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Product Review: Cook Medical- Hercules 100 Transnasal Esophageal Balloon

Healthcare | May, 2021

The use of transnasal endoscopy (TNE) is growing at a rapid pace in the field of otolaryngology as an investigative and interventional method for patients presenting complaints with the head and the neck. Realizing the potential for transnasal endoscopy, Cook Medical recently introduced Hercules 100 Transnasal Esophageal Balloon, a first-of-its-kind medical device designed specifically for the transnasal oesophageal procedures. With a much shorter balloon size than what is available in the market, Hercules 100 is tailored to the scope that ENT physicians commonly use and the patient anatomy they treat. The new tool allows patients to be treated on the same day they are evaluated rather than waiting for weeks or months to get scheduled for the procedure, saving the overall patient’s and physician’s time, and enhancing the quality of treatment. 

Hercules 100 Transnasal Esophageal Balloon is a modification of Cook Medical’s existing Hercules 3 Stage Balloon, which has been created for gastrointestinal use. Because the Hercules 100 balloon needs to be inserted trans nasally, the Cook engineers created the oesophageal tool 140 cm shorter than its GI counterpart. The transnasal esophagoscopy can be performed without administering general anesthesia as it is a minimally invasive procedure and can be done in an office setting, which leads to shorter recovery time and lower out-of-pocket costs to the patients and the healthcare system. The Hercules 100 balloon comes in different diameters to accommodate varying patient requirements.  

Key Features and Benefits of Hercules 100 Transnasal Esophageal Balloon 

P.E.T. Flex™ technology

The oesophageal balloon is made with proprietary P.E.T. Flex™ technology, a material with good barrier and clarity properties made for optimal combination of high tensile strength, hardness, durability, accuracy, and flexibility. The one-of-its-kind technology generates a greater radial force on the oesophageal stricture at the same or lower pressures when compared with other stageable balloon dilators.  


Express Evacuation Catheter 

When negative pressure is applied to the catheter with an inflation device, the Express Evacuation Catheter deflates the balloon and even if the clinicians initiate the withdrawal process before deflation, Hercules can be still withdrawn into the endoscope. The patient-pending Rapid Deflation Sleeve makes Hercules fast and efficient. 


Kink-resistant Nitinol Catheter

Nitinol catheter supports minimally invasive interventional endoscopic procedures due to its superelasticity (10 times more elasticity than stainless steel) and thermal shape memory. The nitinol catheter can handle serious bending without kinking or permanent deformation and operate smoothly while bending around the tortuous paths. 


Flexible Atraumatic Tip

The flexible atraumatic tip allows smooth accessibility through tight strictures and is configured to guide the elongated shaft through the body lumen without any perforation. 


Through-the-balloon Visualization 

The ultra-thin translucent balloons permit excellent visualization of the stricture during the dilation progress. The distal chip charge-coupled device technology enables rapid visualization of the esophagus in the office setting without risking the morbidity and mortality associated with anesthesia. 


Hercules 100 Transnasal Esophageal Balloon facilitates the conjunction of transnasal endoscopy with balloon dilation, that present physician an opportunity to dilate all areas of the esophagus through the nasal cavity and perform therapeutic procedures like placing gastroenteric feeding tubes, oesophageal botulinum toxin injection, and tracheoesophageal Puncture. The balloon dilators are being utilized for decades in sedated endoscopy but due to its limitation, the new and novel transnasal technique has gained more recognition by offering several advantages. Transnasal balloon dilation can be performed either under local or general anesthesia, at the preference of the patient however the dilation technique is the same regardless of the anesthesia indication. Transnasal endoscopy alleviates 50% of the complications by eliminating the administration of general anesthesia, and thus decreases health risks for patients. Transitioning the approach from transoral to transnasal via Hercules 100, the gag reflex becomes less prominent or even absent in some cases, which enhances the tolerability of the patients for the procedure. 


Another advantage of transnasal balloon endoscopy with Hercules 100 is that patients with anatomic limitations, which prevents treatment using rigid endoscopy under general anesthesia such as severe trismus or limited neck extension due to previous oncologic therapy, among other complications have a viable alternative. Utilizing Hercules 100 under topical anesthesia, the physicians can receive direct feedback from the patient and aid them in reducing post-procedural pain. 


In addition to being an ideal screening tool, Hercules 100 can also be utilized for biopsies of the esophagus, as well as other interventions such as reflux, dysphagia, and difficulty swallowing, arising from different pathologies. The thin, distal-chip, video esophagoscopes have transformed patients' care and allow the clinicians to perform a comprehensive evaluation for proper diagnosis and treatment. 


Hercules 100 transnasal balloon dilators are designed to offer enhanced procedural benefits compared to bougie dilators. While balloon dilators provide controlled radial dilation and can be used with a transnasal endoscope to provide visualization during the procedure, bougies are not compatible with transnasal endoscopes and enable blind passage of dilators for oesophageal perforation.


How is Hercules 100 balloon endoscopy performed?

  • The patient is given topical anesthesia to numb the nostrils and the procedure takes about 15 minutes.
  • From the nostril, an endoscope tube with a tiny light and camera at the end is inserted slowly into your esophagus. The fluoroscopy imaging method is used to create a moving X-ray image of the esophagus on the screen. 
  • Hercules 100 balloon dilator is carefully guided into the scope working channel and positioned in the middle of the stricture. 
  • Incremental dilation is performed through an inflation device to fill the air with a balloon and widen the tight strictures by relaxing the muscle fibers. 
  • The inflated balloon is then pulled against the tip of the endoscope to allow the mucosal lining of the muscle to be visualized. 



Compared to transoral endoscopy, patients are showing high affinity towards the transnasal balloon endoscopy, owing to its advantages such as fewer complications, relatively less costs, etc. Although the duration of TNE can take longer, the total time of transnasal procedure is shorter than transoral procedure when pre-treatment and post-treatment monitoring events are taken into consideration. Transnasal esophagoscopy with Hercules 100 is safer and viable alternative to both unsedated and sedated conventional transoral endoscopy. 

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