Oesophageal dilation
Yesterday was my last day with the gastros at Freo. A bit of a sad occasion, but it was time to move on. I had a great time, the people there were a really nice bunch and they taught me a lot without knowing it. Gastro seems to me to be a really good specialty to consider in future, as long as I can get over having to stick the finger up people's bums. >:O
There were again two interesting cases yesterday. Both were of guys with oesophageal strictures. The first guy had a narrowing that had been dilated before, so we did the same thing again. It's called a CRE dilator (controlled radial expansion) and it's pretty much just a balloon. The baloon is attached to a length of guidewire which is threaded down the oesophagus (you observe with the endoscope). And then once it's in the correct place you can inflate the ballon with a fixed amount of water. It was kind of cool, and the trauma to the oesophagus isn't that huge, although there were a few bleeding spots when we looked again. So pretty much you just blow it up bigger and bigger each time until you get to the size you want to get to. In this guy's case it was 15mm.
The second case was another guy with a similar problem, except that it was much more severe. This guy couldn't even talk. He had a trachesotomy tube and had been quite sick in the past. The oesophageal narrowing was so marked that we actually planned to use a paediatric scope. We ended up using the XP one, ie 'extra-paediatric', meaning really really small. John managed to just get into the stomach using the scope. With this guy, we planned to use the push dilating method, in which you just push a dilating probe down the oesophagus to open it up. There's lots of risks involved with these procedures, and this guy was in a lot of pain. It was my job to hold him down, and even with the heavy sedation we gave him (as usual fentanyl and midzolam) we struggled with a great deal of vigour.
The problem in this case was the fact that the stenosis was very high up. This meant that pushing the dilator down didn't work as the angle was wrong. We couldn't get the dilator in enough before we hit the stricture, so the force just created trauma instead of pushing down the lumen (hole) of the oesophagus. It was a failure, but it was a good learning experience for both me and John.
After that, there was the gastro grand round, where I got a free lunch. And that was it for the term!
On to paediatrics.
There were again two interesting cases yesterday. Both were of guys with oesophageal strictures. The first guy had a narrowing that had been dilated before, so we did the same thing again. It's called a CRE dilator (controlled radial expansion) and it's pretty much just a balloon. The baloon is attached to a length of guidewire which is threaded down the oesophagus (you observe with the endoscope). And then once it's in the correct place you can inflate the ballon with a fixed amount of water. It was kind of cool, and the trauma to the oesophagus isn't that huge, although there were a few bleeding spots when we looked again. So pretty much you just blow it up bigger and bigger each time until you get to the size you want to get to. In this guy's case it was 15mm.
The second case was another guy with a similar problem, except that it was much more severe. This guy couldn't even talk. He had a trachesotomy tube and had been quite sick in the past. The oesophageal narrowing was so marked that we actually planned to use a paediatric scope. We ended up using the XP one, ie 'extra-paediatric', meaning really really small. John managed to just get into the stomach using the scope. With this guy, we planned to use the push dilating method, in which you just push a dilating probe down the oesophagus to open it up. There's lots of risks involved with these procedures, and this guy was in a lot of pain. It was my job to hold him down, and even with the heavy sedation we gave him (as usual fentanyl and midzolam) we struggled with a great deal of vigour.
The problem in this case was the fact that the stenosis was very high up. This meant that pushing the dilator down didn't work as the angle was wrong. We couldn't get the dilator in enough before we hit the stricture, so the force just created trauma instead of pushing down the lumen (hole) of the oesophagus. It was a failure, but it was a good learning experience for both me and John.
After that, there was the gastro grand round, where I got a free lunch. And that was it for the term!
On to paediatrics.
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