Esophagoscopy

Esophagoscopy makes it possible to directly examine the internal surface of the esophagus with the help of a rigid esophagoscope or a flexible fibroscope. Esophagoscopy can determine the presence of foreign bodies and conduct their removal, diagnose tumors, diverticula, scar and functional stenoses, carry out a series of diagnostic (biopsy) and medical procedures (opening an abscess with pereezophagitis, administering a radioactive capsule for esophageal cancer, bougie scarring strictures, ).

The beginning of the creation of modern esophagoscopic drugs was laid in 1807 by the Italian physician Philip Bozzini (Filip Vozzini), who designed a device that carried sunlight into the pharynx and its lower parts. In 1860 the Italian doctor Voltolini adapted the Garcia mirror to examine the larynx to a special tube, which he injected into the esophagus for examination. In 1865, to study the various cavities of the human body, the French doctor Desormaux constructed a special tube equipped with a kerosene lamp. He first called this instrument an "endoscope". Outstanding German therapist A. Kussmaul (1822-1902) actively supported and popularized the developing method of esophagoscopy. However, the entire development of endoscopy, and in particular of esophagoscopy, rested on the lack of sufficiently effective illumination, in which a ray of light could penetrate into the deep sections of the endoscope. The creation of such a source of light was carried out in 1887 by a major German surgeon I. Mikulich, who rightfully is considered the founder of modern esophagoscopy, who designed the first esophagoscope with internal illumination. Since 1900, esophagoscopy has been introduced into practice everywhere. Paying tribute to the history of esophagoscopy, mention should be made of the esophagoscopes of the French authors Moure and Guisez. Their technique consisted in the introduction of an esophagoscope blindly, for which the frontal reflector was used as a means of illumination, and at the ends of the tube there was a metallic or rubber mandrane. It should also be mentioned the significant improvement of the esophagoscope by FSBokshtein, which allowed to rotate the tube in the handle of the esophagoscope and thereby produce, without special difficulties, a circular examination of all the walls of the esophagus. The original model of a broncho-esophagoscope with a proximal illuminator was created by MP Mezrin (1954). In the XX century. In the arsenal of endoscopists and ENT doctors there were models of broncho- esophagogoscopes of authors such as Brunings, C.Jackson, Kahler, Haslinger, and others. Some esophagoscopes are equipped with insertion tubes for bronchoscopy, for example bronchosophagogoscopes Brunings, Haslinger, Mezrin. Bronchoesophagoscopes are equipped with a number of manipulation tools inserted into the tube, for biopsy, removal of foreign bodies of various shapes, rubbing the walls of the esophagus, sucking off mucus, etc.

Esophagoscopy refers to a very important operation and requires the doctor good practical skills, knowledge of anatomy and topography of the esophagus. This responsibility is many times higher in certain pathological conditions of the esophageal wall (burn, tumor, wedged foreign bodies, varicose veins, etc.), in which its strength and compliance are violated, which creates the risk of iatrogenic damage to the esophagus, up to its perforation followed by severe inflammatory and hemorrhagic complications in the mediastinum.

Esophagoscopy is divided into urgent and planned. The first is carried out in the provision of emergency care (foreign bodies, food obstruction) and often without a preliminary detailed clinical examination of the patient. Indications for urgent esophagoscopy are based on anamnesis, patient complaints, some external signs of the pathological condition and data of radiologic examination. Planned esophagoscopy is performed in the absence of emergency indications after a careful special examination of a specific disease and a general clinical examination of the patient with an assessment of the condition of neighboring organs, after an X-ray examination of the organs of the chest, larynx, trachea, spine, aorta, mediastinal lymph nodes.

Esophagoscopy is performed in a specially adapted darkened room with a convenient table, an electric pump and means for introducing flushing fluids into the esophagus. In the endoscopy room there should be a tracheotomy set, appropriate means for infiltration anesthesia and resuscitation. For esophagoscopy, people of different ages need different sizes of intubation tubes. So, for children under 3 years old, use a tube 5-6 mm in diameter, 35 cm in length; for children 4-6 years old, use a tube with a diameter of 7-8 mm and a length of 45 cm (8/45); children after 6 years of age and adults with short necks and standing teeth (prognathia) - 10/45, with the intercalary tube extending the esophagoscope to 50 cm. Adults often use tubes with a larger diameter (12-14 mm) and a length of 53 cm.

Indications for esophagoscopy: esophagoscopy (fibroesophagoscopy) is carried out in all cases when there are signs of esophageal disease and it is necessary either to establish their character or to conduct appropriate medical manipulation, for example, extraction of foreign bodies, evacuation of the diverticulum filled with food masses, removal of food blockage, etc. To esophagoscopy is the need for a biopsy.

Contraindications to esophagoscopy in urgent situations practically does not exist, except for cases when this procedure itself can be dangerous for its serious complications, for example, if a foreign body is infiltrated, mediastinitis, myocardial infarction, cerebral stroke. If it is necessary to carry out esophagoscopy and the presence of relative contraindications, appropriate preoperative preparation is carried out, or, in agreement with an anesthesiologist-resuscitator, this procedure is performed under general anesthesia. Contraindications to esophagoscopy revealed during a planned examination of a patient are divided into general, regional and local.

General contraindications are most often due to the presence of decompensation of the functions of the cardiovascular system, asthmatic state, hypertensive crisis, severe general and cerebral atherosclerosis, acute impairment of cerebral circulation. Esophagoscopy is absolutely contraindicated when belching with scarlet or dark-brown blood. The source of scarlet blood is, as a rule, varicose-dilated and usurized veins of the esophagus mucous membrane, dark-brown blood - the same veins when blood enters the stomach with the formation of hydrochloric acid hematin having a dark brown color, or blood vessels of the stomach. However, with the use of fibro-esophagoscopy, the procedure is permissible for stopping esophageal bleeding.

Regional contraindications are caused by diseases of the organs adjacent to the esophagus (aneurysm of the aorta, compression and deformation of the trachea, inflammatory banal and specific diseases of the pharynx and trachea, bilateral stenosing paralysis of the larynx, mediastinitis, massive pereezophageal adenopathy, etc.). In some cases, esophagoscopy is difficult with little mobility or deformity of the spine in the cervical or thoracic region, with a short neck, ankylosis or contracture of one or both temporomandibular joints, trimese, etc.

Local contraindications are caused by acute banal or specific esophagitis. With chemical burns of the esophagus, esophagoscopy is permissible only on the 8th-12th day, depending on the depth of the esophagus wall and the general intoxication syndrome.

Technique of esophagoscopy. Preparation of the patient for esophagoscopy begins the day before: prescribe sedatives, sometimes tranquilizers, at night - sleeping pills. Limit drinking, exclude dinner. Planned esophagoscopy is expedient to spend in first half of day. On the day of the procedure, food and liquid intake is excluded. 30 minutes prior to the procedure, morphine is administered subcutaneously at a dose corresponding to the patient's age (children under 3 years are not prescribed, 3-7 years - a dose of 0.001-0.002 g, 7-15 years is 0.004-0.006 g, adults - 0.01 g ). At the same time, a solution of atropine hydrochloride is injected subcutaneously: children from 6 weeks are prescribed a dose of 0.05-015 mg, adults - 2 mg.

Anesthesia. For the esophagoscopy and the more fibro-esophagoscopy in the vast majority of cases, local anesthesia is used, and it is sufficient to pulverize or lubricate the mucous membrane of the pharynx, the laryngopharynx and enter the esophagus with 5-10% cocaine hydrochloride solution up to 3-5 times with breaks of 3-5 minutes. To reduce the absorption of cocaine and potentize its anesthetic effect, an adrenaline solution is usually added to its solutions (5% of the cocaine solution with 3-5 drops of 0.1% solution of adrenaline hydrochloride). When using cocaine, one should keep in mind its high toxicity, which can manifest itself in vasospastic crises, up to anaphylaxis. It can be replaced with modern local anesthetics, such as anilocaine, benzocaine, bumecaine, lidocaine, etc. In the middle of the 20th century, some authors recommended the use of so-called subnarcose esophagoscopy with the use of relaxants, other authors expressed the opinion that this procedure is preferably carried out without local anesthesia, since the resulting pharyngeal (emetic) reflex makes it easier to carry the instrument into the esophagus. However, this opinion has not found practical application.

The position of the patient. For the introduction of the esophagoscopic tube into the esophagus it is necessary that the anatomical curves of the spine and the cervico-facial angle be straightened. For this there are several positions of the patient. VIVoyachek (1962) writes that esophagoscopy is performed in the sitting, lying or knee-elbow position, while he preferred the method of lying on his stomach with a slightly raised leg of the operating table. At this position, it is easier to eliminate the saliva flowing into the respiratory tract and accumulation of gastric juice in the esophagoscope tube. In addition, the orientation is easier when the tube is inserted into the esophagus.

Gh.Popovici (1964) describes the method of esophagoscopy in the supine position, at which the humeral girdle somewhat protrudes beyond the edge of the table (to the level of the scapula), with the occipital region of the skull above the table surface - for adults 15 cm, for children and teenagers by 8 cm. This position helps to straighten the spine, and the elimination of the cervico-facial angle is achieved by maximum extension of the head in the cervical spine by rotation back to the atlanto-occipital joint. The head of the patient is held in position by the assistant, who is to the right of the patient sitting on a chair. So that the patient does not eat the esophagoscope tube, a rotor expander is used. Sometimes there is a need for one more assistant holding the shoulders of the patient. The third assistant provides tools, includes suction, etc.

The endoscope is injected under constant vision control. The success of esophagoscopy depends on the ability to find the upper mouth of the esophagus, which is at the level of the posterior wall of the larynx in the form of a closed, hardly discernible gap. To get into it by the end of the instrument, it is necessary to direct it exactly along the middle line of the oral cavity, for this purpose they are guided along the line of the closure of the vocal folds. With a large value of the front incisors or with a short neck, the tube is inserted first from the angle of the mouth, and then it is transferred to the median plane.

After this, the tube is slowly advanced along the root of the tongue and is guided somewhat posteriorly relative to the inter-head space, lifting the larynx lightly, avoiding pressure by the end of the tube on the throat part of the pharynx and keeping the midline of the larynx constantly under visual control. This is achieved by pressure down the handle of the esophagoscope, while trying not to damage the upper incisors. If, during the movement of the tube, its end rests against the formed pleat of the mucous membrane, then it must be "saddled" by the beak and pass, moving further. Advancement of the tube does not cause difficulties before entering the esophagus, at the level of which resistance to its progress arises. This resistance is familiar to all endoscopists, but it may be false if the tube is pressed against the upper incisors. It is during the passage of the upper esophageal pulp that it is necessary that the tube does not come in contact with the teeth. Penetration into the upper aperture of the esophagus is carried out by light effort. Involuntary (reflex) reduction m. Cricopharyngeus can dramatically hamper the passage of the tube into the esophagus, and forced pushing its end through the spasmodic area often leads to severe damage to this area, characterized by a reduced strength of tissues.

It should be borne in mind that the esophagoscopists should keep in mind that keeping the tube in the middle line is not an easy task, since its end slides all the time due to the convexity of the vertebral bodies to which the esophagus is due. Straightening of the tube is carried out, constantly directing it parallel to the axis of the throat and to the cutting of the sternum. The entrance to the esophagus, as already noted above, is determined by its shape, which looks like a horizontal slit. If there are difficulties in determining this gap, the patient is offered to do a swallowing movement, then the entrance to the esophagus is revealed.

After passing the first narrowing of the esophagus, the tube easily slides along it, and it must be ensured that its end does not stick to one direction for too long, pushing out only one of the walls of the esophagus. In this lies the danger of its damage. In the region of the second narrowing, the lumen of the esophagus has the form of pulsating pulp, to which the pulsation of the aorta is transmitted. The end of the tube, passing through this narrowing, is directed to the left towards the upper anterior iliac awn, while the assistant holding the patient's head drops it below the plane of the table on which the patient lies. The nondiaphragmatic part of the esophagus is represented by a multitude of folds of the mucosa located around the central opening, and in the region of the cardia these folds are located around the slit-oval aperture.

The level of the end of the esophagoscopic tube can be determined not only by the visual picture described above, but also by the depth of the tube: in adults, the distance from the upper incisors to the pharyngeal esophagus is 14-15 cm, and to the cardia - from 40 to 45 cm.

The method of esophagoscopy in the sitting position with the help of the Chevalier-Jackson esophagoscope. The doctor in the standing position in front of the sitting patient holds the distal end of the tube I and II with the fingers of the hand, and the proximal end - like a pencil. The assistant stands at the back of the patient and fixes his head in the unbending position, having as a guide II a finger placed on the handle pointing upward. The esophagoscope tube is directed vertically downwards, pressing it to the upper incisors and adhering to the median plane. As soon as the back wall of the pharynx appears in sight, the end of the tube is directed to the right arytenoid cartilage and searches for the right pear-shaped sinus. Entering the sine, the end of the tube is directed to the middle plane, with the doctor orienting it in the direction of cutting the handle of the sternum. After the general direction of the esophagoscope has been fixed, it is advanced along the esophagus according to the procedure described above and with the same precautions. Inspection of the esophagus is performed both with the introduction of the tube and with its extraction; at the latter it is especially good to examine the area of the first narrowing of the esophagus. Often, when the tube is moving in the direction of the cardia, it is not possible to consider what can be seen when it is removed, and this situation applies primarily to small foreign bodies such as fish bones.

Endoscopic aspects of esophagoscopy. A qualified evaluation of the endoscopic picture of the esophagus requires certain experience and manual skills. There are special models on which they are trained in the technique of esophagoscopy and acquire knowledge in the field of diagnosis of various diseases of the esophagus. Below is a brief description of the normal endoscopic picture of the esophagus, which appears to the eye of the examinee as the tube moves toward the cardia.

Normal mucosa of the esophagus has pink coloration, moist, blood vessels do not appear through it. Folding of the mucosa of the esophagus varies depending on the level: at the entrance to the esophagus, as already mentioned above, there are two transverse folds covering the slit-like entrance to the esophagus; as you go down, the number of folds increases; so, in the thoracic part of these folds 4-5, and in the area of the diaphragmatic opening there are already 8-10, with the lumen of the esophagus here closed with diaphragm pulp. In pathological conditions, the color of the mucosa changes: in inflammation, it becomes bright red, with stagnant phenomena in the portal vein system - cyanotic. Erosions and ulceration, edema, fibrinous raids, diverticulums, polyps, disturbances of peristaltic movements, up to their complete break, changes in the lumen of the esophagus, arising either as a result of stenosing scars, or due to compression by extra-esophageal volumetric formations can be observed. Many signs of other diseases of the esophagus and the organ of the esophagus, which will be discussed below, are also revealed in the corresponding sections.

In certain circumstances and depending on the nature of the pathological process, there is a need for special esophagoscopic techniques. Thus, cervical esophagoscopy is performed with a strongly wedged foreign body, which can not be removed in the usual way. In this case, cervical esophagology is produced, and the esophagus is examined through the hole made in its wall. If the foreign body is located in the neck of the esophagus, it is removed by forceps if it is lower, then it is removed with the help of an esophagoscope, and if it exceeds the largest diameter of the esophagoscope tube, its foreign body is seized with esophagoscopic forceps and removed together with the tube . Retrograde esophagoscopy is performed through the stomach after gastrostomy, and it is used to expand the lumen of the esophagus by the method of bougie with considerable cicatricial stenoses. This procedure begins to be carried out 10-15 days after gastrostomy, provided free passability of the cardia. The esophagoscope tube is inserted through the gastrostomy and cardia into the esophagus to the level of the stricture, the expansion of which is made by special bougies or by the "endless thread" method.

Esophageal biopsy is used in cases when esophagus or fibroesophagogastroscope in the lumen of the esophagus reveals a tumor with external signs of malignancy (lack of coverage of its normal mucous membrane), and the general condition of the patient, his nutrition and a number of specific complaints may indicate the presence of a malignant tumor. When biopsy, in addition to conventional training and anesthesia, used in conventional esophagoscopy (fibroscopy), anesthetize and subject to biopsy education by lubricating them with 10% cocaine solution with adrenaline. Then, the end of the esophagoscopic tube is fixed to the corresponding part of the tumor and its part is bitten in the most "suspicious" place by special cup-shaped forceps with sharp edges. At the same time, the biting instrument is directed frontal to the biopsy object, while avoiding the tangential removal of the biopsy. The material is obtained both from the "body" of the tumor itself, and at its border with a healthy tissue. Biopsy, as a rule, is ineffective if it is done superficially or from the inflammation zone. In the latter case, there is considerable resistance to resection of the biopsy and its traction.

It is also possible to use the method of aspiration biopsy, in which a secret aspirated from the lumen of the esophagus is subjected to a cytological examination. A biochemical study of the obtained mucus in aspiration biopsy is also conducted to determine its pH, organic and inorganic substances that are formed in inflammatory or malignant processes.

Bacteriological study is carried out for various kinds of microbial nonspecific inflammations, fungal infections, specific diseases of the esophagus.

Difficulties and complications of esophagoscopy. As VI Voyachek notes (1964), anatomical conditions may favor or, conversely, create certain difficulties in esophagoscopy. Obstructive problems occur in the elderly due to the loss of flexibility of the spine, with a short neck, curvature of the spine, birth or congenital defects in the cervical spine (torticollis), with strongly prominent upper anterior incisors, etc. Esophagoscopy is easier for children than for children adults, but often the resistance and anxiety of children require the use of general anesthesia.

Due to the fact that the wall of the esophagus is characterized by a certain weakness, with careless insertion of the tube, abrasions of the mucous membrane and deeper damage can occur, which causes a different degree of bleeding, which in most cases is unavoidable. However, with varicose veins and aneurysms caused by congestion in the portal portal vein system, esophagoscopy can cause profuse bleeding, therefore, for this pathological condition, this procedure is almost contraindicated. With tumors of the esophagus, wedged foreign bodies, deep chemical burns, esophagoscopy conceals the danger of perforation of the esophageal wall with the subsequent occurrence of pereezophagitis and mediastinitis.

With deep esophagoscopy, touching the instrument to the area of the cardia can cause shock, which is due to the rich pain and vegetative innervation of this area. With planned esophagoscopy, V.Voyachek recommends pre-sanitation of teeth, oral cavity, palatine tonsils in the presence of foci of infection in them to prevent the risk of secondary infection of the esophagus.

The use of flexible fiber optics greatly simplified the procedure of endoscopy of the esophagus and made it much safer and more informative. However, the removal of a foreign body is often not without the use of rigid endoscopes, since for the safe extraction of a foreign body, especially acute or cutting, they must first be inserted into the esophagoscope tube protecting the walls of the esophagus from damage by these bodies and removed together with the latter.

Esophagus - anatomical and functional continuation of the pharynx, is often prone to the same diseases as the latter, and often combined with them. However, due to the fact that it continues into the stomach, the diseases of the latter are peculiar to him. But there are also diseases of the esophagus proper, related both to the inflammatory and traumatic, and to the functional, dysplastic and tumor. In general, this is a vast class of diseases, encompassing numerous and diverse forms of them, from strictly local ones, characterized by morphological changes in its structures, to vascular, genetic deformities and oncological processes.

[1], [2], [3], [4]