Esophagoscopy

Esophagoscopy allows direct examination of the inner surface of the esophagus using a rigid esophagoscope or flexible fibroscope. Esophagoscopy can be used to determine the presence of foreign bodies and remove them, diagnose tumors, diverticula, cicatricial and functional stenosis, and perform a number of diagnostic (biopsy) and therapeutic procedures (opening an abscess in periesophagitis, inserting a radioactive capsule in esophageal cancer, bougienage of cicatricial strictures, etc.).

The creation of modern esophagoscopic means was initiated in 1807 by the Italian physician Filip Bozzini, who designed a device that conducted sunlight into the pharynx and its lower sections. In 1860, the Italian physician Voltolini adapted Garcia's mirror for examining the larynx to a special tube, which he inserted into the esophagus for its examination. In 1865, the French physician Desormaux designed a special tube equipped with a kerosene lamp for examining various cavities of the human body. He was the first to call this instrument an "endoscope". The outstanding German physician A. Kussmaul (1822-1902) actively supported and popularized the developing method of esophagoscopy. However, the entire development of endoscopy, and esophagoscopy in particular, was hampered by the lack of sufficiently effective lighting, with which the light beam could penetrate into the deep sections of the endoscope. The creation of such a light source was carried out in 1887 by the prominent German surgeon I. Mikulich, who is rightfully considered the founder of modern esophagoscopy, who designed the first esophagoscope with internal lighting. Since 1900, esophagoscopy has been introduced into practice everywhere. Paying tribute to the history of the development of esophagoscopy, it is necessary to mention the esophagoscopes of the French authors Moure and Guisez. Their technique consisted of blind insertion of the esophagoscope, for which a forehead reflector was used as a means of illumination, and a metal or rubber mandrin was located at the ends of the tube. It is also necessary to mention the significant improvement of the esophagoscope by F.S. Bokshteyn, which made it possible to rotate the tube in the handle of the esophagoscope and thus perform a circular examination of all the walls of the esophagus without any particular difficulties. The original model of a bronchoesophagoscope with a proximal lighting device was created by M.P. Mezrin (1954). In the 20th century, endoscopists and ENT doctors were armed with models of bronchoesophagoscopes by such authors as Brunings, C. Jackson, Kahler, Haslinger, etc. Some esophagoscopes are equipped with insertion tubes for bronchoscopy, for example, the bronchoesophagoscopes of Brunings, Haslinger, Mezrin. Bronchoesophagoscopes are equipped with a number of manipulation instruments inserted into the tube for biopsy, removal of foreign bodies of various shapes, wiping the walls of the esophagus, suctioning mucus, etc.

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

Esophagoscopy is divided into urgent and planned. The first is performed when providing emergency care (foreign bodies, food impaction) and often without a preliminary detailed clinical examination of the patient. Indications for urgent esophagoscopy are based on the patient's medical history, complaints, some external signs of the pathological condition and X-ray data. Planned esophagoscopy is performed in the absence of emergency indications after a thorough special, disease-specific, and general clinical examination of the patient with an assessment of the condition of adjacent organs, after an X-ray examination of the chest, larynx, trachea, spine, aorta, and mediastinal lymph nodes.

Esophagoscopy is performed in a specially adapted darkened room with a convenient table, electric suction and means for introducing washing fluids into the esophagus. The endoscopy room should have a tracheotomy set, appropriate means for infiltration anesthesia and resuscitation. For esophagoscopy, people of different ages need different sizes of intubation tubes. Thus, for children under 3 years old, a tube with a diameter of 5-6 mm, a length of 35 cm is used; for children 4-6 years old, a tube with a diameter of 7-8 mm and a length of 45 cm (8/45) is used; for children over 6 years old and adults with a short neck and protruding incisors (prognathia) - 10/45, while the insertion tube should extend the esophagoscope to 50 cm. Tubes of a larger diameter (12-14 mm) and a length of 53 cm are often used for adults.

Indications for esophagoscopy: esophagoscopy (fibroesophagoscopy) is performed in all cases where there are signs of esophageal disease and it is necessary to either establish their nature or perform the appropriate therapeutic manipulation, such as removing foreign bodies, emptying a diverticulum filled with food masses, removing food blockage, etc. An indication for esophagoscopy is the need for a biopsy.

There are practically no contraindications to esophagoscopy in urgent situations, except for those cases when the procedure itself can be dangerous due to its severe complications, for example, in the case of an embedded foreign body, mediastinitis, myocardial infarction, or cerebral stroke. If esophagoscopy is necessary and there are relative contraindications, appropriate preoperative preparation is carried out or, in agreement with the anesthesiologist-resuscitator, this procedure is carried out under general anesthesia. Contraindications to esophagoscopy detected during a routine examination of the patient are divided into general, regional, and local.

General contraindications are most often caused by the presence of decompensation of the cardiovascular system, asthma, hypertensive crisis, severe general and cerebral atherosclerosis, acute cerebrovascular accident. Esophagoscopy is absolutely contraindicated in case of belching of scarlet or dark-brown blood. The source of scarlet blood is, as a rule, varicose and eroded veins of the mucous membrane of the esophagus, dark-brown blood - the same veins when blood enters the stomach with the formation of hydrochloric hematin, which has a dark-brown color, or blood vessels of the stomach. However, when using fibroesophagoscopy, the procedure is permissible for stopping esophageal bleeding.

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

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

Esophagoscopy technique. The patient's preparation for esophagoscopy begins the day before: sedatives are prescribed, sometimes tranquilizers, and a sleeping pill at night. Drinking is limited, and dinner is excluded. It is advisable to perform a planned esophagoscopy in the first half of the day. On the day of the procedure, food and liquid intake are excluded. Morphine is administered subcutaneously 30 minutes before the procedure in a dose corresponding to the patient's age (not prescribed for children under 3 years; 3-7 years - a dose of 0.001-0.002 g is acceptable; 7-15 years - 0.004-0.006 g; adults - 0.01 g). At the same time, atropine hydrochloride solution is administered subcutaneously: children from 6 weeks old are prescribed a dose of 0.05-015 mg, adults - 2 mg.

Anesthesia. For esophagoscopy and especially fibroesophagoscopy, local anesthesia is used in the vast majority of cases, and it is sufficient to simply spray or lubricate the mucous membrane of the pharynx, laryngopharynx and entrance to the esophagus with a 5-10% solution of cocaine hydrochloride up to 3-5 times with breaks of 3-5 minutes. To reduce the absorption of cocaine and potentiate its anesthetic effect, an adrenaline solution is usually added to its solutions (3-5 drops of 0.1% adrenaline hydrochloride solution per 5 ml of cocaine solution). 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 by modern local anesthetics such as anilocaine, benzocaine, bumecaine, lidocaine, etc. In the middle of the 20th century, cocaine was widely used in the treatment of bronchial asthma. Some authors recommended the use of so-called subanesthetic esophagoscopy with the use of relaxants, while other authors expressed the opinion that this procedure is preferably performed without local anesthesia, since the resulting pharyngeal (vomiting) reflex facilitates the passage of the instrument into the esophagus. However, this opinion has not found practical application.

Patient position. To insert an esophagoscopic tube into the esophagus, it is necessary that the anatomical curves of the spine and the cervicofacial angle be straightened. There are several patient positions for this. V. I. Voyachek (1962) writes that esophagoscopy is performed in a sitting, lying, or knee-elbow position, while he preferred the method of lying on the stomach with the foot of the operating table slightly raised. In this position, it is easier to eliminate the flow of saliva into the respiratory tract and the accumulation of gastric juice in the esophagoscope tube. In addition, orientation is facilitated when inserting the tube into the esophagus.

Gh. Popovici (1964) describes a method of esophagoscopy in the supine position, in which the shoulder girdle protrudes slightly beyond the edge of the table (to the level of the shoulder blades), while the occipital region of the skull should be above the surface of the table - for adults by 15 cm, for children and adolescents - by 8 cm. This position helps straighten the spine, and the elimination of the cervicofacial angle is achieved by maximum extension of the head in the cervical spine by rotating backwards in the atlanto-occipital joint. The patient's head is held in a given position by an assistant who is to the right of the patient sitting on a chair. To prevent the patient from biting the esophagoscope tube, a mouth gag is used. Sometimes there is a need for another assistant to hold the patient's shoulders. The third assistant hands over the instruments, turns on the suction, etc.

The endoscope is inserted under constant visual control. The success of esophagoscopy depends on the ability to find the upper mouth of the esophagus, which is located at the level of the back wall of the larynx in the form of a closed, difficult to distinguish gap. To get into it with the end of the instrument, it is necessary to direct it exactly along the midline of the oral cavity, for this purpose they are guided by the line of closure of the vocal folds. With a significant size of the front incisors or with a short neck, the tube is first inserted from the side of the corner of the mouth, and then transferred to the median plane.

After this, the tube is slowly advanced along the root of the tongue and directed somewhat posteriorly relative to the interarytenoid space, lifting the larynx with a slight effort, avoiding pressure with the end of the tube on the laryngeal part of the pharynx and constantly keeping the midline of the larynx under visual control. This is achieved by pressing downwards on the handle of the esophagoscope, trying not to damage the upper incisors. If, when advancing the tube, its end rests against the forming fold of the mucous membrane, then it is necessary to "saddle" it with the beak and pass, advancing further. Advancing the tube does not cause difficulties until the entrance to the esophagus, at the level of which resistance to its advancement arises. This resistance is familiar to all endoscopists, but it may be false if the tube is pressed against the upper incisors. It is precisely when passing the upper esophageal sphincter that it is necessary that the tube does not come into contact with the teeth. Penetration into the upper opening of the esophagus is achieved with a slight effort. Involuntary (reflex) contraction of m. cricopharyngeus can greatly complicate the passage of the tube into the esophagus, and forced pushing of its end through the spasmodic area often leads to severe damage to this area, which is characterized by reduced tissue strength.

Beginning esophagoscopists should keep in mind that holding the tube in the midline is not an easy task, since its end constantly slides to the side due to the convexity of the vertebral bodies to which the esophagus is adjacent. Straightening of the tube is carried out by constantly directing it parallel to the axis of the throat and to the notch of the sternum. The entrance to the esophagus, as noted above, is determined by its shape, which has the appearance of a horizontal slit. If difficulties arise in determining this slit, the patient is asked to make a swallowing movement, then the entrance to the esophagus opens.

After passing the first narrowing of the esophagus, the tube slides easily along it, while it is necessary to ensure that its end does not stick to one direction for too long, protruding only one of the walls of the esophagus. This is where the danger of its damage lies. In the area of the second narrowing, the lumen of the esophagus has the appearance of a pulsating sphincter, to which the pulsation of the aorta is transmitted. The end of the tube, having passed through this narrowing, is directed to the left towards the superior anterior iliac spine, while the assistant holding the patient's head lowers it below the plane of the table on which the patient lies. The supradiaphragmatic part of the esophagus appears as a multitude of folds of the mucous membrane located around the central opening, and in the area of the cardia, these folds are located around the slit-oval opening.

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

A method of esophagoscopy in a sitting position using a Chevalier-Jackson esophagoscope. The physician, standing in front of a sitting patient, holds the distal end of the tube with the first and second fingers of the hand, and the proximal end like a pencil. An assistant stands behind the patient and fixes his head in an extension position, using the second finger as a reference, placed on the handle directed upward. The tube of the esophagoscope is directed vertically downward, pressing it against the upper incisors and adhering to the median plane. As soon as the posterior wall of the pharynx appears in the field of vision, the end of the tube is directed toward the right arytenoid cartilage and the right piriform sinus is searched for. Having entered the sinus, the end of the tube is directed toward the median plane, while the physician orients it in the direction of the notch of the manubrium of the sternum. After the general direction of the esophagoscope has been fixed, it is advanced along the esophagus using the method described above and with the same precautions. The esophagus is examined both when the tube is inserted and when it is removed; the latter allows for a particularly good examination of the area of the first stenosis of the esophagus. Often, when the tube is advanced toward the cardia, it is not possible to see 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 certain experience and manual skills are required for a qualified assessment of the endoscopic picture of the esophagus. There are special dummies on which the technique of esophagoscopy is taught and knowledge in the field of diagnostics of various diseases of the esophagus is acquired. Below is a brief description of the normal endoscopic picture of the esophagus, which appears to the examiner's gaze as the tube moves towards the cardia.

The normal mucous membrane of the esophagus is pink, moist, and blood vessels are not visible through it. The folding of the mucous membrane of the esophagus varies depending on the level: at the entrance to the esophagus, as mentioned above, there are two transverse folds covering the slit-like entrance to the esophagus; as you move downwards, the number of folds increases; so, in the thoracic region there are 4-5 of these folds, and in the area of the diaphragmatic opening there are already 8-10, while the lumen of the esophagus here is closed by the diaphragmatic sphincter. In pathological conditions, the color of the mucous membrane changes: with inflammation, it becomes bright red, with congestion in the portal vein system - cyanotic. Erosions and ulcerations, edema, fibrinous deposits, diverticula, polyps, disturbances of peristaltic movements, up to their complete interruption, changes in the lumen of the esophagus, arising either as a result of stenotic scars or due to compression by extraesophageal volumetric formations, may be observed. Many signs of other diseases of the esophagus and paraesophageal organs are also revealed, which will be discussed below, in the relevant sections.

Under certain circumstances and depending on the nature of the pathological process, it is necessary to perform special esophagoscopic techniques. Thus, cervical esophagoscopy is performed in case of strongly wedged foreign bodies, the removal of which is impossible in the usual way. In this case, cervical esophagotomy is performed, and the esophagus is examined through an opening made in its wall. If the foreign body is located in the cervical hotel of the esophagus, it is removed with forceps, if it is located lower, it is removed with an esophagoscope, and if its volume exceeds the largest diameter of the esophagoscope tube, the foreign body is grasped with esophagoscopic forceps and removed together with the tube. Retrograde esophagoscopy is performed through the stomach after gastrostomy, it is used to expand the lumen of the esophagus by bougienage in case of significant cicatricial stenosis. This procedure is started 10-15 days after gastrostomy, provided that the cardia is freely patent. The esophagoscope tube is inserted through the gastrostomy and cardia into the esophagus to the level of the stricture, which is expanded using special bougies or the “endless thread” method.

Esophageal biopsy is used in cases where esophagoscopy or fibroesophagogastroscopy reveals a tumor with external signs of malignancy (lack of coverage by normal mucous membrane) in the lumen of the esophagus, and the general condition of the patient, his diet and a number of specific complaints may indicate the presence of a malignant tumor. During biopsy, in addition to the generally accepted preparation and anesthesia used in conventional esophagoscopy (fibroscopy), the formations to be biopsied are also anesthetized by lubricating them with a 10% solution of cocaine with adrenaline. Then, the end of the esophagoscopic tube is used to fix the corresponding section of the tumor and a part of it is bitten off in the most “suspicious” place with special cup-shaped forceps with sharp edges. In this case, the biting instrument is directed frontally to the biopsy object, avoiding tangential removal of the biopsy. The material is obtained both from the "body" of the tumor itself and at its border with healthy tissue. Biopsy, as a rule, is ineffective if it is performed superficially or from the inflammation zone. In the latter case, there is significant resistance to resection of the biopsy and its traction.

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

Bacteriological examination is carried out for various types of microbial non-specific inflammations, mycoses, and specific diseases of the esophagus.

Difficulties and complications of esophagoscopy. As noted by V.I. Voyachek (1964), anatomical conditions may favor or, on the contrary, create certain difficulties during esophagoscopy. Difficulties arise in elderly people due to 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 protruding upper anterior incisors, etc. In children, esophagoscopy is easier than in adults, but often the resistance and anxiety of children require the use of general anesthesia.

Since the esophageal wall is somewhat fragile, careless insertion of the tube may cause abrasions of the mucous membrane and deeper damage, which causes varying degrees of bleeding, which are inevitable in most cases. However, in the case of varicose veins and aneurysms caused by congestion in the hepatic portal vein system, esophagoscopy may cause profuse bleeding, so this procedure is practically contraindicated in this pathological condition. In the case of esophageal tumors, wedged foreign bodies, deep chemical burns, esophagoscopy carries the risk of perforation of the esophageal wall with subsequent occurrence of periesophagitis and mediastinitis.

During deep esophagoscopy, touching the instrument to the cardia area can cause shock, which is due to the rich pain and vegetative innervation of this area. During planned esophagoscopy, V.I. Voyachek recommends preliminary sanitation of teeth, oral cavity, and palatine tonsils if there are foci of infection in them, in order to prevent the risk of secondary infection of the esophagus.

The use of flexible fiber optics has significantly simplified the procedure of esophageal endoscopy and made it much safer and more informative. However, the removal of a foreign body often cannot be done without the use of rigid endoscopes, since for the safe removal of a foreign body, especially acute-angled or cutting ones, 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.

The esophagus is an anatomical and functional continuation of the pharynx, often subject to the same diseases as the latter, and often combined with them. However, due to the fact that it continues into the stomach, it is also prone to diseases of the latter. But there are also diseases of the esophagus itself, related to both inflammatory and traumatic, and functional, dysplastic and tumor. In general, this is an extensive class of diseases, covering numerous and varied forms, from strictly local, characterized by morphological changes in its structures, to vascular, genetic deformities and oncological processes.

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