Oesophagoscopy

Oesophagoscopy is of two types:
1. Rigid oesophagoscopy.
2. Flexible fibre-optic oesophagoscopy.
RIGID OESOPHAGOSCOPY
Indications
A. Diagnostic
1. To inves tigate cause for dysphag ia, e. g. cancer
oesophagus, cardiac achalas ia, strictures, oesophagitis,
diverticula, etc.
2. To find cause for retrosternal burning, e.g. reflux
oesophag itis or hiatus hernia.
3. To find cause for haematemesis, e.g. oesophageal
varices.
4. Secondaries neck with unknown primary (as a pan
of panendoscopy).
B. Therapeutic
1. Remova l of a foreign body.
2. Dilatation in case of oesophageal strictures or card
iac achalas ia.
3. Endoscopic removal of benign lesio ns, e. g. fibrom a,
papilloma, cysts, etc.
4. Insertion of Soutar's or Mou sseau ~B a rb in tube in
palliati ve treatment of oesophageal carcinoma.
5. Injection of oesophageal varices.
Contraindications
l.
2.
Trismus-makes the procedure technically difficult.
Disease of cervical spine, e.g. cervical trauma, spondylosis,
tu be rculous sp ine, osteophytes, kyphos is. They
make rigid oesophagoscopy technically difficult. Flexible
fibre -optic oesophagoscopy is performed in these
cases.
3. Receding mandible.
4. Aneurysm of aorta for fear of rupture and fatal haemorrhage.
5. Advanced heart, liver or kidney disease may be a
relative contraindication.
Anaesthesia
Genenll anaesthesia with oro-tracheal intubation, with
tube in the left corner of the mouth. it can be performed
under local anaesthesia in seleC(ed ind ividuals.
Position
Same as for direct laryngoscopy. Patient lies supine, head
is elevated by 10-15 cm, neck flexed on chest, and head
extended at adanto-occipital jo int. The purpose of this
positio n is to attain the axes of mouth, pharynx and
oesophagus in a straight line to pass the rigid tube easily.
This position can be achieved with the help of an ass istant
or a special head rest.
Technique
1. A piece of gauze is placed over the upper teeth to
protect teeth and lips.
2. Oesophagoscope is lubricated with a swab of autoclaved
liquid paraffin or jelly.
3. The oesophagoscope is held by its proximal end in
a pen-like fashion and introduced into the mouth
by the right side of the tongue and then towards the
midd le of its dorsum.
Now there a re 4 basic steps:
1. Identification of drytenoids. Once oesophagoscope
has been introduced to the back of tongue, it is
advanced gently by the left thumb and index finge r.
Epiglo ttis is first seen , then the endotracheal tube
and a little furth er down arytenoids can be identified.
2. Passing the cricophar)'ngeal sphincter. Keeping the tip
of oesophagoscope stric tly in the midline, behind
the larynx, it is lifted with movements of left thumb
to open the h ypopharynx. With slow but sustained
pressure, the sph incter will open and then the tip of
oesophagoscope can be guided easily into the
oesophag us. Never apply force to open the sphincter.
Sometimes, a fine bougie can be lIsed to find the
lumen. An add itional dose of muscle relaxant may
be required if sphincter does not open. Once oeso~
phagus has been entered, it is easier to advance the
scope, provided, oesophagea l lumen is kept constantly
in view.
3. Crossing the aortic arch and left bronchus. In an adult.
this natural narrowing lies about 25 cm from the
incisors. Aortic pulsa tion can be seen . When cro~sing
this area, head of the patient is slightly lowe red
so that oesophageal lumen is in line with that of the
scope.
4. Passing the cardia. Head and shoulders remain be 10\\'
the level of the table, head being slightly higher
than the shoulders and moved slightly to the right
At this stage, the oesophagoscope points to the lefr
ante rior-superior iliac spine. Cardia is identified b)
its redder and more velvety or rugose mucosa.
Never forget to inspect the oesophageal wall again
when the oesophagoscope is withdrawn.
Post-operative Care
1. Sips of plain water followed by usual diet may be
given in an uneventful oesophagoscopy.
2. Pat ient is watched for pain in the interscapular region,
surgical emphysema of neck, and ahrupt rise of temperatu
re. They indicate oesophageal perfora tion.
Complications
1. Injury to lips and teeth.
2. InJulY to ar)' tenoids.
3. Injur )' to pharyngeal mucosa. They are al l the result of
careless technique and can be avoided.
4. Perforation of oesophagus. Most often it occurs at the
site of Killian's dehiscence (near cricopharyngeal
sphincter) when undue force has been used to l'ass
the oesophagoscope. Surgical emphysema develops
within an hOLlr or so and the patient complains of
pain in the interscapular region. This may be complicated
by abscess in retropharyngeal space or
mediastinum ..
5. Compression of trachea. Oesophagoscope may press on
posterior tracheal wall, especially in child ren, causing
obstruction to respiration and cyanosis. Treatment is
immediate withdrawal of oesophagoscope.
FLEXIBLE FIBRE OPTIC OESOPHAGOSCOPY
Irs main ad va ntage over the rigid oesophagoscopy is
that it is an outdoor procedure , does not require general
anaesthes ia and can be used in patients wi th abnormalities
of spine or jaw where rigid endoscopy is technica
lly difficult. The oesophagus, stomach and duodenum
can all be examined in one sitting. Good illumination
and magni ication provided by the fibrescope helps in
the accurate diagnosis of the mucosa l disease affecting
these sites an.J permits taking of prec ision biopsies,
remova l of small fore ign bodies or benign tumours,
dila tation of webs or strictures and even injection of
bleeding varices with scleroSing agents. In ca 'es of malignant
disease, oesophrtgeal stent can be placed as a palliative
measure.
The procedure is pelfonned under local anaesthesia
with or without intravenous sed ation. The patient lies in
left lateral position and fib r>scope is pas eJ th rough a plastic
mouth prop inro the pharynx, post-cricoid area and
oesophagus, insufflating air as the endoscope is advanced,
to open tl1e lumen of oesophagus. These days flexible fibre
optic oesophagoscopy has practically replaced rigid
oesophagoscopyexc pt in some cases of foreign bodies.