Anatomical Data

The length of the esophagus ranges from 20 to 34 cm in adults. The esophagus has three physiologic constrictions that are relevant to endoscopy. The first constriction, caused by the tone of the constrictor muscles, is located at the esophageal inlet approximately 14 cm (12–16 cm) from the upper incisor teeth. The middle constriction, formed by the aortic arch and left main bronchus, is located ca. 27 cm (22–29 cm) from the upper incisor teeth, and the lower constriction (cardia) is located at ca. 41 cm (32–50 cm).

Esophagoscopy can be performed with a rigid tube or flexible esophagoscope. The indications for both methods overlap somewhat, but the choice of an endoscope will depend partly on the preference and experience of the surgeon. The rigid esophagoscope can be used both diagnostically and therapeutically and is the instrument of choice for foreign body extractions. Fiber-optic instruments, on the other hand, are better for performing diagnostic endoscopy under local anesthesia. This technique is often combined with gastroduodenoscopy.

Surgical Principle

A rigid tube is introduced transorally into the esophagus for dilation, inspection, incisional biopsy, or foreign body extraction.

Indications

Suspected foreign body in the esophagus.

Esophageal polyps.

Dilation of strictures or webs.

Suspected esophageal neoplasm.

Investigation of wall changes due to caustic ingestion.

Cardiospasm.

Suspected esophageal varices or for sclerotherapy (flexible esophagoscopy is generally preferred).

Contraindications

Severe changes in the cervical or thoracic spine.

Severe systemic diseases that would contraindicate general anesthesia.

Specific Points Regarding Informed Consent

Dental injury or tooth loss.

Dysphagia, gastric intubation.

Hoarseness or voice loss.

Dyspnea, which may necessitate a tracheostomy.

Mucosal injury, perforation of the esophageal wall.

Pneumonitis with associated lung changes.

Mediastinitis.

Paralysis of the lingual nerve and hypoglossal nerve.

Subcutaneous emphysema in the neck.

Operative Planning

Contrast radiography of the esophagus. Barium should be withheld if there is possible esophageal wall injury from a foreign body or risk of aspiration.

Special Instruments

Esophagoscopes of assorted lengths and diameters. Endoscopic forceps, cup forceps, suction tips, dilators, optical esophagoscope with telescopes (if needed), optical forceps, and apparatus for air insufflation. The tube length and diameter should conform to patient anatomy (height, age, sex, condition of cervical spine).

Anesthesia

General endotracheal anesthesia (relatively large endotracheal tube with minimal cuff inflation, complete muscular relaxation).

Surgical Technique

Positioning. Supine with the head initially elevated for introducing the endoscope. As the endoscope is advanced, the head is lowered. Protection of the upper teeth is mandatory.

Entering the esophagus. To advance the scope across the esophageal inlet, the patient’s head is slightly lowered until the transverse opening of the inlet is centered in the field of view. With the patient fully relaxed, the surgeon can easily advance the tube into the esophagus with just two fingers and without having to apply force.

Stabilizing the tube. The left hand stabilizes the tube against the dental arch while simultaneously protecting the teeth and retracting the lips.

Fig. 12.1a–f Rigid esophagoscopy.

a The head is elevated and tilted back for insertion of the esophago-scope. The pharynx is expanded with a laryngoscope blade.

b The tip of the tube is carefully advanced behind the visible arytenoid cartilages.

c When the tip of the scope has passed through the esophageal inlet, the head is lowered.

d This permits the tube to remain centered on the esophageal lumen.

e At deeper levels the head is lowered further and the tip of the tube is elevated slightly in the anterior direction.

f With a pneumatic esophagoscope, visualization is improved by insufflating air into the esophagus.

Postoperative Care

No special measures are necessary after esophagoscopy. Oral intake may have to be withheld in patients with mucosal lesions. Antibiotic coverage is generally withheld as it could mask an incipient mediastinitis.

Foreign bodies most frequently become lodged at the first esophageal constriction and less commonly at the second or third constriction. Predisposing factors are esophageal strictures due to caustic ingestion or neoplasia.

Surgical Technique

Exposure of the foreign body. The esophagoscope is introduced as described above, and the foreign body is visualized. The tip of the scope is brought to bear on the foreign body, which should be centered in the tube. Occasionally the foreign body is lost to view when the tube is advanced but is reacquired by withdrawing the tube slightly.

Extraction of smooth-surfaced foreign bodies. Smooth-surfaced foreign bodies such as coins and buttons are grasped with an alligator forceps or other suitable instrument, pulled against the end of the tube, and carefully extracted along with the tube. The scope is then reintroduced to inspect the esophagus for injuries or additional foreign bodies.