A concern with use of the “push technique” in patients with multiple esophageal rings

Abstract

Two articles in the February 2001 edition of Gastrointestinal Endoscopy recommended the “push technique” as a safe and effective method of relieving esophageal food impaction. Vicari et al.1Vicari JJ Johanson JF Frakes JT. Outcomes of acute esophageal food impaction: success of the push technique.Gastrointest Endosc. 2001; 53: 178-181Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar retrospectively evaluated 189 patients and Longstreth et al.2Longstreth GF Longstreth KJ Yao JF. Esophageal food impaction: epidemiology and therapy. A retrospective, observational study.Gastrointest Endosc. 2001; 53: 193-198Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar retrospectively studied 194 patients. Neither of these groups of investigators encountered a complication, either with disimpaction or subsequent esophageal dilation. There were 4 patients in Longstreth's series who had multiple esophageal webs, a subset of patients with dysphagia who are reported to have a substantially higher rate of bleeding, pain, and perforation with both endoscopy and esophageal dilation.3Argarawal VP Marcel BR. Multiple esophageal rings.Gastrointest Endosc. 1990; 36: 147-149Abstract Full Text PDF PubMed Scopus (10) Google Scholar, 4McKinley MJ Eisner TD Fisher ML Bronzo RL Weissman GS. Multiple rings of the esophagus associated with gastroesophageal reflux.Am J Gastroenterol. 1996; 91: 574-576PubMed Google Scholar, 5Carlisle WR. A case of multiple esophageal webs and rings.Gastrointest Endosc. 1984; 30: 1984-1985Google Scholar, 6Shafi MA Eisen GE Al-Kawas FH Benjamin SB. Increased risk of esophageal perforation with dilation in patients with multiple esophageal webs (feline esophagus): a case control study.Gastrointest Endosc. 1997; 45 ([abstract]): AB56Abstract Full Text PDF Scopus (5) Google Scholar The experience at our tertiary referral center corresponds to that of Vicari et al. and Longstreth et al. with respect to the safety of the “push technique.”7Kozarek RA Ball TJ Belic L Brandabur JJ Bredfeldt JE. Food impaction at a regional referral center. Should we push? Pull? Or poke?.Gastrointest Endosc. 1999; 49 ([abstract]): AB113Google Scholar However, in our group of patients with multiple esophageal rings (a.k.a. multiple esophageal webs), now totaling 14, 2 had significant pain after use of the push technique for relief of acute esophageal food impaction at community hospitals before referral for dilation at our institution. One had crepitus without free perforation and remained in hospital for 2 days during which time the patient was treated with antibiotics. Another, who had marked pain after dislodgment, was observed in the hospital overnight. Our earlier experience with 8 patients with multiple esophageal rings was reported in abstract form.8Gluck M Raltz S Jiranek G Gelfand M Brandabur J Patterson D et al.Multiple esophageal rings: patient characteristics and therapeutic suggestions.Am J Gastroenterol. 1998; 93 ([abstract]): 1616Google Scholar Since then, 6 new patients have been identified, one of whom had significant pain after dilation. He was subsequently discharged a few hours after the procedure without evidence of either bleeding or perforation. Patients with multiple esophageal rings appear to be at higher risk for complications from both endoscopy and esophageal dilation. Many of the patients with this finding seen at our institution have impressive proximal esophageal lacerations simply with the passage of the endoscope. Most of the patients with multiple esophageal rings are men (80%), are younger than those reported in the studies of Vicari et al. and Longstreth et al. (mean age 36 versus 60 years), lean (body mass index <26 kg/m2), and present with proximal esophageal food impaction. In patients suspected of having multiple esophageal rings, use of smaller-diameter endoscopes, adequate luminal visualization, and avoidance of dilation in excess of 39F (13 mm) at the initial procedure, may preclude procedure-related pain and complications.