Esophageal Rupture Associated with the Use of the Combitube[trade mark sign]

To the Editor: We read with interest the first publication on iatrogenic esophageal perforation during Combitube[trade mark sign] use by Klein et al. [1]. However, the evidence is not convincing that the Combitube[trade mark sign] (Kendall-Sheridan, Argyle, NY) per se caused the rupture. Before the diagnosis of esophageal trauma, not only was a Combitube[trade mark sign] inserted, but also a suctioning catheter, a laryngeal mask airway, a laryngoscope, and a regular endotracheal tube. Furthermore, blind Combitube[trade mark sign] insertion proved difficult. The first and second attempts were terminated because resistance was met 10-12 cm from the teeth, whereas the rupture site was located at a distance of 25 cm. Furthermore, we do not believe that increased esophageal pressure caused the perforation because pressure equilibration was provided via the second Combitube[trade mark sign] lumen. Nevertheless, we strongly argue against the elective use of a Combitube[trade mark sign] in patients with esophageal pathologies (hiatal hernia). In 258 surgical patients 4-6 feet tall, we found that a small adult Combitube[trade mark sign] (37F) works adequately. We believe that esophageal trauma is a rare complication during Combitube[trade mark sign] use and that such incidences may further be reduced by using the small adult Combitube[trade mark sign], when appropriate, and by insertion under direct vision and adequate depth of anesthesia. Peter Krafft, MD Departments of Anesthesiology and Intensive Care Medicine; University of Vienna; A-1090 Vienna, Austria Ajsa Nikolic Michael Frass, MD Department of Internal Medicine I; University of Vienna; A-1090 Vienna, Austria