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Preparation Of The Patient For Peroral Endoscopy
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Category: ACUTE STENOSIS OF THE LARYNX
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery
The stomach of any individual having a normal esophagus and normal
spine can be explored with an open-tube gastroscope. The adult size
esophagoscope being 53 cm. long will reach the stomach of the average
individual. Longer gastroscopes are used, when necessary, to explore a
ptosed stomach. Various lens-system gastroscopes have been devised,
which afford an excellent view of the walls of the air-inflated
stomach. The optical system, however, interferes with the insertion of
instruments, so that the open-tube gastroscope is required for the
removal of gastric foreign bodies, the palpation of, or sponging
secretions from, gastric lesions. The open-tube gastroscope may be
closed with a window plug (Fig. 6) having a rubber diaphragm with a
central perforation for forceps, when it is desired to inflate the
Technic.--Relaxation by general anesthesia permits lateral
displacement of the dome of the diaphragm along with the esophagus,
and thus makes possible a wider range of motion of the distal end of
the gastroscope. All of the recent gastroscopies in the Bronchoscopic
Clinic, however, have been performed without anesthesia. The method of
introduction of the gastroscope through the esophagus is precisely the
same as the introduction of the esophagoscope (q.v.). It should be
emphasized that with the lens-system gastroscopes, the tube should be
introduced into the stomach under direct ocular guidance, without a
mandrin, and the optical apparatus should be inserted through the tube
only after the stomach has been entered. Blind insertion of a rigid
metallic tube into the esophagus is an extremely dangerous procedure.
The descriptions and illustrations of the stomach in anatomical works
must be disregarded as cadaveric. In the living body, the empty
stomach is usually found, on endoscopic inspection, to be a collapsed
tube of such shape as to fit whatever space is available at the
particular moment, with folds and rugae running in all directions, the
impression given as to form being strikingly like searching among a
mass of earth worms or boiled spaghetti. The color is pink, under
proper illumination, if no food is present. Poor illumination may make
the color appear deep crimson. If food is present, or has just been
regurgitated, the color is bright red. To appreciate the appearance of
gastritis, the eye must have been educated to the endoscopic
appearances under a degree of illumination always the same. The left
two-thirds of the stomach is most easily examined. The stomach wall
can be pushed by the tube into almost any position, and with the aid
of gentle external abdominal manipulation to draw over the pylorus it
is possible to examine directly almost all of the gastric walls except
the pyloric antrum, which is reachable in relatively few cases. A
lateral motion of from 10 to 17 cm. can be imparted to the
gastroscope, provided the diaphragmatic musculature is relaxed by deep
anesthesia. The stomach is explored by progressive traverse. That is,
after exploring down to the greater curvature, the tube-mouth is moved
laterally about 2 centimeters, and the withdrawing travel explores a
new field. Then a lateral movement affords a fresh field during the
next insertion. This is repeated until the entire explorable area has
been covered. Ballooning the stomach with air or oxygen is sometimes
helpful, but the distension fixes the stomach, lessens the mobility of
the arch of the diaphragm, and thus lessens the lateral range of
gastroscopic vision. Furthermore, ballooning pushes the gastric walls
far away from the reach of the tube-mouth. A window plug (Fig. 6) is
inserted into the ocular end of the gastroscope for the ballooning
 Like many other valuable diagnostic means, gastroscopy is very
valuable in its positive findings. Negative results are entitled to
little weight except as to the explorable area.
The gastroscopist working in conjunction with the abdominal surgeon
should be able to render him invaluable assistance in his work on the
stomach. The surgeon with his gloved hand in the abdomen, by
manipulating suspected areas of the stomach in front of the tube-mouth
can receive immediately a report of its interior appearance, whether
cancerous, ulcerated, hemorrhagic, etc.
Lens-system ballooning gastroscopy may possibly afford additional
information after all possible data from open-tube gastroscopy has
been obtained. Care must be exercised not to exert an injurious degree
of air-pressure. The distended portion of the stomach assumes a
funnel-like form ending at the apex in a depression with radiating
folds, that leads the observer to think he is looking at the pylorus.
The foreshortening produced by the lens system also contributes to
this illusion. The best lens-system gastroscope is that of Henry
Janeway, which combines the open-tube and the lens system.
Gastroscopy for Foreign Bodies.--The great majority of foreign
bodies that reach the stomach unassisted are passed per rectum,
provided the natural protective means are not impaired by the
administration of cathartics, changes in diet, etcetera. This,
however, does not mean that esophageal foreign bodies should be pushed
into the stomach by blind methods, or by esophagoscopy, because a
swallowed object lodged in the esophagus can always be returned
through the mouth. Foreign bodies in the stomach and intestines should
be fluoroscopically watched each second day. If an object is seen to
lodge five days in one location in the intestines, it should be
removed by laparotomy, since it will almost certainly perforate.
Certain objects reaching the stomach may be judged too large to pass
the pylorus and intestinal angles. These should be removed by
gastroscopy when such decision is made. It is to be remembered that
gastric foreign bodies may be regurgitated and may lodge in the
esophagus, whence they are easily removed by esophagoscopy. The
double-planed fluoroscope of Manges is helpful in the removal of
gastric foreign bodies, but there is great danger of injury to the
stomach walls, and even the peritoneum, unless forceps are used with
the utmost caution.
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