Letters to the Editor: Letters & Announcements
Insertion of the endoscopic guidewire-assisted esophageal dilators, with or without fluoroscopic guidance, is as commented on by Chon et al., occasionally associated with severe complications (0.1% to 0.22%) including esophageal perforation and pneumomediastinum.1–4 Causes of severe complications include patient factors such as tight esophageal strictures and malignant esophageal diseases, operator inexperience, or might be related to the Savary-Gilliard wire guide, the endoscope, and the Savary-Gilliard esophageal dilators.2
Our study excluded patients with esophageal strictures as screened by clinical history and surgical workup.5 Also, our study was related to the procedure of nasogastric tube (NGT) insertion in patients with an anatomically normal esophagus.5 Manual forward displacement of the larynx probably safeguards against laryngeal entry of the wire guide–NGT assembly, while it passes from the hypopharynx into the cervical esophagus. The Savary-Gilliard wire guide also has a progressively flexible tip, which is again sheathed inside an NGT and follows the path of least resistance in the hypopharynx to the esophagus, since the laryngeal inlet is already blocked by the cuffed tracheal tube and displaced anteriorly by gentle manual traction.5
For any blindly performed wire guide–assisted clinical procedure, the most important principle is to “stop and retreat whenever any undue resistance is encountered.” Live fluoroscopy is perhaps the “gold standard” to guide the safe placement of any esophageal device. However, it is cumbersome, costly, and involves exposing the patient and the operator to ionizing radiation.
Transcutaneous cervical esophageal ultrasound is a standard technique used by radiologists and gastroenterologists to measure esophageal wall thickness and luminal diameter as an adjunct to diagnosis of gastroesophageal reflux disorders.6 This might be helpful in guiding NGT placements in patients who are not tracheally intubated.7
We performed in-plane approach high-resolution B-mode ultrasound (using a high-frequency linear probe of the LOGIQ e USG console, GE Healthcare, Wauwatosa, WI) to visualize the passage of the NGT with and without laryngeal traction in 3 anesthetized and tracheally intubated patients. Although the trachea with the tracheal tube was clearly visible entirely along the long axis, the esophagus with the NGT was barely visible and that too from the right side only. With manual laryngeal displacement, visualization was even more difficult due to artefact from the operator’s fingers in the laryngoesophageal groove. Of course, an ill-defined motion artefact induced by the NGT movement was visualized.
We suggest that real-time ultrasound imaging of the cervical esophagus in tracheally intubated patients requires refinement and standardization before being useful to the clinician as a tool to monitor the safe passage of the NGT.
Jyotirmay Kirtania, MD
Department of Anesthesiology
Tata Medical Center, Kolkata
Shreyasi Ray, MD
Department of Anesthesiology
Medical College Hospital Kolkata
1. Moon HS, Chon JY, Kang JM. Beware of lung complications when using guidewire-assisted nasogastric tube insertion. Anesth Analg 2013;116:263.
2. Dupin B, Meric B, Dumon JF. Techniques, results and complications of oesophageal dilatation. Baillieres Clin Gastroenterol. 1987;1:809–20
3. Kabbaj N, Salihoun M, Chaoui Z, Acharki M, Amrani N. Safety and outcome using endoscopic dilatation for benign esophageal stricture without fluoroscopy. World J Gastrointest Pharmacol Ther. 2011;2:46–9
4. Pereira-Lima JC, Ramires RP, Zamin I Jr, Cassal AP, Marroni CA, Mattos AA. Endoscopic dilation of benign esophageal strictures: report on 1043 procedures. Am J Gastroenterol. 1999;94:1497–501
5. Kirtania J, Ghose T, Garai D, Ray S. Esophageal guidewire-assisted nasogastric tube insertion in anesthetized and intubated patients: a prospective randomized controlled study. Anesth Analg. 2012;114:343–8
6. Kacar S, Uysal S, Kuran S, Dagli U, Ozin Y, Karabulut E, Sasmaz N. Transcutaneous cervical esophagus ultrasound in adults: relation with ambulatory 24-h pH-monitoring and esophageal manometry. World J Gastroenterol. 2007;13:5245–52
7. Kim HM, So BH, Jeong WJ, Choi SM, Park KN. The effectiveness of ultrasonography in verifying the placement of a nasogastric tube in patients with low consciousness at an emergency center. Scand J Trauma Resusc Emerg Med. 2012;20:38