Insertion of Dent sleeve catheter using a guidewire in achalasia Nahum Freidin, MD Shmuel Eidelman, MD Zahava Danieli, RN Ina Bergman, RN
An important diagnostic criterion for achalasia is lack or subnormal lower esophageal sphincter (LES) relaxation during swallows. 1 To demonstrate this abnormality the manometric catheter should first cross the LES into the stomach and then be pulled aborally, so that its LES recording site (the sleeve) straddles the LES.2 In long-standing achalasia the esophagus may be very large and tortuous, and its LES spastic. A failure in insertion of the catheter into the stomach may occur. 3 Recently, we faced such a difficulty and used a guidewire to push the catheter into the stomach. CASE REPORT
An 82-year-old women was referred to the gastrointestinal motility laboratory at the Rambam Medical Center for evaluation of dysphagia. Forty years before she underwent an appendectomy and 17 years before a cholecystectomy. Fourteen years ago she suffered an acute myocardial infarction and since then had stable angina pectoris. Her dysphagia began 16 years ago. During this period she lost 20 kg. In the 2 years before evaluation, she suffered two episodes ofpneumonia. On admission, she was cachectic and weighed 38 kg. On upper gastrointestinal endoscopy, a large curved, esophagus was found, and some difficulty in penetrating through the esophago-gastric junction was felt. A barium meal demonstrated a wide and tortuous esophagus with beaking of its distal end (Fig. 1). A manometric study to confirm the diagnosis of achalasia failed repeatedly, as the Dent catheter coiled inside the esophagus and did not penetrate into the stomach. The Dent catheter that we use has a lumen ending distally to the sleeve. We took advantage of that feature for insertion of a guidewire. A wire from the Rigiflex achalasia dilator set (Microvasive, Billerica, Mass.) was introduced into the stomach through the biopsy channel of an Olympus XQ20 gastroscope. The endoscope was removed and the Dent catheter was pushed on the guidewire into the stomach, through the hole located distally to the sleeve (Fig. 2). Reinsertion of the endoscope confirmed proper position of the catheter inside the stomach. The endoscope and the guidewire were removed, and a manometric recording showed gastric respiratory waves on the sleeve channel. Thereafter, a withdrawal of the sleeve to the LES location was performed. The manometric recording showed 30 mm
Figure 1. Barium meal that demonstrates the patient's huge, tortuous esophagus with beaking of its distal end.
Hg of resting LES pressure with less than 10% relaxation of the LES during wet swallows (normal >80%). The mean contraction amplitude of the simultaneous esophageal body contractions during those wet swallows was 15 mm Hg (normal >50 mm Hg).
DISCUSSION Received December 18,1991. For revision January 27,1992. Accepted April 13, 1992. From the Department of Gastroenterology, Rambam Medical Center, Haifa, Israel and Technion-Israel Institute of Technology, Faculty of Medicine, Haifa, Israel. Reprint requests: Nahum Freidin, MD, Department of Gastroenterology, Rambam Medical Center, Haifa 31096, Israel. VOLUME 38, NO.6, 1992
The diagnosis of achalasia is based on lack of relaxation of the LES. To demonstrate this abnormality, the LES recording site of the manometric tube, the sleeve, should first be placed inside the LES. This is accomplished by pushing the tube into the stomach and then pulling it back aborally stepwisely.2 An in699
The commercial Dent sleeve catheter (ESM 3 DSArndorfer) has no lumen ending distally to the sleeve. Our tube was specially designed for investigational needs to record pressure distally to the LES inside the stomach4 or to insufflate a balloon with air inside the fundus. 5 We utilized this lumen to pass a guidewire and to push the manometric tube on it into the stomach. However, the same guidewire technique can be employed by using the central lumen of any non-sleeve catheter. This central lumen was originally designed for pH probe insertion and gastric aspiration. We recommend the described guidewire endoscopic technique only when routine and fluoroscopic guided attempts fail in passing the manometric tube into the stomach. Figure 2. The Dent sleeve catheter with the guidewire. The wire is passed through the side hole located distally to the sleeve, along the entire length of the corresponding lumen and out the proximal end. In the upper left corner a magnification of the distal tip of the catheter is demonstrated.
crease in the pressure on the sleeve channel from the baseline gastric pressure indicates the LES location. 2 To test relaxation of the LES, 5 ml of water are swallowed repeatedly. Normally, a sharp drop of the pressure to the baseline gastric pressure is achieved (complete or 100% relaxation). Lack or less than 60% relaxation is very suggestive of the diagnosis of achalasia. However, in achalasia the demonstration of this abnormality may be unattainable. The esophagus may be wide, tortuous, and its distal end spastic. The manometric tube may coil inside the wide esophagus and not penetrate into the stomach. Even fluoroscopy may not help.
A tracheo-esophageal puncture technique for voice restoration after laryngectomy Tam Le, MD John S. Wilson, MD Multiple methods to restore voice after totallaryngectomy have been reported since Billroth performed the first laryngectomy in 1-873. 1• 2 Voice restoration may occur with diversion of exhaled pulmonary air through planned or spontaneous fistulas into the esophagus or hypopharynx.
Received January 22, 1992. For revision March 2, 1992. Accepted May 21, 1992. From the Department of Surgery, University of South Alabama Medical Center, Mobile, Alabama. Reprint requests: Tam Le, MD, Kaiser Permanente, 411 N. Lakeview Avenue, Anaheim, California 92807.
700
ADDENDUM Since the submission of the manuscript, we used the same technique successfully in two other patients with achalasia.
REFERENCES 1. Cohen S, Lipshutz W. Lower esophageal sphincter dysfunction in achalasia. Gastroenterology 1971;61:814-20. 2. Dodds WG. Esophageal manometry. In proceedings of methodology of gastrointestinal motility measurements. International Symposium on gastrointestinal motility-Oxford. London: Mediscript, 1988:11-2. 3. Clouse RE. Motor disorders. In: Sleisenger MH, ed. Gastrointestinal disease. 4th ed. Philadelphia: WB Saunders, 1989:571. 4. Freidin N, Mittal RK, McCallum RW. Does body posture affect the incidence and mechanisms of gastroesophageal reflux. Gut 1991;32:133-6. 5. Freidin N, Mittal RK, Sluss J, McCallum RW. Characteristics of spontaneous and gastric distention evoked, transient LES relaxations (TLESR's) in man [Abstract). Gastroenterology 1988;95:865.
In 19.79, Singer and Blom1 proposed a simplified method for voice restoration using an endoscopic procedure and midline tracheo-esophageal puncture with subsequent insertion of a valved voice prosthesis. The intravenous catheter and the silk suture that are used in this technique do not facilitate dilation and passage of the tracheo-esophageal catheter. Subsequent to development of the percutaneous endoscopic gastrostomy (PEG) technique, several different procedure kits have been provided for PEG. 3- 6 We found that using these kits or central venous split sheath introducer kits significantly adds ease, safety, and efficiency of the tracheo-esophageal puncture procedure. From July 1987 to June 1989 we performed tracheo-esophageal punctures in four patients using a rigid esophagoscope and PEG kits or split sheath introducer kits. All four patients had the procedure done as outpatients and had no complication in followGASTROINTESTINAL ENDOSCOPY
An important diagnostic criterion for achalasia is lack or subnormal lower esophageal sphincter (LES) relaxation during swallows. 1 To demonstrate this abnormality the manometric catheter should first cross the LES into the stomach and then be pulled aborally, so that its LES recording site (the sleeve) straddles the LES.2 In long-standing achalasia the esophagus may be very large and tortuous, and its LES spastic. A failure in insertion of the catheter into the stomach may occur. 3 Recently, we faced such a difficulty and used a guidewire to push the catheter into the stomach. CASE REPORT
An 82-year-old women was referred to the gastrointestinal motility laboratory at the Rambam Medical Center for evaluation of dysphagia. Forty years before she underwent an appendectomy and 17 years before a cholecystectomy. Fourteen years ago she suffered an acute myocardial infarction and since then had stable angina pectoris. Her dysphagia began 16 years ago. During this period she lost 20 kg. In the 2 years before evaluation, she suffered two episodes ofpneumonia. On admission, she was cachectic and weighed 38 kg. On upper gastrointestinal endoscopy, a large curved, esophagus was found, and some difficulty in penetrating through the esophago-gastric junction was felt. A barium meal demonstrated a wide and tortuous esophagus with beaking of its distal end (Fig. 1). A manometric study to confirm the diagnosis of achalasia failed repeatedly, as the Dent catheter coiled inside the esophagus and did not penetrate into the stomach. The Dent catheter that we use has a lumen ending distally to the sleeve. We took advantage of that feature for insertion of a guidewire. A wire from the Rigiflex achalasia dilator set (Microvasive, Billerica, Mass.) was introduced into the stomach through the biopsy channel of an Olympus XQ20 gastroscope. The endoscope was removed and the Dent catheter was pushed on the guidewire into the stomach, through the hole located distally to the sleeve (Fig. 2). Reinsertion of the endoscope confirmed proper position of the catheter inside the stomach. The endoscope and the guidewire were removed, and a manometric recording showed gastric respiratory waves on the sleeve channel. Thereafter, a withdrawal of the sleeve to the LES location was performed. The manometric recording showed 30 mm
Figure 1. Barium meal that demonstrates the patient's huge, tortuous esophagus with beaking of its distal end.
Hg of resting LES pressure with less than 10% relaxation of the LES during wet swallows (normal >80%). The mean contraction amplitude of the simultaneous esophageal body contractions during those wet swallows was 15 mm Hg (normal >50 mm Hg).
DISCUSSION Received December 18,1991. For revision January 27,1992. Accepted April 13, 1992. From the Department of Gastroenterology, Rambam Medical Center, Haifa, Israel and Technion-Israel Institute of Technology, Faculty of Medicine, Haifa, Israel. Reprint requests: Nahum Freidin, MD, Department of Gastroenterology, Rambam Medical Center, Haifa 31096, Israel. VOLUME 38, NO.6, 1992
The diagnosis of achalasia is based on lack of relaxation of the LES. To demonstrate this abnormality, the LES recording site of the manometric tube, the sleeve, should first be placed inside the LES. This is accomplished by pushing the tube into the stomach and then pulling it back aborally stepwisely.2 An in699
The commercial Dent sleeve catheter (ESM 3 DSArndorfer) has no lumen ending distally to the sleeve. Our tube was specially designed for investigational needs to record pressure distally to the LES inside the stomach4 or to insufflate a balloon with air inside the fundus. 5 We utilized this lumen to pass a guidewire and to push the manometric tube on it into the stomach. However, the same guidewire technique can be employed by using the central lumen of any non-sleeve catheter. This central lumen was originally designed for pH probe insertion and gastric aspiration. We recommend the described guidewire endoscopic technique only when routine and fluoroscopic guided attempts fail in passing the manometric tube into the stomach. Figure 2. The Dent sleeve catheter with the guidewire. The wire is passed through the side hole located distally to the sleeve, along the entire length of the corresponding lumen and out the proximal end. In the upper left corner a magnification of the distal tip of the catheter is demonstrated.
crease in the pressure on the sleeve channel from the baseline gastric pressure indicates the LES location. 2 To test relaxation of the LES, 5 ml of water are swallowed repeatedly. Normally, a sharp drop of the pressure to the baseline gastric pressure is achieved (complete or 100% relaxation). Lack or less than 60% relaxation is very suggestive of the diagnosis of achalasia. However, in achalasia the demonstration of this abnormality may be unattainable. The esophagus may be wide, tortuous, and its distal end spastic. The manometric tube may coil inside the wide esophagus and not penetrate into the stomach. Even fluoroscopy may not help.
A tracheo-esophageal puncture technique for voice restoration after laryngectomy Tam Le, MD John S. Wilson, MD Multiple methods to restore voice after totallaryngectomy have been reported since Billroth performed the first laryngectomy in 1-873. 1• 2 Voice restoration may occur with diversion of exhaled pulmonary air through planned or spontaneous fistulas into the esophagus or hypopharynx.
Received January 22, 1992. For revision March 2, 1992. Accepted May 21, 1992. From the Department of Surgery, University of South Alabama Medical Center, Mobile, Alabama. Reprint requests: Tam Le, MD, Kaiser Permanente, 411 N. Lakeview Avenue, Anaheim, California 92807.
700
ADDENDUM Since the submission of the manuscript, we used the same technique successfully in two other patients with achalasia.
REFERENCES 1. Cohen S, Lipshutz W. Lower esophageal sphincter dysfunction in achalasia. Gastroenterology 1971;61:814-20. 2. Dodds WG. Esophageal manometry. In proceedings of methodology of gastrointestinal motility measurements. International Symposium on gastrointestinal motility-Oxford. London: Mediscript, 1988:11-2. 3. Clouse RE. Motor disorders. In: Sleisenger MH, ed. Gastrointestinal disease. 4th ed. Philadelphia: WB Saunders, 1989:571. 4. Freidin N, Mittal RK, McCallum RW. Does body posture affect the incidence and mechanisms of gastroesophageal reflux. Gut 1991;32:133-6. 5. Freidin N, Mittal RK, Sluss J, McCallum RW. Characteristics of spontaneous and gastric distention evoked, transient LES relaxations (TLESR's) in man [Abstract). Gastroenterology 1988;95:865.
In 19.79, Singer and Blom1 proposed a simplified method for voice restoration using an endoscopic procedure and midline tracheo-esophageal puncture with subsequent insertion of a valved voice prosthesis. The intravenous catheter and the silk suture that are used in this technique do not facilitate dilation and passage of the tracheo-esophageal catheter. Subsequent to development of the percutaneous endoscopic gastrostomy (PEG) technique, several different procedure kits have been provided for PEG. 3- 6 We found that using these kits or central venous split sheath introducer kits significantly adds ease, safety, and efficiency of the tracheo-esophageal puncture procedure. From July 1987 to June 1989 we performed tracheo-esophageal punctures in four patients using a rigid esophagoscope and PEG kits or split sheath introducer kits. All four patients had the procedure done as outpatients and had no complication in followGASTROINTESTINAL ENDOSCOPY
