Pediatric therapeutic endoscopy using standard fiberoptic instruments Paul Rozen, MD Tuvia Gilat, MD Tel Aviv, Israel
Standard, adult-sized, forward-viewing endoscopes were used in 3 children, 9 months to 6 years old, for therapeutic procedures. This experience illustrates the feasibility of using standard instruments in infants and their advantages over special pediatric endoscopes in therapeutic endoscopy.
Other than the reports of Rosch and Classen et al Y most descriptions of fiberendoscopic therapeutic procedures, such as the removal of intragastric foreign bodies, concern adults.3.4 In children, diagnostic endoscopy has been made easier with the production of special pediatric instruments. s However, these lack the facility for therapeutic procedures, a common reason for endoscopy in this age group. For this reason we would like to describe the successful use of standard, adult-sized instruments in infants for diagnostic and therapeutic procedures. CASE REPORTS 1. A 9 month old female infant was seen after ENT surgeons, using a rigid esophagoscope, removed an impacted food bolus from her esophagus (Figure 1). Because of the dysphagia with solid foods and an unclear diagnosis, esophagoscopy was performed with the Olympus EF instrument. Using general anesthesia, the instrument was inserted under direct vision using a laryngoscope. The baby tolerated the esophagoscope well, care being taken to prevent compression of the endotracheal tube. A congenital diaphragm was seen in the lower third of the esophagus. This was successfully dilated at 2 further sessions by passing a guidewire into the stomach through the biopsy channel of the esophagoscope or GIF panendoscope. Over this, metal olives were passed through the narrow opening in the diaphragm. 6
Figure 1. Radiograph of the esophagus (patient 1) demonstrating a dilated, obstructed esophagus due to a congenital diaphragm.
From the Department of Gastroenterology, Municipal Governmental Medical Center, Ichilov Hospital, and the Tel Aviv University Medical School, Tel Aviv, Israel. Reprint requests: Dr. P. Rozen, Ichilov Hospital, Tel Aviv, Israel.
88
GASTROINTESTINAL ENDOSCOPY
2. A 5 year old child swallowed a coin 2.7 cm in diameter. After 3 weeks an attempt was made to remove it from the stomach. Under general anesthesia by means of an endotracheal tube, the Olympus GIF was inserted easily into the stomach. However, in spite of special grasping forceps,' the coin could not be lifted from the gastric mucosa and the child underwent laparotomy. 3. A 6 year old chi Id swallowed a haircl ip 5 cm long (Figure 2). Two days later, under general anesthesia by means of an endotracheal tube, the Olympus GIF panendoscope was introduced under direct vision using a laryngoscope and passed easily into the stomach. The clip was removed using a special 2-tooth grasping forceps. Only by approaching the head of the clip could it be grasped firmly in its long axis. Then there was no problem taki ng it out together with the endoscope, through the cardia and esophagus. DISCUSSION In the last few years there have been a number of descriptions of therapeutic endoscopic procedures in the upper gastrointestinal tract.'-4 The flexible panendoscopes and the use of grasping forceps or snare have made it possible to treat conditions that had previously been the province of the ENT surgeon with his rigid esophagoscope or that of the abdominal surgeon. a.9 In only a few reports has the use of standard, adult-sized fiberoptic endoscopes in children been discussed, whether for diagnostic or therapeutic purposes (usually for the removal of foreign bodies).'" In 1 case a fiberbronchoscope was used to aid the removal of a nasogastric tube from the stomach of an
infant. ' ° Gleason et a 1." specifically discuss the successful use of diagnostic fiberoptic endoscopy in children without entering into technical details, while Papp12 and Cotton 13 mention diagnostic pediatric endoscopy in their reviews of endoscopic experience. Cotton 13 also discusses the use of a fiberbronchoscope or lateral viewing duodenoscope in infants. Recently, a smaller caliber panendoscope (Olympus GIF-P) has been offered for use in passage through narrowed areas or in children. Its extreme flexibility makes it inconvenient for routine adult use, but probably it is more comfortable and safer for pediatric diagnostic use. However, the lack of a wide channel for grasping forceps and only a 2-directional bending angle limit its usefulness in the removal of foreign bodies or other therapeutic procedures. Our three cases illustrate that standard instruments can be used safely in children, even in a baby, taking care to insert the fiberscope under direct vision and avoiding pressure on the endotracheal tube. The advantages of having a wide channel for grasping forceps or snares, good tip control in 4 directions, and not being excessively flexible outweigh the disadvantage of their wide caliber in therapeutic endoscopic procedures in children.
ADDENDUM A standard instrument (GIF-D) was used successfully for removing intragastric foreign bodies from 2 additional infants aged 2 and 5 years. Case 1 has recently been described in detail in Am J Dig Dis 20:781, 1975.
REFERENCES
Figure 2. Plain film of the abdomen (patient 2) showing a hairclip in
the stomach; the 2-tooth grasping forceps holding the hairclip by
its head in order to remove it from the stomach, keeping it parallel to the long axis of the scope (right).
VOLUME 22, NO.2, 1975
1. ROSCH W, CLASSEN M: Fiberendoscopic foreign body removal from the upper gastrointestinal tract. Endoscopy 4:193,1972 2. ROESCH W, KOCH H, FRUEHMORGEN P, CLASSEN M: Operative endoscopy of the upper gastrointestinal tract. Gastrointestinal Endoscopy 20: 108, 1974 3. LARKWORTHY W, JONES RTB, MAHONEY M, HOLGATE PFL: Removal of ingested coins utilizing fiber-endoscopy and special forceps. Br J Surg 61 :750, 1974 4. WITZEL L, SCHEURER U, MUHLEMANN A, HALTER F: Removal of razor blades from stomach with fiberoptic endoscope. Br Med J 2:539,1974 5. CREMER M, PEETERS JP, EMONTS P, RODESCH P, CADRANEL S: Fiberendoscopy of the gastrointestinal tract in children; experience with newly designed fiberscopes. Endoscopy 6:186,1974 6. LILLY jO, MCCAFFEREY TO: Esophageal stricture dilatation. Am J Dig Dis 16:1137, 1971 7. SEIFERT E: Appliances for surgical endoscopy. Endoscopy 5:96, 1973 8. KLINE MM: Endoscopic snare in removal of an esophageal foreign body. Gastrointestinal Endoscopy 20:165, 1974 9. OE GEROME jH: Snare extraction of a gastric foreign body. Gastrointestinal Endoscopy 20:73, 1973 10. GRAHAM OY, SCHWARTZ jT: Endoscopic removal of a knotted feeding tube from an infant. Gastrointestinal Endoscopy 21 :32,1974 11. GLEASON WA, TEDESCO jF, KEATING JP, GOLDSTEIN PO: Fiberoptic gastrointestinal endoscopy in infants and children. J Pediatr 85:810,1974 12. PAPP JP: Endoscopic experience in 100 consecutive cases with the Olympus GIF endoscope. Am J Gastroent 60:466, 1973 13. COTTON PB: Fiberoptic endoscopy and the barium meal; results and implications. Br Med J 2:161,1973
89
Standard, adult-sized, forward-viewing endoscopes were used in 3 children, 9 months to 6 years old, for therapeutic procedures. This experience illustrates the feasibility of using standard instruments in infants and their advantages over special pediatric endoscopes in therapeutic endoscopy.
Other than the reports of Rosch and Classen et al Y most descriptions of fiberendoscopic therapeutic procedures, such as the removal of intragastric foreign bodies, concern adults.3.4 In children, diagnostic endoscopy has been made easier with the production of special pediatric instruments. s However, these lack the facility for therapeutic procedures, a common reason for endoscopy in this age group. For this reason we would like to describe the successful use of standard, adult-sized instruments in infants for diagnostic and therapeutic procedures. CASE REPORTS 1. A 9 month old female infant was seen after ENT surgeons, using a rigid esophagoscope, removed an impacted food bolus from her esophagus (Figure 1). Because of the dysphagia with solid foods and an unclear diagnosis, esophagoscopy was performed with the Olympus EF instrument. Using general anesthesia, the instrument was inserted under direct vision using a laryngoscope. The baby tolerated the esophagoscope well, care being taken to prevent compression of the endotracheal tube. A congenital diaphragm was seen in the lower third of the esophagus. This was successfully dilated at 2 further sessions by passing a guidewire into the stomach through the biopsy channel of the esophagoscope or GIF panendoscope. Over this, metal olives were passed through the narrow opening in the diaphragm. 6
Figure 1. Radiograph of the esophagus (patient 1) demonstrating a dilated, obstructed esophagus due to a congenital diaphragm.
From the Department of Gastroenterology, Municipal Governmental Medical Center, Ichilov Hospital, and the Tel Aviv University Medical School, Tel Aviv, Israel. Reprint requests: Dr. P. Rozen, Ichilov Hospital, Tel Aviv, Israel.
88
GASTROINTESTINAL ENDOSCOPY
2. A 5 year old child swallowed a coin 2.7 cm in diameter. After 3 weeks an attempt was made to remove it from the stomach. Under general anesthesia by means of an endotracheal tube, the Olympus GIF was inserted easily into the stomach. However, in spite of special grasping forceps,' the coin could not be lifted from the gastric mucosa and the child underwent laparotomy. 3. A 6 year old chi Id swallowed a haircl ip 5 cm long (Figure 2). Two days later, under general anesthesia by means of an endotracheal tube, the Olympus GIF panendoscope was introduced under direct vision using a laryngoscope and passed easily into the stomach. The clip was removed using a special 2-tooth grasping forceps. Only by approaching the head of the clip could it be grasped firmly in its long axis. Then there was no problem taki ng it out together with the endoscope, through the cardia and esophagus. DISCUSSION In the last few years there have been a number of descriptions of therapeutic endoscopic procedures in the upper gastrointestinal tract.'-4 The flexible panendoscopes and the use of grasping forceps or snare have made it possible to treat conditions that had previously been the province of the ENT surgeon with his rigid esophagoscope or that of the abdominal surgeon. a.9 In only a few reports has the use of standard, adult-sized fiberoptic endoscopes in children been discussed, whether for diagnostic or therapeutic purposes (usually for the removal of foreign bodies).'" In 1 case a fiberbronchoscope was used to aid the removal of a nasogastric tube from the stomach of an
infant. ' ° Gleason et a 1." specifically discuss the successful use of diagnostic fiberoptic endoscopy in children without entering into technical details, while Papp12 and Cotton 13 mention diagnostic pediatric endoscopy in their reviews of endoscopic experience. Cotton 13 also discusses the use of a fiberbronchoscope or lateral viewing duodenoscope in infants. Recently, a smaller caliber panendoscope (Olympus GIF-P) has been offered for use in passage through narrowed areas or in children. Its extreme flexibility makes it inconvenient for routine adult use, but probably it is more comfortable and safer for pediatric diagnostic use. However, the lack of a wide channel for grasping forceps and only a 2-directional bending angle limit its usefulness in the removal of foreign bodies or other therapeutic procedures. Our three cases illustrate that standard instruments can be used safely in children, even in a baby, taking care to insert the fiberscope under direct vision and avoiding pressure on the endotracheal tube. The advantages of having a wide channel for grasping forceps or snares, good tip control in 4 directions, and not being excessively flexible outweigh the disadvantage of their wide caliber in therapeutic endoscopic procedures in children.
ADDENDUM A standard instrument (GIF-D) was used successfully for removing intragastric foreign bodies from 2 additional infants aged 2 and 5 years. Case 1 has recently been described in detail in Am J Dig Dis 20:781, 1975.
REFERENCES
Figure 2. Plain film of the abdomen (patient 2) showing a hairclip in
the stomach; the 2-tooth grasping forceps holding the hairclip by
its head in order to remove it from the stomach, keeping it parallel to the long axis of the scope (right).
VOLUME 22, NO.2, 1975
1. ROSCH W, CLASSEN M: Fiberendoscopic foreign body removal from the upper gastrointestinal tract. Endoscopy 4:193,1972 2. ROESCH W, KOCH H, FRUEHMORGEN P, CLASSEN M: Operative endoscopy of the upper gastrointestinal tract. Gastrointestinal Endoscopy 20: 108, 1974 3. LARKWORTHY W, JONES RTB, MAHONEY M, HOLGATE PFL: Removal of ingested coins utilizing fiber-endoscopy and special forceps. Br J Surg 61 :750, 1974 4. WITZEL L, SCHEURER U, MUHLEMANN A, HALTER F: Removal of razor blades from stomach with fiberoptic endoscope. Br Med J 2:539,1974 5. CREMER M, PEETERS JP, EMONTS P, RODESCH P, CADRANEL S: Fiberendoscopy of the gastrointestinal tract in children; experience with newly designed fiberscopes. Endoscopy 6:186,1974 6. LILLY jO, MCCAFFEREY TO: Esophageal stricture dilatation. Am J Dig Dis 16:1137, 1971 7. SEIFERT E: Appliances for surgical endoscopy. Endoscopy 5:96, 1973 8. KLINE MM: Endoscopic snare in removal of an esophageal foreign body. Gastrointestinal Endoscopy 20:165, 1974 9. OE GEROME jH: Snare extraction of a gastric foreign body. Gastrointestinal Endoscopy 20:73, 1973 10. GRAHAM OY, SCHWARTZ jT: Endoscopic removal of a knotted feeding tube from an infant. Gastrointestinal Endoscopy 21 :32,1974 11. GLEASON WA, TEDESCO jF, KEATING JP, GOLDSTEIN PO: Fiberoptic gastrointestinal endoscopy in infants and children. J Pediatr 85:810,1974 12. PAPP JP: Endoscopic experience in 100 consecutive cases with the Olympus GIF endoscope. Am J Gastroent 60:466, 1973 13. COTTON PB: Fiberoptic endoscopy and the barium meal; results and implications. Br Med J 2:161,1973
89
