Oesophageal perforation remains a devastating event that is difficult to diagnose
and manage, especially in the presence of malignancy. In 59 % to 81 % of all cases
the injury is iatrogenic, and the increasing use of endoscopic procedures can be expected
to lead to an even higher incidence of perforation in coming years [1]
[2]. Over the past 30 years, the actual risk of perforation during diagnostic flexible
oesophagoscopy has remained low, and is estimated to occur at a frequency of 0.03
% compared with 0.11 % during rigid endoscopy [3]. However, during instrumental procedures with obstructing oesophageal tumours, such
as dilation and stenting, perforation rates of 1 % - 10 % have been reported with
mortality rates of up to 60 % despite treatment [4]
[5].
The conventional approach employs a stiff endoscopic guide wire with a flexible tip
screened under video fluoroscopy, which is passed across the lesion into the stomach,
and over which the stent is deployed. However, it has been our experience that with
very friable tumours that completely occlude the lumen, a stiff guide wire can perforate
or dissect the oesophageal wall. We therefore now use an endoscopically placed 0.035-inch
polytetrafluoroethylene (PTFE)-coated J-tip coronary angiography wire (Figure [1]), which is floppy enough to avoid perforation but stiff enough to cross tightly
obstructing tumours and allow subsequent passage of instruments. Following the British
Society of Gastroenterology guidelines, published in October 2003, which state that
guide wires should be single-use to minimize any possible risk of transmitting prion
disease, this also represents a cost-effective alternative with the angiography wire
being approximately one-fifth the cost of a standard endoscopic guide wire (£ 7 vs.
£ 35, € 10 vs. € 51 or $ 12 vs. $ 60).
Figure 1 A 0.035-inch polytetrafluoroethylene (PTFE)-coated standard exchange J-tip Emerald
guide wire (Cordis Corporation, Miami, USA).
We have used this technique in 70 procedures over a 22-month period, with no complications.
It is a useful technique to have in the armamentarium of all endoscopists treating
oesophageal cancer.
Competing interests: None
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