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Response to: Role of fluoroscopy in Maloney dilation of esophageal strictures
of my patients who could not be blindly dilated had hiatal hernia size of greater than or equal to 5 cm. It is not our custom to do serial dilation in mostly asymptomatic patients. Patients with severe strictures that might require frequent dilation (more often than every 3 to 9 months) are maintained on omeprazole therapy or referred for surgery. I agree with the authors that most patients can be safely dilated without fluoroscopy if the esophagus is relatively straight and a large hiatal hernia is not present. I also agree that patients who have been previously dilated successfully without problems do not require fluoroscopy, and that patients with minimal symptoms undergoing serial dilation do not require fluoroscopy. Their study group consisted of patients who met these criteria. I also no longer advocate mandated fluoroscopy in patients undergoing dilation for simple strictures, either Schatzki's ring or peptic strictures, if the esophagus is straight and a large hiatal hernia is absent. I feel strongly, however, that complicated strictures, those with stricture size less than 30F, those with angulation of the esophagus, and hernia size greater than 5 cm benefit from fluoroscopy. We have always recommend change in patient position if necessary to accomplish successful dilation. One could be an optimist and say that only 9 of our 145 patients (6.2%) or 9 of 279 dilations (3.2%) required fluoroscopy for successful dilation. However, what is the risk of perforation and hemorrhage in this select group ff blind dilation is pursued? Our present morbidity of 1 complication (minor hemorrhage) involving 813 patients and 1789 dilations over a 13-year experience attests to the safety of esophageal dilation utilizing fluoroscopy.
Leslie E. Tucker, MD
esophageal lumen. If the patient is put at an angle of 30 ° above horizontal, half of the force of the weight of the dilator is directed into the esophageal wall. If the angle of the patient is reduced to zero (with the patient placed horizontally in the lefl lateral decubitis position), then the entire weight of the Maloney is directed into the esophageal wall. This would promote more adverse events that might benefit from fluoroscopic guidance. Hence the differences in success of Maloney dilations without fluoroscopy in patients placed in the horizontal 1 or 30 ° to 45 ° positions 2 compared with our observations. 3 We see no advantage in the passage of the Maloney dilator in any but the upright position. No sedation is required other than a topical anesthetic. If the patient must be sedated and dilated in a recumbent position, then a wire guided Savary-type dilator should be used in order to avoid impaction of the dilator in the esophageal wall or within a hiatal hernia. The use of Maloney dilators at our institution is largely for patients with chronic peptic strictures that have been treated with H2 antagonists. Most of these patients have ongoing peptic inflammation and stricturing and generally have required periodic dilation to prevent significant dysphagia from occurring. From 1988 to 1990, an average of 360 Maloney dilation and 274 Savary dilation procedures were performed each year. Since the introduction of omeprazole at our institution in 1990, the number of Maloney dilations performed has decreased each year, and in 1994 only 115 Maloney dilations were performed. During this same period of time the number of dilations performed with Savary dilators (298 in 1994) has remained relatively constant. Advances in therapy of peptic esophagitis may soon make Maloney dilation procedures obsolete.
SL John's Mercy Hospital Washington, Misssouri
REFERENCES 1. Ho SB, Cass O, Katsmann RJ, et al. Fluoroscopyis not necessary for Maloney dilation of chronic esophageal strictures. Gastrointest Endosc 1995;41:11-4. 2. Tucker LE. The importance of fluoroscopicguidance for Maloney dilation. Am J Gastroenterol 1992;87:1709-11. Response: We would like to thank Dr. Tucker very much for clarification of his data 1 that we previously quoted. We would like to emphasize the following points. First, patients to be treated with Maloney dilators need to be carefully selected. They must have uncomplicated, mild strictures. Strictures that are associated with esophageal diverticula, malignancy, or are narrow enough to cause difficulty for an endoscope to pass should be dilated using a wire-guided Savarytype dilator. Second, mercury-weighted Maloney dilators were designed to be passed by their own weight. These dilators are constructed to be quite heavy (a 50F Maloney dilator weighs 750 gm). The percentage of the force that is directed along the esophageal lumen by the weight of a Maloney dilator is directly related to the angle at which it is passed (Fig. 1). With the patient in the upright position, the entire weight of the Maloney is directed in the center of the
VOLUME 42, NO. 4, 1995
Samuel B. Ho, MD Stephen E. Silvis, MD VAMC Minneapolis, Minnesota
REFERENCES 1. Reference 2 above. 2. McClave SA, Wright RA, Brady PG. Prospective randomized study of Maloney esophageal dilation: blinded versus fluoroscopic guidance. Gastrointest Endosc 1990;36:272-5. 3. Reference 1 above.
Color vision and endoscopic diagnosis To the Editor: The image in the eyepiece of the fiberscope or on the screen of the videoscope is projected onto the retina of the endoscopist and conveyed as optical information (information on light) from and through the optic nerve to the endoscopist's brain. The factors processed in his or her brain are shape and color, and the endoscopic diagnosis comes about when the endoscopist's experience and knowledge or expertise are added to the above shape and color information. While color provides important information for the endoscopist, human
GASTROINTESTINAL ENDOSCOPY 377
Leslie E. Tucker, MD
esophageal lumen. If the patient is put at an angle of 30 ° above horizontal, half of the force of the weight of the dilator is directed into the esophageal wall. If the angle of the patient is reduced to zero (with the patient placed horizontally in the lefl lateral decubitis position), then the entire weight of the Maloney is directed into the esophageal wall. This would promote more adverse events that might benefit from fluoroscopic guidance. Hence the differences in success of Maloney dilations without fluoroscopy in patients placed in the horizontal 1 or 30 ° to 45 ° positions 2 compared with our observations. 3 We see no advantage in the passage of the Maloney dilator in any but the upright position. No sedation is required other than a topical anesthetic. If the patient must be sedated and dilated in a recumbent position, then a wire guided Savary-type dilator should be used in order to avoid impaction of the dilator in the esophageal wall or within a hiatal hernia. The use of Maloney dilators at our institution is largely for patients with chronic peptic strictures that have been treated with H2 antagonists. Most of these patients have ongoing peptic inflammation and stricturing and generally have required periodic dilation to prevent significant dysphagia from occurring. From 1988 to 1990, an average of 360 Maloney dilation and 274 Savary dilation procedures were performed each year. Since the introduction of omeprazole at our institution in 1990, the number of Maloney dilations performed has decreased each year, and in 1994 only 115 Maloney dilations were performed. During this same period of time the number of dilations performed with Savary dilators (298 in 1994) has remained relatively constant. Advances in therapy of peptic esophagitis may soon make Maloney dilation procedures obsolete.
SL John's Mercy Hospital Washington, Misssouri
REFERENCES 1. Ho SB, Cass O, Katsmann RJ, et al. Fluoroscopyis not necessary for Maloney dilation of chronic esophageal strictures. Gastrointest Endosc 1995;41:11-4. 2. Tucker LE. The importance of fluoroscopicguidance for Maloney dilation. Am J Gastroenterol 1992;87:1709-11. Response: We would like to thank Dr. Tucker very much for clarification of his data 1 that we previously quoted. We would like to emphasize the following points. First, patients to be treated with Maloney dilators need to be carefully selected. They must have uncomplicated, mild strictures. Strictures that are associated with esophageal diverticula, malignancy, or are narrow enough to cause difficulty for an endoscope to pass should be dilated using a wire-guided Savarytype dilator. Second, mercury-weighted Maloney dilators were designed to be passed by their own weight. These dilators are constructed to be quite heavy (a 50F Maloney dilator weighs 750 gm). The percentage of the force that is directed along the esophageal lumen by the weight of a Maloney dilator is directly related to the angle at which it is passed (Fig. 1). With the patient in the upright position, the entire weight of the Maloney is directed in the center of the
VOLUME 42, NO. 4, 1995
Samuel B. Ho, MD Stephen E. Silvis, MD VAMC Minneapolis, Minnesota
REFERENCES 1. Reference 2 above. 2. McClave SA, Wright RA, Brady PG. Prospective randomized study of Maloney esophageal dilation: blinded versus fluoroscopic guidance. Gastrointest Endosc 1990;36:272-5. 3. Reference 1 above.
Color vision and endoscopic diagnosis To the Editor: The image in the eyepiece of the fiberscope or on the screen of the videoscope is projected onto the retina of the endoscopist and conveyed as optical information (information on light) from and through the optic nerve to the endoscopist's brain. The factors processed in his or her brain are shape and color, and the endoscopic diagnosis comes about when the endoscopist's experience and knowledge or expertise are added to the above shape and color information. While color provides important information for the endoscopist, human
GASTROINTESTINAL ENDOSCOPY 377