic instruments are incorrect. A problem facing anyone responsible for training endoscopists today is obtaining enough cases where the unique capabilities of an open esophagoscope require its use. Many of our trainees may spend 2 years and encounter no such patient. This problem is increased in a community where ENT or thoracic surgery specialists do most of the foreignbody removals and pediatric endoscopy. As a practical matter, our trainees will probably have to rely on others to do endoscopies which require the use of an open lumen esophagoscope. Such is the price of progress. I. TAYLOR, H.: Difficulties and dangers in gastroscopy. Gastroenterology
35:79,1958
Beach Barrett, M.D. Division of Gastroenterology Department of Medicine University of Washington Seattle, Washington 98105
Was it really murder? More on the marvelous GT-V The late lament for the gastrocamera (GT-V) struck, as it must in all enthusiastic gastrophotographers, a sympathetic note. Why, indeed, is it not more generally used in the United States? Is it really dead, or alive and well in certain clinics where its loyal supporters employ it regularly and enthusiastically with appropriate ceremony? The recent admission by its most enthusiastic protagonist that the Olympus Fiberesophagoscope (EF) has led to the almost complete eclipse of the GT-V in his clinic would seem to indicate that the main bulwark had fallen, although it is difficult to understand exactly why this should be SO.1 Certainly, the EF is a relatively poor instrument for viewing the entire stomach, especially the lower half, and the G T-V was highly touted as valuable for this purpose.