up time was 34 months for successful bougienage, with a median of 22 months. A review of the literature in the treatment of achalasia will reveal comparable follow-up pe- riods. Of note, more recent studies have indicated high success rates (95 to 97.8%) using pneumatic balloon dilation. 2 ,3 Admittedly, such outcomes are compelling. However, based on previous literature, it is unlikely that all those performing pneumatic dilation will have such dramatic results, and significant complications will persist, as was the case in these studies. In addition, recent concerns have been raised over the perforation rate with the more commonly used polyethylene balloon dilators. 4 Therefore, an initial trial of 60 F bougienage at the time of completed diagnostic evalu- ation seems reasonable, since pneumatic dilation is fre- quently scheduled and performed later as a separate proce- dure. We, too, have concluded that further evaluation of this approach is warranted, but believe that with routine dili- gence, the "risks" of large diameter bougienage in achalasia are far outweighed by the well-recognized risks of pneumatic dilation or surgery. Brittain McJunkin, MD Charleston Area Medical Center and West Virginia University Health Sciences Center (Charleston Division) Charleston, West Virginia REFERENCES 1. Ref 1 above. 2. Barkin JW, Guelrud M, Reiner DK, Goldberg RI, Philips RS. Forceful balloon dilation: an outpatient procedure for achalasia. Gastrointest Endosc 1990;36:123-6. 3. Tandon RK, Arora A, Mehta S. Pneumatic dilation is a satis- factory first line treatment for achalasia. Ind J Gastroenterol 1991;10:4-6. 4. Fried RL, Rosenberg S, Goyal R. Perforation rate in achalasia with polyethylene balloon dilators [Letter). Gastrointest En- dose 1991;37:405. A method to overcome dilator placement failure in achalasia patients with markedly dilated esophagus To the Editor: As the initial treatment of achalasia, we prefer forceful pneumatic dilation unless absolute contraindications are present. We do not accept a markedly dilated (sigmoid- shaped) esophagus as an absolute contraindication for dila- tion therapy. A polyethylene balloon is passed over an endoscopically placed floppy-tipped guidewire in each case and dilation is performed under fluoroscopic control. Since 1989 we have treated 26 adult patients without any compli- cations. There were two treatment failures. One patient was unresponsive to three dilation sessions with a 40-mm bal- loon, and he refused surgery. The other patient had a mark- edly dilated esophagus, and we were unable to pass the dilator through the lower esophageal sphincter (LES), and he was referred for myotomy. Recently, we encountered three patients with a sigmoid-shaped esophagus, and in all of these cases we were again unable to pass the balloon through the LES. To overcome this problem we passed an VOLUME 37, NO. 6, 1991 esophageal balloon (20-mm wide, 80-mm long) over the guidewire that had been inserted, and then introduced the endoscope beside it simultaneously. Under endoscopic vision and external torque movements, we placed the esophageal balloon through the LES and inflated the balloon to its full size. The balloon was kept inflated for 1 min and then deflated. Then both the balloon and endoscope were with- drawn. We did not use polyethylene balloon dilators in such cases under simultaneous endoscopic vision because of the following reasons. First, our policy is to dilate patients under fluoroscopic control in the radiology department, as we do not measure the inflated balloon pressure, but inflate the balloon until the waist at the LES disappears. 1 Second, the larger size of the deflated polyethylene balloon interferes with the endoscopic view. In one case immediately after this session, and in the other two cases on the following day, we successfully managed to dilate the patients with standard balloons without experiencing any difficulty in passing through the LES. Although difficulty or failure in balloon placement is not reported in most of the dilation treatment series,2.3 we had this problem in four patients, and using the method men- tioned above, we successfully dilated three patients. We would like to share our experience with other gastroenter- ologists who may encounter the same difficulty in their patients. A. Remzi Dalay, MD Sedat Boyacioglu, MD K. Bahri MD Fatih Hilmioglu, MD M. Emin Caner, MD Burhan $ahin, MD YOksek Thtisas Hospital Ankara, Turkey REFERENCES 1. Barkin JS, Guelrud M, Reiner DK, Goldberg RI, Phillips RS. Forceful balloon dilation: an outpatient procedure for achalasia. Gastrointest Endosc 1990;36:123-6. 2. Robertson CS, Fellows IW, Mayberry JF, Atkinson M. Choice of therapy for achalasia in relation to age. Digestion 1988;40:244-50. 3. McJunkin B, McMillan WO Jr, Duncan HE, Harman KM, White JJ, McJunkin JE. Assessment of dilation methods in achalasia: large diameter mercury bougienage followed by pneu- matic dilation as needed. Gastrointest Endosc 1991;37:18-21. Conservative management of hemorrhoids To the Editor: A modification in the treatment of symptomatic hemor- rhoids was reported by Ponsky et al. l This is an interesting technique utilizing endoscopic injection sclerotherapy with hypertonic saline. The authors, however, fail to mention that the majority of patients with symptomatic hemorrhoids will improve with conservative management alone (high fiber diet, bulk supplements, sitz baths, increasing fluid intake, topical agents).2 The endoscopic photographs depict injection of grade 1 hemorrhoids. This patient should be offered a trial of con- 653