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Rules For Endoscopic Foreign Body Extraction

Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

1. Never endoscope a foreign body case unprepared, with the idea of

taking a preliminary look.

2. Approach carefully the suspected location of a foreign body, so

as not to override any portion of it.

[175] 3. Avoid grasping a foreign body hastily as soon as seen.

4. The shape, size and position of a foreign body, and its relations

to surrounding structures, should be studied before attempting to

the forceps. (Exception cited in Rule 10.)

5. Preliminary study of a foreign body should be from a distance.

6. As the first grasp of the forceps is the best, it should be well

planned beforehand so as to seize the proper part of the intruder.

7. With all long foreign bodies the motto should be Search, not for

the foreign body, but for its nearer end. With pins, needles, and the

like, with point upward, search always for the point. Try to see it


8. Remember that a long foreign body grasped near the middle

becomes, mechanically speaking, a toggle and ring.

9. Remember that the mortality to follow failure to remove a foreign

body does not justify probably fatal violence during its removal.

10. Laryngeally lodged foreign bodies, because of the likelihood

of dislodgment and loss, may be seized by any part first presented,

and plan of withdrawal can be determined afterward.

11. For similar reasons, laryngeal cases should be dealt with only

in the author's position (Fig. 53).

12. An esophagoscopy may be needed in a bronchoscopic case, or a

bronchoscopy in an esophageal case. In every case both kinds of tubes

should be sterile and ready before starting. It is the unexpected that

happens in foreign body endoscopy.

13. Do not pull on a foreign body unless it is properly grasped to

come away readily without trauma. Then do not pull hard.

14. Do no harm, if you cannot remove the foreign body.

15. Full-curved hooks are to be used in the bronchi with greatest

caution, if used at all, lest they catch inextricably in branch


[176] 16. Don't force a foreign body downward. Coax it back. The

deeper it gets the greater your difficulties.

17. The watchword of the bronchoscopist should be, If I can do no

good, I will at least do no harm.

Fluoroscopic bronchoscopy is so deceptively easy from a superficial,

theoretical, point of view that it has been used unsuccessfully in

cases easily handled in the regular endoscopic way with the eye at the

proximal tube-mouth. In a collected series of cases by various

operators the object was removed in 66.7 per cent with a mortality of

41.6 per cent. In the problem of a pin located out of the field of

bronchoscopic vision, the fluoroscopist will yield invaluable aid. An

extremely delicate forceps is to be inserted closed into the invaded

bronchus, the grasp on the object being confirmed by the

fluoroscopist. It is to be kept in mind that while the object itself

may be in the grasp of the forceps, the fluoroscope will not show

whether there may not be included in the forceps' grasp a bronchial

spur or other tissue, the tearing of which may be fatal. Therefore

traction must not be sufficient to lacerate tissue. If the foreign

body does not come readily it must be released, and a new grasp may

then be taken. All of the cautions in faulty seizure already

mentioned, apply with particular force to fluoroscopic bronchoscopy.

The fluoroscope is of aid in finding foreign bodies held in abscess

cavities. The fluoroscope should show both the lateral and

anteroposterior planes. To accomplish this quickly, two Coolidge tubes

and two screens are necessary. Fluoroscopic bronchoscopy, because of

its high mortality and low percentage of successes, should be tried

only after regular, ocularly guided, peroral bronchoscopy has failed,

and only by those who have had experience in ocularly guided