A new prototype 2-channel upper gastrointestinal operating fiberscope Walter D. Gaisford, MD Salt Lake City, Utah
The prototype of a new, dual channel, operating, peroral fiberscope (Olympus TGF) is described, and its clinical use in 75 patients is reviewed. Although the new instrument probably will not replace the smaller caliber, more maneuverable, standard fiberscope for routine upper gastrointestinal examination, it can be invaluable for endoscopic treatment of bleeding lesions, removal and retrieval of polyps, the dissolution of bezoars, and the extraction of foreign bodies.
Earlier models of upper gastrointestinal fiberscopes were designed for diagnostic examinations and simplicity of application. A new generation of fiberscopes is now evolving, and current prototypes emphasize operating capability. The latter requires larger and multiple instrument channels. One of these prototypes, a 2-channel upper gastrointestinal fiberscope designated as Olympus TGF, has been evaluated clinically in 75 patients and contrasted with the author's experience in over 1,000 procedures with the single channel fiberscope, Olympus GIF-D. THE INSTRUMENT The Olympus TGF has a working length of 106 cm and an outside diameter of 13.6 mm (Figure 1). The 2 instrument channels measure 3.2 mm and 2.8 mm, and both channels have suction capability. At its distal end each channel has a controllable instrument elevator maneuvered at the head of the 'scope by the operator's thumb on the elevator
control knobs. The bending section of thetip allows forturning 1800 up, 1000 down, left and right. Control knobs and trumpet valves for insufflation, lens washing, and suction are similar to previous model single channel fiberscopes.,·2 Special operating instruments used through the 2 channels included electrosurgical snare devices, various biopsy forceps, irrigating cannulas, fulgurating electrodes, polyp grasping forceps, and foreign body grasping forceps. Cold light sources used with the fiberscope included the halogen lamp CLE and the xenon lamp CLX (Olympus). The electrosurgical fulgurating unit was the Valley Lab SSE-2. CLINICAL METHODS Preliminary clinical experience with the TGF 2-channel 'scope included elective and emergency diagnostic esophagogastroduodenoscopy and elective and emergency endoscopic operating procecures in 75 patients. Elective diagnostic examinations and operative procedures
Reprint requests: Walter D. Gaisford, MD, 508 East on South Temple, Salt Lake City, Utah 84102. 148
GASTROINTESTINAL ENDOSCOPY
were performed on inpatients and outpatients after a 6 to 8 hour fast. The patients gargled with 20 ml of Dyclone 0.5% and were given mild intravenous sedation with meperidine 25 mg to 50 mg and diazepam 2.5 mg to 10 mg. The patients were examined in the left lateral decubitus position. The TGF end-viewing 'scope was passed through the oral pharynx under direct vision smoothly in all but 6 patients. In these 6 patients, the passage of the larger fiberscope through the pharynx was facilitated by the preliminary passage of the teflon washing-pipe through the 'scope and through the pharynx into the esophagus as a guide to insertion under direct vision. The esophagus, entire stomach, pylorus, and duodenum to the third or fourth part were examined in each patient. A U-turn maneuver of the 'scope was usually done for retrograde examination of the fundus and esophagogastric junction from below. Still and cine photography was done in selected cases. Small and large biopsies were obtained as needed. Operative endoscopic procedures included gastric polypectomies, removal of foreign bodies, placement of esophageal prosthetic conduit, debridement of gastric bezoars, and fulguration of actively bleeding lesions including peptic ulcers of the stomach and duodenum, Mallory-Weiss tears, gastric varices, gastric polyps, gastric leiomyoma, and ulcerated esophageal diverticulum.
A
TECHNIQUES Upper gastrointestinal bleeding. Emergency
c
h
Figure 1 A, The 2-channel upper gastrointestinal operating fiberscope (Olympus TeF); 2 instruments have been passed through the dual channels and 4 accessory biopsy and grasping forceps are shown. B, The handle incorporates control knobs for distal bending section, trumpet valves for air insufflation, lens washing and suction, openings for 2 instrument channels and 2 control knobs for distal tip instrument elevators. C, Close-up view of distal tip with fulgurating electrode (a) and washing pipe (b) projecting through the 2 instrument channels, (cl and (d) elevators for instruments, (e) light guide where cold light is emitted, (f) objective lens, (g) air/water feeding ports for washing lens and air insufflation, (h) rubber hood. VOLUME 22, NO.3, 1976
fiberendoscopy for upper gastrointestinal bleeding was performed in the hospital intensive care unit after initial resucitation and when the patients' vital signs were reasonably stabilized. Under these conditions the patients were given minimal intravenous sedation and were examined in the bed lying on their left side. Gastric lavage and controlled reflex~induced vomiting were used to clear the stomach of large clots. After completion of the examination of the esophagus, lower body, antrum, pylorus, and duodenum to the fourth part, the patient (with the 'scope in place) was turned to the right lateral decubitus position. This maneuver greatly facilitates accurate evaluation of the upper body, fundus, and gastroesophageal junction from below because it allows remaining clot and blood to then pass by gravity into the antrum and duodenum which were previously examined. For active bleeding, the washing pipe was passed through one of the channels and left in place for simultaneous target irrigation and suction through the second channel. When the exact site of active bleeding was localized, a fulgurating probe was passed down the second channel and simultaneous target irrigation and accurate target fulguration of the bleeding vessel were performed. Using this technic, minimal fulgurating current was used thus avoiding unnecessary tissue damage and minimizing the risks of perforation (Figure 2). Gastric polypectomy. The general technique used was similar to that previously outlined for the single channel 'scope 2 However, the second channel was used for passing a grasping forceps and securing the gastric polyp before electrosurgical snare excision. This maneuver insures that the excised polyp will not suddenly disappear through the pylorus and down the duodenum never to be seen again. Grasping forceps passed through the opened snare wire were also used to position difficult semipedunculated or sessile gastric polyps for accurate snare placement. 149
Figure 2 a, Bleeding gastric varix in 80 year old man with portal vein thrombosis. b, Simultaneous target irrigation and electrofulguration of bleeding site. c, Immediate appearance after fulguration. d, Appearance 4 days after fulguration. Gastric bezoars. Mechanical debridement and breaking-up of thickly congealed bezoars were aided by using 2 different grasping forceps simultaneously. Total treatment of these phytobezoars included multiple direct injections with enzymes (through washing pipes), mechanical debridement, and post-endoscopic oral Gastroenterase® and clear liquid diet for several days. Placement of tubes, removal of foreign bodies. The second channel was used in these cases to grasp the tube or foreign body with another forceps to control more accurately positioning and to obtain a firmer grip. The large channel also allowed the free passage of a larger grasping forceps to obtain a secure hold on the foreign body. RESULTS The experience with the TGF Olympus 2-channel upper gastrointestinal fiberscope was compared with the author's experience in over 1,000 procedures with the single channel GIF-D Olympus 'scope. The TGF instrument was successfully used in 73 patients. In 2 patients it was not possible to safely pass the larger diameter tip into the esophagus because of small neck structures, unusual angulation of the pharynx, and probably pharyngeal spasm. In these 2 cases the GIF-D instrument was subsequently intubated into the esophagus, stomach, and duodenum without difficulty. Although successful examination of the duodenum to the third or fourth part was accomplished in each attempt, the larger TGF 'scope was more difficult to pass around the superior duodenal angle. Retrograde flexion and U-turn maneuver of the TGF 'scope in the stomach was more difficult but could be accomplished in most patients. Post-endoscopic pharyngeal soreness was an uncommon minor complaint after use of the TGF 'scope, butthis did not seem to be increased in frequency Table I. Fulguration of active upper gastrointestinal bleeding with the TGF 2-channel fiberscope. type of lesion
number of
hemostasis obtained
patients
permanenVtemporary
number of
patients requiring subsequent operation
Esophageal diverticular ulcer Mallory-Weiss tear Gastric varix Gastric ulcer Gastric leiomyoma Channel ulcer Duodenal ulcer
150
o o o
1
1
3
3
2
9
2 7
1
1
o
2 2
2 2
o
20
18
2
2
or severity over that with use of the GIF 'scope. The single most valuable application of the new 2-channel 'scope was in the management of active upper gastroi ntestinal bleeding (Table I). Thirty-five patients were emergently examined with the TGF fiberscope because of upper gastrointestinal bleeding. A complete fiberendoscopy and accurate diagnosis were accomplished in 34 patients. In 1 patient the endoscopic examination eliminated the esophagus, fundus, antrum, and duodenum as the sites of bleeding; a suspected area on the lesser curvature was noted, but the exact site could not be seen because of adherent clot. Localization of the bleeding site to that area greatly assisted the surgical approach in that patient. Endoscopic control of bleeding by fulguration was attempted in 20 patients with the TGF instrument and was successful in each patient. Permanent hemostasis was achieved in 18 patients who had no further bleeding and did not require subsequent surgery. In 2 patients complete but temporary hemostasis was achieved; after 24 hours these patients had a second bleeding episode but were normovolemic and had prompt, successful, open abdominal surgery. One patient who had complete endoscopic hemostasis of bleeding had a subsequent elective gastrectomy for chronic peptic ulcer disease. There were no complications in the series of patients examined and treated with the TGF fiberscope. COMMENT The major advantages of the larger TGF 2-channel fiberscope are (1) improved irrigation-suction capability in bleeding, (2) simultaneous target irrigation and suction, (3) simultaneous target irrigation and electrofulguration, (4) elevator controls for both channel instruments, (5) large biopsy and immediate fulguration capability, (6) accurate positioning of polyps preparatory to snaring, and (7) postexcision control of polyp retrieval. Although the advantages are significant, the TGF fiberscope has the disadvantages of being slightly more difficult to intubate, more difficult to maneuver in the duodenum, and more difficult to retroflex in the stomach for examination of the fundus and cardia. As a routine upper gastrointestinal examining 'scope, it is too large. As an operating 'scope for elective surgical procedures and for emergency management of gastrointestinal bleeding, it offers many improvements and advantages over the standard, single channel instrument.
1
2
3
REFERENCES 1. GAISFORD W D: Gastrointestinal fiberendoscopyAmj Surg 124:744, 1972 2. GAISFORD W D: Gastrointestinal polypectomy via the fiberscope Arch Surg 106:458, 1973
GASTROINTESTINAL ENDOSCOPY
The prototype of a new, dual channel, operating, peroral fiberscope (Olympus TGF) is described, and its clinical use in 75 patients is reviewed. Although the new instrument probably will not replace the smaller caliber, more maneuverable, standard fiberscope for routine upper gastrointestinal examination, it can be invaluable for endoscopic treatment of bleeding lesions, removal and retrieval of polyps, the dissolution of bezoars, and the extraction of foreign bodies.
Earlier models of upper gastrointestinal fiberscopes were designed for diagnostic examinations and simplicity of application. A new generation of fiberscopes is now evolving, and current prototypes emphasize operating capability. The latter requires larger and multiple instrument channels. One of these prototypes, a 2-channel upper gastrointestinal fiberscope designated as Olympus TGF, has been evaluated clinically in 75 patients and contrasted with the author's experience in over 1,000 procedures with the single channel fiberscope, Olympus GIF-D. THE INSTRUMENT The Olympus TGF has a working length of 106 cm and an outside diameter of 13.6 mm (Figure 1). The 2 instrument channels measure 3.2 mm and 2.8 mm, and both channels have suction capability. At its distal end each channel has a controllable instrument elevator maneuvered at the head of the 'scope by the operator's thumb on the elevator
control knobs. The bending section of thetip allows forturning 1800 up, 1000 down, left and right. Control knobs and trumpet valves for insufflation, lens washing, and suction are similar to previous model single channel fiberscopes.,·2 Special operating instruments used through the 2 channels included electrosurgical snare devices, various biopsy forceps, irrigating cannulas, fulgurating electrodes, polyp grasping forceps, and foreign body grasping forceps. Cold light sources used with the fiberscope included the halogen lamp CLE and the xenon lamp CLX (Olympus). The electrosurgical fulgurating unit was the Valley Lab SSE-2. CLINICAL METHODS Preliminary clinical experience with the TGF 2-channel 'scope included elective and emergency diagnostic esophagogastroduodenoscopy and elective and emergency endoscopic operating procecures in 75 patients. Elective diagnostic examinations and operative procedures
Reprint requests: Walter D. Gaisford, MD, 508 East on South Temple, Salt Lake City, Utah 84102. 148
GASTROINTESTINAL ENDOSCOPY
were performed on inpatients and outpatients after a 6 to 8 hour fast. The patients gargled with 20 ml of Dyclone 0.5% and were given mild intravenous sedation with meperidine 25 mg to 50 mg and diazepam 2.5 mg to 10 mg. The patients were examined in the left lateral decubitus position. The TGF end-viewing 'scope was passed through the oral pharynx under direct vision smoothly in all but 6 patients. In these 6 patients, the passage of the larger fiberscope through the pharynx was facilitated by the preliminary passage of the teflon washing-pipe through the 'scope and through the pharynx into the esophagus as a guide to insertion under direct vision. The esophagus, entire stomach, pylorus, and duodenum to the third or fourth part were examined in each patient. A U-turn maneuver of the 'scope was usually done for retrograde examination of the fundus and esophagogastric junction from below. Still and cine photography was done in selected cases. Small and large biopsies were obtained as needed. Operative endoscopic procedures included gastric polypectomies, removal of foreign bodies, placement of esophageal prosthetic conduit, debridement of gastric bezoars, and fulguration of actively bleeding lesions including peptic ulcers of the stomach and duodenum, Mallory-Weiss tears, gastric varices, gastric polyps, gastric leiomyoma, and ulcerated esophageal diverticulum.
A
TECHNIQUES Upper gastrointestinal bleeding. Emergency
c
h
Figure 1 A, The 2-channel upper gastrointestinal operating fiberscope (Olympus TeF); 2 instruments have been passed through the dual channels and 4 accessory biopsy and grasping forceps are shown. B, The handle incorporates control knobs for distal bending section, trumpet valves for air insufflation, lens washing and suction, openings for 2 instrument channels and 2 control knobs for distal tip instrument elevators. C, Close-up view of distal tip with fulgurating electrode (a) and washing pipe (b) projecting through the 2 instrument channels, (cl and (d) elevators for instruments, (e) light guide where cold light is emitted, (f) objective lens, (g) air/water feeding ports for washing lens and air insufflation, (h) rubber hood. VOLUME 22, NO.3, 1976
fiberendoscopy for upper gastrointestinal bleeding was performed in the hospital intensive care unit after initial resucitation and when the patients' vital signs were reasonably stabilized. Under these conditions the patients were given minimal intravenous sedation and were examined in the bed lying on their left side. Gastric lavage and controlled reflex~induced vomiting were used to clear the stomach of large clots. After completion of the examination of the esophagus, lower body, antrum, pylorus, and duodenum to the fourth part, the patient (with the 'scope in place) was turned to the right lateral decubitus position. This maneuver greatly facilitates accurate evaluation of the upper body, fundus, and gastroesophageal junction from below because it allows remaining clot and blood to then pass by gravity into the antrum and duodenum which were previously examined. For active bleeding, the washing pipe was passed through one of the channels and left in place for simultaneous target irrigation and suction through the second channel. When the exact site of active bleeding was localized, a fulgurating probe was passed down the second channel and simultaneous target irrigation and accurate target fulguration of the bleeding vessel were performed. Using this technic, minimal fulgurating current was used thus avoiding unnecessary tissue damage and minimizing the risks of perforation (Figure 2). Gastric polypectomy. The general technique used was similar to that previously outlined for the single channel 'scope 2 However, the second channel was used for passing a grasping forceps and securing the gastric polyp before electrosurgical snare excision. This maneuver insures that the excised polyp will not suddenly disappear through the pylorus and down the duodenum never to be seen again. Grasping forceps passed through the opened snare wire were also used to position difficult semipedunculated or sessile gastric polyps for accurate snare placement. 149
Figure 2 a, Bleeding gastric varix in 80 year old man with portal vein thrombosis. b, Simultaneous target irrigation and electrofulguration of bleeding site. c, Immediate appearance after fulguration. d, Appearance 4 days after fulguration. Gastric bezoars. Mechanical debridement and breaking-up of thickly congealed bezoars were aided by using 2 different grasping forceps simultaneously. Total treatment of these phytobezoars included multiple direct injections with enzymes (through washing pipes), mechanical debridement, and post-endoscopic oral Gastroenterase® and clear liquid diet for several days. Placement of tubes, removal of foreign bodies. The second channel was used in these cases to grasp the tube or foreign body with another forceps to control more accurately positioning and to obtain a firmer grip. The large channel also allowed the free passage of a larger grasping forceps to obtain a secure hold on the foreign body. RESULTS The experience with the TGF Olympus 2-channel upper gastrointestinal fiberscope was compared with the author's experience in over 1,000 procedures with the single channel GIF-D Olympus 'scope. The TGF instrument was successfully used in 73 patients. In 2 patients it was not possible to safely pass the larger diameter tip into the esophagus because of small neck structures, unusual angulation of the pharynx, and probably pharyngeal spasm. In these 2 cases the GIF-D instrument was subsequently intubated into the esophagus, stomach, and duodenum without difficulty. Although successful examination of the duodenum to the third or fourth part was accomplished in each attempt, the larger TGF 'scope was more difficult to pass around the superior duodenal angle. Retrograde flexion and U-turn maneuver of the TGF 'scope in the stomach was more difficult but could be accomplished in most patients. Post-endoscopic pharyngeal soreness was an uncommon minor complaint after use of the TGF 'scope, butthis did not seem to be increased in frequency Table I. Fulguration of active upper gastrointestinal bleeding with the TGF 2-channel fiberscope. type of lesion
number of
hemostasis obtained
patients
permanenVtemporary
number of
patients requiring subsequent operation
Esophageal diverticular ulcer Mallory-Weiss tear Gastric varix Gastric ulcer Gastric leiomyoma Channel ulcer Duodenal ulcer
150
o o o
1
1
3
3
2
9
2 7
1
1
o
2 2
2 2
o
20
18
2
2
or severity over that with use of the GIF 'scope. The single most valuable application of the new 2-channel 'scope was in the management of active upper gastroi ntestinal bleeding (Table I). Thirty-five patients were emergently examined with the TGF fiberscope because of upper gastrointestinal bleeding. A complete fiberendoscopy and accurate diagnosis were accomplished in 34 patients. In 1 patient the endoscopic examination eliminated the esophagus, fundus, antrum, and duodenum as the sites of bleeding; a suspected area on the lesser curvature was noted, but the exact site could not be seen because of adherent clot. Localization of the bleeding site to that area greatly assisted the surgical approach in that patient. Endoscopic control of bleeding by fulguration was attempted in 20 patients with the TGF instrument and was successful in each patient. Permanent hemostasis was achieved in 18 patients who had no further bleeding and did not require subsequent surgery. In 2 patients complete but temporary hemostasis was achieved; after 24 hours these patients had a second bleeding episode but were normovolemic and had prompt, successful, open abdominal surgery. One patient who had complete endoscopic hemostasis of bleeding had a subsequent elective gastrectomy for chronic peptic ulcer disease. There were no complications in the series of patients examined and treated with the TGF fiberscope. COMMENT The major advantages of the larger TGF 2-channel fiberscope are (1) improved irrigation-suction capability in bleeding, (2) simultaneous target irrigation and suction, (3) simultaneous target irrigation and electrofulguration, (4) elevator controls for both channel instruments, (5) large biopsy and immediate fulguration capability, (6) accurate positioning of polyps preparatory to snaring, and (7) postexcision control of polyp retrieval. Although the advantages are significant, the TGF fiberscope has the disadvantages of being slightly more difficult to intubate, more difficult to maneuver in the duodenum, and more difficult to retroflex in the stomach for examination of the fundus and cardia. As a routine upper gastrointestinal examining 'scope, it is too large. As an operating 'scope for elective surgical procedures and for emergency management of gastrointestinal bleeding, it offers many improvements and advantages over the standard, single channel instrument.
1
2
3
REFERENCES 1. GAISFORD W D: Gastrointestinal fiberendoscopyAmj Surg 124:744, 1972 2. GAISFORD W D: Gastrointestinal polypectomy via the fiberscope Arch Surg 106:458, 1973
GASTROINTESTINAL ENDOSCOPY
