Application of a diathermic dilator for negotiating near-total antropyloric strictures.

Three patients with caustic substanceinduced near-total antropyloric obstruction with recurrent vomiting were found to have a totally blocked antropyloric region with no flow of contrast distally (●" Fig.1). Patient characteristics, the treatment provided, and the outcome are summarized in●" Table1. After the patient had given informed consent, esophagogastroscopy was carried outwith the patient under conscious sedation. The site of narrowing was identified as a dimple or depression. Attempts were made to pass a 6–8-mm wire-guided, through-the-scope balloon dilator (CRE; Boston Scientific Corp., Natick, Massachusetts, USA) into the duodenum. When this failed, it was followed by passing a hydrophilic 0.025-inch guidewire (Visiglide; Terumo Corp., Shibuya-ku, Tokyo, Japan) under fluoroscopy. A 6-Fr wire-guided coaxial diathermic dilator (Cysto-GastroSet; Endo-Flex GmbH, Voerde, Germany) was threaded over the guidewire under fluoroscopic guidance to the level of the stricture. It was used to traverse the cicatrized segment step by step by applying an intermittent diathermy current (cut mode, 40W, ERBE electrosurgical unit (ERBE USA Inc., Marietta, Georgia, USA) until the dilator passed through the entire length of the stricture (●" Video 1). Subsequent dilations were carried out in an incremental manner, ranging from 6mm to 15mm, with wire-guided through-thescope balloon dilators twice weekly as described previously, with a close watch for complications [1]. The patients were followed up periodically for 12 months and then imaging was repeated (●" Fig.1). Ingestion of caustic substances leads to gastric cicatrization and gastric outlet obstruction in 36%–44% of patients [2–4]. All three patients in this report had neartotal antropyloric obstruction that was negotiated using a coaxial diathermy dilator followed by balloon dilation. To the best of our knowledge, this is the first report to describe the use of this technique in patients with caustic-induced gastric outlet obstruction. A review of the literature found that a similar diathermy catheter has been used to dilate tight bile duct and pancreatic duct strictures [5]. In conclusion, our case series describes for the first time the application of a coaxial diathermy dilator for the management of near-total gastric outlet obstruction.