In Response

Abstract

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 [email protected] Shreyasi Ray, MD Department of Anesthesiology Medical College Hospital Kolkata Kolkata, India