Technique of fibroendoscopy for foreign bodies

Methodology for conducting fibroendoscopy with foreign bodies. In all cases, it is better to take an esophagogastroduodenoscope with end optics for the examination. You should not take a new device, since when removing foreign bodies, devices are often damaged. If a foreign body is detected in the duodenum after a preliminary examination with a device with end optics, a duodenoscope is used.

In case of foreign bodies located in the esophagus, the device is inserted only under visual control, starting the examination from the area of the oropharynx, the root of the tongue, the pyriform sinuses - foreign bodies often get stuck there, and X-ray diagnostics is not effective. Most foreign bodies of the esophagus get stuck between the I and II physiological constrictions, which corresponds to the Lammer triangle, where a physiological diverticulum is formed. The wall of the esophagus does not participate in peristalsis here and foreign bodies are retained here. When the esophagus is stretched with air, they fall lower. It is often possible to pass the device below the foreign body. Often, foreign bodies have an unusual appearance: there are remains of meat on the bone, the metal quickly darkens, acquiring a dark or black color. Foreign bodies are often covered with mucus, food residues, which complicates diagnostics. If the foreign body is known in advance, it is good, but sometimes its nature is extremely difficult to determine. Foreign bodies in the esophagus are usually easy to diagnose: narrow lumen, foreign bodies are often single. Foreign bodies in the stomach are often multiple. It is necessary to try to wash out foreign bodies with a stream of water.

Then, the foreign bodies are sorted using an instrument - foreign bodies are often located on the greater curvature. Diagnosis of foreign bodies in the duodenum is difficult. Foreign bodies with sharp ends and edges get stuck here. When examining the duodenum, the "corrugation" technique is used. As a rule, it is not possible to extract foreign bodies from the small intestine.

Methods of foreign body extraction

Removal of foreign bodies from the esophagus. Foreign bodies can be removed from the esophagus using rigid and flexible esophagoscopes. Each device has its own indications for use. In the presence of large foreign bodies that cannot be reliably captured by small instruments passed through the instrument channel of the fibroscope, preference is given to rigid endoscopes. The lumen of a rigid esophagoscope is quite large, and a wide variety of instruments of the required size can be passed through it.

The choice of the type of endoscope for removing a foreign body depends on:

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

The latest designs of flexible endoscopes, special manipulators and a detailed examination technique allow the removal of most foreign bodies from the esophagus during fibroesophagoscopy. Depending on the type of foreign body, different techniques are used. The general technical requirements for removing foreign bodies are as follows:

1. all manipulations should be carried out under constant visual control;
2. It is safer to remove a foreign body with a constant supply of air to straighten out folds and increase the lumen of the organ;
3. the grasping of a foreign body must be firm, and its extraction smooth, without violence or forcing, especially in areas of physiological constriction and the cricopharyngeal region, where it is easy to damage the walls of the esophagus;
4. After removing the foreign body, it is necessary to immediately perform a diagnostic esophagoscopy to rule out damage to the esophagus and to clarify the condition of the esophageal walls in the area where the foreign body was located.

Significant difficulties arise when removing sharp objects (needles, pins): with imprecise movements of the endoscope or grasping instrument, they can penetrate the wall of the esophagus and disappear from view. If the foreign body is located in such a way that it is impossible to remove it from the esophagus, the following method is used: the body is passed into the stomach, turned and removed in an advantageous position. A sharp object that has penetrated the wall is removed from it using forceps and removed using a loop.

When removing a bone, grasp it with an instrument and apply traction towards yourself. If this is easy to do, the foreign body is removed together with the endoscope. If elastic resistance is detected during traction, the bone is fixed: if a fold is formed during traction, the bone is embedded at the level of the mucous membrane; if no fold is formed, the bone is embedded in the muscle layer. It is necessary to try to move the wall away from one of the edges; to do this, grasp the foreign body near the mucous membrane. If this fails, a rigid endoscope must be inserted and the bone crushed in its middle part. Pieces of meat in the esophagus are grasped with a loop and an attempt is made to extract them by traction. If they slip into the stomach, they are not removed.

Most patients after removal of a foreign body can be under observation of a local doctor. If there is a suspicion of esophageal perforation due to unsuccessful attempts to remove a foreign body and there is a need to observe the patients, they should be hospitalized in the surgical department.

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

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

Most swallowed small objects are excreted naturally. A significant portion (up to 85%) of foreign bodies lodged in the stomach cavity (bezoars) or left behind during surgery (silk ligatures, "lost" drains, metal staples, etc.) are removed using endoscopes, and only 12-15% of foreign bodies are removed surgically. Surgery is recommended only after endoscopic diagnostics if it is impossible to remove the foreign body during endoscopy. The most frequent failures are observed during endoscopic removal of large bezoars that cannot be crushed, flat foreign bodies (glass, plates), and large objects, the removal of which may injure the cardia and esophagus.

The success of endoscopic removal of foreign bodies from the stomach largely depends on how the stomach is prepared. Food, liquid and mucus make it difficult to detect a foreign body and firmly grasp it with an instrument. In some cases, if there are contents in the stomach, the foreign body can be detected by changing the patient's position, but it is better to wash the stomach with careful suction of the contents. Grasping objects is much easier when using endoscopes with two manipulation channels. In this case, one instrument fixes and holds the foreign body, and the second firmly grasps it. Most often, loops used for polypectomy and baskets are used. The captured object is pulled to the endoscope lens and removed together with it under constant visual control. Sharp objects must be grasped closer to the blunt end, which helps prevent injury to the mucous membrane at the time of extraction. This is also facilitated by bringing the object as close as possible to the endoscope.

Small and sharp foreign bodies most often get stuck in the duodenum. They are captured and removed in the same way as foreign bodies from the stomach.

Removal of ligatures.Modern endoscopes allow eliminating some consequences of previous surgeries. After gastric resection, suturing of perforated ulcers, application of bypass biliodigestive anastomoses, silk ligatures often remain in the lumen of the stomach and duodenum, which cause various painful conditions. In addition, removal of ligatures leads to the cessation of inflammation in the anastomosis zone. Removal of ligatures is a technically simple manipulation, it can be performed without additional anesthetic aids both in hospital and outpatient settings. Ligatures are removed using biopsy forceps or pincers with a strong grip. If the ligature has the shape of a loop (usually when applying a continuous twisting suture), is firmly fixed to the tissues, does not separate with significant force and traction on it causes pain, then the ligature should be cut with scissors or an electrocoagulator. The thread should be pulled out of the tissues carefully, sometimes in several stages. After removing a firmly fixed ligature, moderate bleeding is almost always observed, which usually stops on its own and does not require additional medical manipulations.

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

With transpapillary drainage, its capture and removal do not cause difficulties. Under visual control, a polypectomy loop is thrown onto the end of the drainage protruding from the BDS and tightened. The captured drainage is pulled tightly to the endoscope and, removing the endoscope, the foreign body is removed into the lumen of the duodenum and further into the stomach. Here, having determined the level of capture and making sure that the anterior (captured) end of the drainage tube will not injure the esophagus, the endoscope is removed together with the drainage.

After the drainage is removed, it is advisable to conduct a revision of the duodenum, and in some cases, the bile ducts. For revision of the bile ducts, BDS catheterization and retrograde cholangiography are used.

Extraction of bezoars. Small bezoars are usually not firmly attached to the gastric mucosa; they can be easily separated and displaced from the areas where they formed. This can be done using biopsy forceps and extractors. There is no need to extract a bezoar that is no larger than 1.5-2.0 cm. If the bezoar is of a dense consistency and cannot be grasped with forceps or other devices (basket), the bezoar can be left in the stomach or moved into the duodenum with the end of the endoscope. If the bezoar is not fixed, it will come out on its own naturally.

Large bezoars, with a diameter of more than 5 cm, usually cannot be removed with an endoscope. They are removed after being crushed into several pieces. Phyto- and trichobezoars are most easily destroyed. Polypectomy loops are used for this purpose, sometimes in combination with electrothermocoagulation. Bezoars can be destroyed with powerful forceps, successively biting off pieces from them. Bezoar fragments are removed with loops, grasping baskets, or by passing them (mostly small ones) into the duodenum. Crushing and removing bezoars is a rather lengthy procedure that requires a lot of patience from both the endoscopist and the patient.

Large fragments left in the gastrointestinal tract may cause complications, such as acute obstructive intestinal obstruction. After removing a bezoar from the stomach or duodenum, it is necessary to carefully examine the site where it was fixed, up to and including performing a targeted biopsy.

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