Method for conducting fibroendoscopy in foreign bodies

Method of conducting fibroendoscopy in foreign bodies. In all cases, it is better to take an esophagogastroduodenoscope with end optics for the study. Do not take a new device, tk. When removing foreign bodies, the apparatus is often damaged. When a foreign body is detected in the duodenum, after a preliminary examination, a duodenoscope is used with the facial optics.

With foreign bodies located in the esophagus, the apparatus is injected only under the control of vision, starting inspection from the oropharynx, the root of the tongue, pear-shaped sinuses - foreign bodies get stuck there often, and X-ray diagnostics is not effective. Most foreign bodies of the esophagus get stuck between I and II physiological constrictions, which corresponds to the Lammer triangle, where a physiological diverticulum is formed. The wall of the esophagus here is not involved in peristalsis and foreign bodies are delayed here. When stretching the esophagus by air, they fall through lower. Often it is possible to pass the device below the foreign body. Often, foreign bodies are not quite the usual form: on the bone there are remains of meat, the metal quickly darkens, acquiring a dark or black color. Foreign bodies are often covered with mucus, remnants of food, which makes diagnosis difficult. If a foreign body is known in advance, it is good, but sometimes it is extremely difficult to determine its nature. Foreign bodies of the esophagus are usually easily diagnosed: narrow lumen, foreign bodies are more often solitary. Foreign bodies of the stomach are often multiple. It is necessary to try to wash the foreign bodies with a stream of water.

Then they sort the foreign bodies with a tool - foreign bodies are more likely to be on a large curvature. It is difficult to diagnose foreign bodies of the duodenum. Here foreign bodies with sharp ends and faces are stuck. When examining the duodenum, a "corrugation" technique is used. Foreign bodies from the small intestine can not, as a rule, be extracted.

Methods of extraction of foreign bodies

Extraction of foreign bodies from the esophagus. Remove foreign bodies from the esophagus by using rigid and flexible esophagoscopes. Each of the instruments has its own indications for use. In the presence of large foreign bodies, which can not be reliably captured by small tools conducted through the instrumental channel of the fibroscope, the advantage is given to rigid endoscopes. The lumen of the rigid esophagoscope is quite large, and through it you can draw a wide variety of instruments of the required size.

The choice of the type of endoscope to remove a foreign body depends on:

1. character, size, shape and structure of the foreign body;
2. its localization and developed complications;
3. condition and age of the patient;
4. availability of appropriate tools;
5. experience of an endoscopist.

The latest designs of flexible endoscopes, special manipulators and a detailed research technique allow you to remove most foreign bodies from the esophagus during fibroesophagoscopy. Depending on the type of foreign body, various techniques are used. General technical requirements for the removal of foreign bodies are as follows:

1. all manipulations should be performed under constant visual control;
2. remove the foreign body more safely with a constant supply of air to spread the folds and increase the lumen of the organ;
3. the capture of a foreign body should be strong, and extraction smooth, without violence and forcing, especially in places of physiological constriction and cryopharyngeal area, where it is easy to damage the walls of the esophagus;
4. after removal of the foreign body, diagnostic esophagoscopy should be performed immediately to exclude damage to the esophagus and to clarify the condition of the esophagus walls in the zone where the foreign body was located.

Significant difficulties arise when extracting sharp objects (needles, pins): with inaccurate movements by an endoscope or a gripping tool they can penetrate into the esophagus wall and disappear from the field of vision. If the foreign body is located so that it can not be removed from the esophagus, the following method is used: carry the body into the stomach, turn it and take it in a favorable position. A sharp object, embedded in the wall, is extracted from it using forceps, and removed with a loop.

When extracting a bone, it is grasped with a tool and produced traction on itself, if this is easily done - the foreign body is removed together with the endoscope. If the elastic resistance is determined during traction, the bone is fixed: if a fold is formed during traction, the bone is implanted at the level of the mucous membrane, if no folds are formed, bone is implanted in the muscle layer. It is necessary to try to remove the wall from one of the edges, for this purpose a foreign body is located near the mucous membrane. If this fails - you need to enter a rigid endoscope and split the bone in its middle part. Pieces of meat in the esophagus are captured by a loop and try to extract by traction. If they slip into the stomach, they are not removed.

Most patients after removal of the foreign body can be under the supervision of a local doctor. If suspicion of perforation of the esophagus is unsuccessful attempts to extract a foreign body and the need to monitor patients should be hospitalized in the surgical department.

Failures of endoscopic removal of foreign bodies are caused by violation of technical methods, lack of the necessary tools, incorrect choice of endoscope type and type of anesthesia, etc. On average, the failure rate is from 1 to 3.5%. In these cases, various types of esophagothia are used to remove foreign bodies.

Extraction of foreign bodies from the stomach and duodenum. Before the creation of fibroscopes to remove foreign bodies stuck in the stomach or in the duodenum, the surgical method was mainly used - laparotomy and gastrotomy. The creation of modern endoscopes radically changed this situation. Currently, the main method of removing foreign bodies, both accidentally swallowed and formed in the cavity of the stomach, is endoscopic.

Most swallowed small items come out naturally. A significant part (up to 85%) of stuck foreign bodies formed in the stomach cavity (bezoars) or left during surgery (silk ligatures, "lost" drains, metal clips, etc.) is removed with the help of endoscopes and only 12-15% of foreign bodies are removed surgically. Operative intervention is recommended to be undertaken only after endoscopic diagnosis if it is impossible to extract a foreign body during endoscopy. The most common failures are observed with endoscopic removal of large bezoars that do not lend themselves to crushing, flat foreign bodies (glass, plates) and large objects, the extraction of which can cause injury to the cardia and esophagus.

The success of endoscopic removal of foreign bodies from the stomach largely depends on how prepared the stomach is. Food, liquid and mucus make it difficult to detect a foreign body and firmly grasping it with a tool. In some cases, in the presence of contents in the stomach, a foreign body can be detected by changing the position of the patient, but it is better to wash the stomach with a thorough suction of the contents. The gripping of objects is much easier when using endoscopes with two manipulation channels. At the same time, a foreign body is fixed and held by one tool, and the second is firmly grasped by it. Most often used loops used for polypectomy, and baskets. The captured object is pulled to the lens of the endoscope and extracted with it under constant visual control. Sharp objects must be taken closer to the blunt end, which helps to prevent injury to the mucous membrane at the time of extraction. This is also facilitated by the maximum approach of the object to the endoscope.

In the duodenum, small and sharp foreign bodies are most often stuck. Capture and extract them in the same way as foreign bodies from the stomach.

Removal of ligatures. Modern endoscopes allow to eliminate some consequences of the transferred operative interventions. After resection of the stomach, suturing the perforated ulcer, the imposition of biologically digestive anastomoses in the lumen of the stomach and duodenum, silk ligatures are often left which cause various painful conditions. In addition, removal of ligatures leads to cessation of inflammation in the anastomosis zone. Removal of ligatures is a technically simple manipulation, it can be performed without additional anesthetic tools both in the hospital and outpatient settings. Ligatures are extracted with the help of biopsy forceps or hammers with a strong grip. If the ligature has the form of a loop (more often when a continuous suture joint is applied), it is firmly fixed to the tissues, it does not separate with considerable effort and the traction causes pain for it, then the ligature should be crossed with scissors or an electrocoagulant. Wrap the thread from the tissues should be cautious, sometimes in several stages. After the removal of a firmly fixed ligature, mild bleeding is almost always observed, which usually stops on its own and does not require additional medical manipulations.

Extraction of drainage from the biliary tract. During surgical interventions in the lumen of the biliary tract, rubber or plastic drains may leave, which, after fulfilling their function in the immediate postoperative period, subsequently cause severe diseases (mechanical jaundice, purulent cholangitis, papillitis, chronic pancreatitis, pronounced duodenitis, etc.). . Before the creation of the endoscopic method, repeated surgical intervention was undertaken in such cases. Removing "lost" drainage with an endoscope is a highly effective therapeutic manipulation that should completely replace the surgical method of removing drains from the bile duct.

At transpapillary arrangement of drainage, its gripping and removal do not cause difficulties. Under the control of vision on the protruding from the OBD, the end of the drain is thrown and the polypectomy loop is tightened. The seized drainage pulls close to the endoscope and, extracting the endoscope, withdraws the foreign body into the lumen of the duodenum and further into the stomach. Here, by determining the level of capture and making sure that the front (trapped) end of the drainage tube does not injure the esophagus, extract the endoscope along with the drainage.

After extracting the drain, it is advisable to perform an audit of the duodenum, and in some cases - the biliary tract. For the revision of the biliary tract, catheterization of the OBD and retrograde cholangiography is used.

Extraction of bezoar. Small bezoars are usually fixed to the gastric mucosa loosely, they can be easily separated and displaced from those areas where they formed. This can be done with biopsy forceps and extractors. There is no need to extract bezoar, the size of which does not exceed 1.5-2.0 cm. If the bezoar is of a dense consistency and it can not be seized with forceps or other devices (basket), then bezoar can be left in the stomach or transferred by the end of the endoscope to the duodenum . Being unfixed, bezoar will come out independently by natural means.

Large bezoars, whose diameter is more than 5 cm, can not be extracted with an endoscope. They are removed after crushing into several parts. The most easily destroyed phyto-and trihobezoary. For this purpose, polypectomy loops are used, sometimes in combination with electrothermocoagulation. Bezoars can be destroyed with the help of powerful forceps, consistently biting off pieces from them. The fragments of the bezoar are removed using loops, picking up baskets or by carrying them (mostly small ones) into the duodenum. Crushing and removal of bezoars is a rather lengthy procedure, requiring great patience for both the endoscopist and the patient.

Left in the gastrointestinal tract large fragments can cause complications, for example, acute obstructive intestinal obstruction. After removal of the bezoar from the stomach or duodenum, it is necessary to carefully examine the place where it was fixed, up to the completion of the targeted biopsy.

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