Poonputt Chotiprasidhi

Effectiveness of single dilation with Maloney dilator versus endoscopic rupture of Schatzki's ring using biopsy forceps.

Current recommendations for treatment of patients with symptomatic Schatzkis ring are based on anecdotal experience or uncontrolled studies. Maloney dilation is the gold standard. We performed a randomized controlled trial to compare the use of a single 52-Fr Maloney dilation versus four quadrant biopsy of Schatzkis ring for relief of dysphagia. The subjects answered standardized dysphagia-related questions on a scale of 0–5 (0 = no dysphagia; 5 = cannot handle secretions). To account for modifications in diet and eating habits, subjects answered 11 question to arrive at a eating/diet score. Patients with Schatzkis ring were randomized into one of the two protocols. Group 1 underwent endoscopic biopsies of the ring, one biopsy in each quadrant. In group 2, the endoscope was taken out, and a single 52-Fr Maloney dilation was performed. Twenty-six patients participated in the study and were followed for up to 15 months. There was no significant difference in age, sex, race, smoking, alcohol abuse, or medication intake between the two groups. Dysphagia score improved by 91% in both groups at three months and 84% and 85% at 12 months in groups 1 and 2, respectively. The eating/diet habit score improved by 78% in both groups. There was one failure in each group, and one recurrence at six months in the dilation group. Fifty-five percent of dilation group and 100% of biopsy group described the procedure as easy. There was no difference in the amount of sedatives used during the procedure or the acid blockers after the procedure. In patients undergoing endoscopy, the superior cost/safety profile of endoscopic biopsy makes it a preferred choice for treatment of Schatzkis ring over bougienage.

PEG using a preexisting abdominal surgical incision in an obese patient with situs inversus

Since its introduction by Gauderer et al.,1 PEG has become a popular method for providing enteral nutrition in patients who are unable to eat but have a functioning GI tract. However, the procedure is usually aborted in the absence of adequate transillumination of the anterior abdominal wall. This may occur in patients with morbid obesity or secondary to altered anatomy because of prior abdominal surgery or congenital anomalies. In such cases, surgical gastrostomy with its associated morbidity and mortality is usually recommended.2 We report a case of PEG tube placement in a morbidly obese patient with situs inversus. The procedure was facilitated by opening the subcutaneous layer of a recent surgical incision.