Esophagoscopes


Categories: INSTRUMENTARIUM
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

The esophagoscope, like the bronchoscope, is a

hollow brass tube with beveled distal end containing a small

electric light. It differs from the bronchoscope in that it has no

perforations, and has a drainage canal on its upper surface, or next

to the light-carrier canal which opens within the distal end of the

tube. The exact size, position, and shape of the drainage outlets is

important on bronchoscopes, and to an even greater degree on

esophagoscopes. If the proximal edge of the drainage outlet is too

near the distal end of the endoscopic tube, the mucosa will be drawn

into the outlet, not only obstructing it, but, most important,

traumatizing the mucosa. If, for instance, the esophagoscope were to

be pushed upon with a fold thus anchored in the distal end, the

esophageal wall could easily be torn. To admit the largest sizes of

esophagoscopic bougies (Fig. 40), special esophagoscopes (Fig. 5) are

made with both light canal and drainage canal outside the lumen of the

tube, leaving the full area of luminal cross-section unencroached

upon. They can, of course, be used for all purposes, but the slightly

greater circumference is at times a disadvantage. The esophageal and

stomach secretions are much thinner than bronchial secretions, and, if

free from food, are readily aspirated through a comparatively small

canal. If the canal becomes obstructed during esophagoscopy, the

positive pressure tube of the aspirator is used to blow out the

obstruction. Two sizes of esophagoscopes are all that are required--7

mm. X 45 cm. for children, and 10 mm. X 53 cm. for adults (Fig. 3, A

and B); but various other sizes and lengths are used by the author for

special purposes.* Large esophagoscopes cause dangerous dyspnea in

children. If, it is desired to balloon the esophagus with air, the

window plug shown in Fig. 6, is inserted into the proximal end of the

esophagoscope, and air insufflated by means of the hand aspirator or

with a hand bulb. The window can be replaced by a rubber diaphragm

with a perforation for forceps if desired. It will be noted that none

of the endoscopic tubes are fitted with mandrins. They are to be

introduced under the direct guidance of the eye only. Mandrins are

obtainable, but their use is objectionable for a number of reasons,

chief of which is the danger of overriding a foreign body or a lesion,

or of perforating a lesion, or even the normal esophageal wall. The

slanted end on the esophagoscope obviates the necessity of a mandrin

for introduction. The longer the slant, with consequent acuting of the

angle, the more the introduction is facilitated; but too acute an

angle increases the risk of perforating the esophageal wall, and

necessitates the utmost caution. In some foreign-body cases an acute

angle giving a long slant is useful, in others a short slant is

better, and in a few cases the squarely cut-off distal end is best. To

have all of these different slants on hand would require too many

tubes. Therefore the author has settled upon a moderate angle for the

end of both esophagoscopes and bronchoscopes that is easy to insert,

and serves all purposes in the version and other manipulations

required by the various mechanical problems of foreign-body

extraction. He has, however, retained all the experimental models, for

occasional use in such cases as he falls heir to because of a problem

of extraordinary difficulty.



* A 9 mm. X 45 cm. esophagoscope will reach the stomach of almost all

adults and is somewhat easier to introduce than the 10 mm. X 53 cm.,

which may be omitted from the set if economy must be practiced.



[FIG. I.--Author's laryngoscopes. These are the standard sizes and

fulfill all requirements. Many other forms have been devised by the

author, but have been omitted from the list as unnecessary. The infant

diagnostic laryngoscope (C) is not for introducing bronchoscopes,

and is not absolutely necessary, as the larynx of any infant can be

inspected with the child's size laryngoscope (B).



A Adult's size; B, child's size; C, infant's diagnostic size; D,

anterior commissure laryngoscope; E, with drainage canal; 17,

intubating laryngoscope, large lumen. All the laryngoscopes are

preferred without drainage canals.]



[FIG. 2.--The author's bronchoscopes of the sizes regularly used.

Various other lengths and diameters are on hand for occasional use

for special purposes. With the exception of a 6 mm. X 35 cm. size

for older children, these special bronchoscopes are very rarely

used and none of them can be regarded as necessary. For special

purposes, however, special shapes of tube-mouth are useful, as,

for instance, the oval end to facilitate the getting of both

points of a staple into the tube-mouth The illustrated instruments

are as follows:



A, Infant's size, 4 mm. X 30 cm.; B, child's size, 5 mm. X 30 cm.;

C, adolescent's size, 7 mm. X 40 cm.; D, adult's size, 9 mm. X 40 cm.;

E, aspirating bronchoscope made in all the foregoing sizes, and in a

special size, 5 mm. X 45 cm.]



[FIG. 3.--The author's esophagoscopes of the sizes he has standardized

for all ordinary requirements. He uses various other lengths and sizes

for special purposes, but none of them are really necessary. A

gastroscope, 10 mm. X 70 cm., is useful for adults, especially in

cases of gastroptosis. Drainage canals are placed at the top or at the

side of the tube, next to the light-carrier canal.



A, Adult's size, 10 mm. X 53 cm.; B, child's size, 7 mm. X 45 cm.; C

and D, full lumen, with both light canal and drainage canal outside

the wall of the tube, to be used for passing very large bougies. This

instrument is made in adult, child, and adolescent (8 mm. by 45 cm.)

sizes. Gastroscopes and esophagoscopes of the sizes given above (A)

and (B), can be used also as gastroscopes. A small form of C, 5 mm. X

30 cm. is used in infants, and also as a retrograde esophagoscope in

patients of any age. E, window plug for ballooning gastroscope, F.]



[FIG. 4.--Author's short esophagoscopes and esophageal specula

A, Esophageal speculum and hypopharyngoscope, adult's size; B,

esophageal speculum and hypopharyngoscope, child's size; C, heavy

handled short esophagoscope; D, heavy handled short esophagoscope with

drainage.]



[FIG. 5.--Cross section of full-lumen esophagoscope for the use of

largest bourgies. The canals for the light carrier and for drainage

are so constructed that they do not encroach upon the lumen of the

tube.]



[25] The special sized esophagoscopes most often useful are the 8 mm.

X 30 cm., the 8 mm. X 45 cm., and the 5 mm. X 45 cm. These are made

with the drainage canal in various positions.



For operations on the upper end of the esophagus, and particularly for

foreign body work, the esophageal speculum shown at A and B, in Fig.

4, is of the greatest service. With it, the anterior wall of the

post-cricoidal pharynx is lifted forward, and the upper esophageal

orifice exposed. It can then be inserted deeper, and the upper third

of the esophagus can be explored. Two sizes are made, the adult's and

the child's size. These instruments serve, very efficiently as

pleuroscopes. They are made with and without drainage canals, the

latter being the more useful form.



[FIG. 6.--Window-plug with glass cap interchangeable with a cap having

a rubber diaphragm with a perforation so that forceps may be used

without allowing air to escape. Valves on the canals (E, F, Fig. 3)

are preferable.]





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