Extraction Of Foreign Bodies From The Strictured Esophagus





Foreign

bodies of relatively small size will lodge in a strictured esophagus.

Removal may be rendered difficult when the patient has an upper

stricture relatively larger than the lower one, and the foreign body

passing the first one lodges at the second. Still more difficult is

the case when the second stricture is considerably below the first,

and not concentric. Under these circumstances it is best to divulse

the upper stricture mechanically, when a small tube can be inserted

past the first stricture to the site of lodgement of the foreign body.



Prolonged sojourn of foreign bodies in the esophagus, while not so

common as in the bronchi is by no means of rare occurrence. Following

their removal, stricture of greater or less extent is almost certain

to follow from contraction of the fibrous-tissue produced by the

foreign body.



Fluoroscopic esophagoscopy is a questionable procedure, for the

esophagus can be explored throughout by sight. In cases in which it is

suspected that a foreign body, such as pin, has partially escaped from

the esophagus, the fluoroscope may aid in a detailed search to

determine its location, but under no circumstances should it be the

guide for the application of forceps, because the transparent but

vital tissues are almost certain to be included in the grasp.



[197] Complications and Dangers of Esophagoscopy for Foreign Bodies.

Asphyxia from the pressure of the foreign body, or the foreign body

plus the esophagoscope, is a possibility (Fig. 91). Faulty position of

the patient, especially a low position of the head, with faulty

direction of the esophagoscope may cause the tube mouth to press the

membranous tracheo-esophageal wall into the trachea, so as temporarily

to occlude the tracheal lumen, creating a very dangerous situation in

a patient under general anesthesia. Prompt introduction of a

bronchoscope, with oxygen and amyl nitrite insufflation and artificial

respiration, may be necessary to save life. The danger is greater, of

course, with chloroform than with ether anesthesia. Cocain poisoning

may occur in those having an idiosyncrasy to the drug. Cocain should

never be used with children, and is of little use in esophagoscopy in

adults. Its application is more annoying and requires more time than

the esophagoscopic removal of the foreign bodies without local

anesthesia. Traumatic esophagitis, septic mediastinitis, cervical

cellulitis, and, most dangerous, gangrenous esophagitis may be

present, caused by the foreign body itself or ill-advised efforts at

removal. Perforation of the esophagus with the esophagoscope is rare,

in skillful hands, if the esophageal wall is sound. The esophageal

wall, however, may be weakened by ulceration, malignant disease, or

trauma, so that the possibility of making a false passage should

always deter the endoscopist from advancing the tube beyond a visible

point of weakening. To avoid entering a false passage previously

created, is often exceedingly difficult, and usually it is better to

wait for obliterative adhesive inflammation to seal the tissue layers

together.





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