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In the 80's I served as a gastroenterologist in Another City for two years. The high point of my week was Thursday morning, when I would travel a few miles to St. Elsewhere to attend GI Grand Rounds.

Grand rounds were hosted by the GI Department of the Major University. During the rounds various topics of GI interest were presented, usually by physicians in training under the very watchful eyes of the professors. The presentations were always state-of-the-art, and were very informative. Plus, just outside the lecture hall you could purchase a cup of cappuccino and a cinnamon roll the size of a manhole lid for only $2.00. If I wasn't excited about the topic I could count on a massive caffeine/sugar rush.

When patients can't swallow it is often due to an esophageal stricture. We then stretch or expand the passage way by means of a dilator. The initial dilators were long candlesticks that were shoved down a patient's gullet.

Instead of candlesticks we now use Maloney dilators, which are soft rubber tubes filled with tungsten. These are much safer and work quite nicely, unless the stricture is tight or very rigid. Then we need to use a dilator that is stiffer and has more leverage.

In my earliest years we used Eder-Puestow dilators, demonic devices in which metal olives were mounted on steel rods. In order to keep the dilator from being ramrodded into the tissues, they were always passed over a guidewire. As long as the guidewire was in place, you could push as hard as you needed to and the dilator itself would stay on the straight and narrow.

During that time, Savary dilators hit the market. These nifty instruments were made of stiff-yet-flexible plastic. They were a big improvement over the older dilators but you had to be careful with them. They could easily penetrate tissues, so you still had to pass them over a guidewire. I purchased a set and liked them so much I pitched the Eder-Puestow dilators.

One day at Grand Rounds the professors at the Major University held a symposium on the new Savary dilators. Since they purchased them, they had had several perforations, occurrences where the dilator drilled through the wall of the esophagus and into the chest.

As I cringed in my seat, they presented a careful review of the world's medical literature and reached the startling conclusion that these dilators should probably be passed over a guidewire instead of just being shoved down the gullet. I have no idea if they contacted the injured parties and shared this research with them.

I thought they could have saved a lot of time and research if they had just read the instruction flier that came with the instruments.