Endoscopy: types of studies, preparation for the procedure. Endoscopic examinations: methods, features of the procedure and reviews Endoscopic ultrasound examination
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Endoscopic studies
Endoscopic examination is an examination, “endo” means inside, so “endoscopy” is an examination inside organs that have at least a minimal space - a cavity. These organs include the esophagus, stomach and intestines, gall bladder, and bronchi. There is an abdominal cavity, a pleural cavity, and a joint cavity. Modern technical means make it possible to examine all these cavities and characterize those tissues that are visible during examination.
The diagram below shows the organs of the abdominal cavity and the endoscopy methods that are used to study them.
endoscopic examination
For endoscopic examinations, two types of devices are used - “rigid” and “flexible”. The first are metal tubes of short length and different diameters, at one end of which there is a lighting bulb or an internal fiber illuminator, and at the other an eyepiece that allows you to magnify the image. Rigid endoscopes are short because they can be inserted over short distances without distorting the image. Using “hard” instruments, the rectum, bladder, and abdominal cavity are examined. A real revolution in medicine was brought about by “flexible” endoscopes. In them, the image is transmitted through a bundle of special optical fibers. Each fiber in a bundle provides an image of one point of the organ mucosa, and a bundle of fibers provides an image of an entire area. At the same time, the image remains clear when bending the fibers and is transmitted over a greater length. The use of flexible endoscopes has made it possible to examine almost the entire gastrointestinal tract - the esophagus, stomach, small and large intestine, as well as the bronchi and joints.
Objectives of the study. Using endoscopic research methods, it is possible to recognize tumor and inflammatory diseases of the stomach, colon, liver and bile ducts, bronchi, joints, and bladder. During the study, it is possible to perform a biopsy of areas of the mucous organs that are suspicious for a tumor. During endoscopic examination, surgical interventions can be performed. Increasingly, endoscopic examination methods are used during preventive examinations, as they make it possible to identify early signs of disease. These methods also make it possible to monitor the effectiveness of disease treatment.
How the research is performed. The general principle of performing endoscopic examinations is the introduction of an endoscopy apparatus through the natural openings of the body. When examining the esophagus, stomach, or small intestine, the endoscope is inserted through the mouth. During bronchoscopy, the device is inserted through the mouth and further into the respiratory tract. The rectum and colon are examined by inserting endoscopes through the anus. The exceptions are laparoscopy, arthroscopy - examination of the abdominal cavity and joints - here artificial holes are created by puncture for the insertion of devices. Naturally, these procedures create subjective inconvenience for patients and require the use of certain manipulations for pain relief; most often this is not very burdensome for patients. After the endoscopes are inserted, they move towards the organ or area of the organ being examined. The cavity and mucous membranes are examined; in most cases, photographs can be taken of those areas that “interested” the doctor. With the progress of technology, it became possible to record the entire research process on videotape. During the examination, especially if a tumor process is suspected, a biopsy is performed (taking a small piece of tissue for examination).
Possibilities of endoscopic examinations for recognizing diseases, their reliability and possible complications.
Esophagoscopy - examination of the esophagus. Redness (hyperemia) and swelling of the mucous membrane, minor hemorrhages, superficial ulcerations (erosions) and ulcers of the mucous membrane are detected, which is characteristic of inflammatory changes. Polyps and tumors of the esophagus are detected, and they can be detected at the earliest stages. There are characteristic changes for hiatal hernias. Less reliable information is provided by the method for recognizing movement disorders of the esophagus; X-ray and some other special methods are more helpful here.
Gastroduodenoscopy - examination of the stomach and duodenum. Erosion, ulcers, polyps, tumors, and signs characteristic of chronic gastritis are detected. The information value of gastroduodenoscopy for identifying these diseases is close to 100%. At the same time, diverticula of the stomach and duodenum, a complication of peptic ulcer disease such as narrowing of the outlet of the stomach, are better recognized using fluoroscopy.
Using devices for endoscopy of the esophagus, stomach and duodenum, stomach polyps are removed and bleeding from the ulcer is stopped.
Complications during esophagoscopy and gastroduodenoscopy in modern conditions are very rare. During the examination, perforation, rupture of the organ being examined, and bleeding may occur.
Anoscopy - examination of the final segment of the rectum.
Sigmoidoscopy - examination of the rectum and sigmoid colon at a distance of no more than 30 cm from the anus.
Colonoscopy is an examination of almost the entire colon.
All these methods reveal signs of inflammation (swelling of the folds of the mucous membrane or their thinning, redness of the mucous membrane, hemorrhages), as well as erosion, ulcers, tumors, polyps. The limitations of anoscopy and sigmoidoscopy relate only to the length of the examination. In this regard, colonoscopy is the most informative. In 80-90% of cases, the entire colon is examined using colonoscopy. Colonoscopy should be used if colon tumors are suspected. With its help, tumors and polyps of minimal size are detected. The method provides significant information for patients with ulcerative colitis, Crohn's disease, intestinal bleeding, colon obstruction, and foreign bodies. At the same time, endoscopic techniques are inferior to X-ray methods in recognizing diseases such as colon diverticulosis and an increase in the size of individual sections of the intestine. Colonoscopy is not performed in patients with acute myocardial infarction, perforation of the colon, or inflammation of the peritoneum. The procedure is prescribed with caution to patients with diverticulitis, severe forms of ulcerative and ischemic colitis, and the acute phase of chemical damage to the colon. It is difficult to perform colonoscopy in patients with diseases of the rectum with severe pain, for example, with thrombosis of hemorrhoids.
Complications of sigmoidoscopy and colonoscopy - perforation, rupture of the intestine, bleeding. They develop very rarely.
Using a sigmoidoscope and colonoscope, intestinal polyps are removed and bleeding from ulcers is stopped.
Laparoscopy is an examination of the abdominal cavity. Tumors of the liver, gall bladder, and other abdominal organs are identified, the shape and size of the abdominal lymph nodes, and changes in the shape of organs due to inflammatory and other diseases are assessed. Laparoscopy is used in situations where doctors have difficulty recognizing diseases, and other research methods do not provide reliable information. Most often, laparoscopy is necessary to determine the causes of liver enlargement, if tumors of the liver, gall bladder, or pelvic organs - uterus, ovaries are suspected. For some types of jaundice, laparoscopy can also help identify the cause. Laparoscopy is not performed for bleeding disorders, inflammation of the peritoneum, and severe heart and lung diseases.
Laparoscopy opens up great opportunities for treating patients. These possibilities are constantly expanding. Currently, a whole new field of surgery has emerged - laparoscopic surgery. A miniature video camera is built into the laparoscope, which allows you to see all the organs of the abdominal cavity on the TV screen. Through additional small incisions in the abdominal cavity next to the laparoscope, surgical instruments are inserted and operations are performed, for example, removal of the gallbladder in patients with bladder stones. The number of operations performed in this way is constantly growing.
Complications are rare - bleeding, perforation of abdominal organs, inflammation of the peritoneum (peritonitis).
Bronchoscopy - examination of the bronchi. Currently, it is performed mainly with the help of flexible devices - fiber-optic bronchoscopes. They are less burdensome for patients; with their help, you can examine the mucous membranes of not only large bronchi, but also bronchi of a smaller diameter. With the help of bronchoscopy, signs of an inflammatory process in the bronchi, lung tumors, sources and causes of hemoptysis, prolonged cough, and enlarged lymph nodes are recognized.
The design of modern devices for bronchoscopy is such that they allow a number of additional manipulations in addition to examination - suction of bronchial secretions, biopsy of the bronchial mucosa, and also, after puncture of the bronchus, biopsy of lung tissue and lymph nodes. A number of medical procedures are carried out - lavage of the bronchi, administration of medications, suction of pus and blood from the bronchi.
Arthroscopy - examination of joints. Traumatic or degenerative changes in the menisci, articular ligaments, various types of damage to articular cartilage, the inner, synovial lining of the joints are recognized. It is possible to perform a biopsy of the synovial membrane and suction of synovial intra-articular fluid. It is performed in patients with inflammatory and dystrophic changes in the joints to determine the nature of the disease.
Currently, with the help of arthroscopy, a number of joint operations are performed, in particular, removal of the meniscus, without opening the joint cavity.
Complications are rare - the main one is the development of inflammation of the joint.
Preparing for the study. Preparation for esophagoscopy, gastroduodenoscopy, bronchoscopy consists of prohibiting eating for 12 hours before the study. A more complex study is performed before colonoscopy. The main goal of the study is to cleanse the colon of contents and gases. 2-4 days before the study, the patient is recommended to eat a diet with a reduced amount of waste (meat broth, boiled meat and fish, protein omelet, white crackers). The day before the study, after the second breakfast, the patient is given 30-40 ml of castor oil, and in the evening a cleansing enema is given. Dinner is cancelled. On the day of the study, a cleansing enema is given 2-2.5 hours before the colonoscopy. Some institutions prescribe special drugs to cleanse the intestines.
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These methods allow you to visually examine hollow organs and body cavities using optical instruments equipped with a lighting device.
With the help of photography, video, and digital technologies, the results of an endoscopic examination can be documented. Endoscopic research methods have found wide application in many areas of medicine:
In gastroenterology (esophagoscopy, gastroscopy, duodenoscopy, colonoscopy, sigmoidoscopy, peritoneoscopy);
In otorhinolaryngology and pulmonology (laryngoscopy, bronchoscopy, thoracoscopy);
Urology and nephrology (cystoscopy, urethroscopy, nephroscopy);
Gynecology (colposcopy, hysteroscopy);
Cardiology (cardioscopy).
Endoscopy makes it possible to detect certain types of tumor and pretumor diseases, carry out differential diagnosis of inflammatory and tumor diseases, and identify the severity of the pathological abnormality and its location. If possible, endoscopy is accompanied by a biopsy with further morphological study of the obtained material.
Endoscopic technology allows for such manipulations as local administration of drugs, removal of benign neoplasms of various organs, removal of foreign bodies, stopping internal bleeding, drainage of the pleural and abdominal cavities. This is especially important for elderly and senile people, people suffering from various aggravating diseases, as it is possible to avoid complex traumatic surgical procedures.
The nurse should carefully prepare the patient for an endoscopic examination. Such preparation includes both psychological and medicinal influences.
Psychological preparation consists of explaining the tasks and basic rules of behavior during an endoscopic examination, medication preparation consists of relieving psycho-emotional stress, pain relief, reducing the secretory activity of the glands, and preventing the occurrence of pathological reflexes.
The devices used for endoscopic examination are complex devices equipped with auxiliary instruments, attachments for biopsy, administration of drugs, electrocoagulation, and laser radiation transmission.
Rigid endoscopic devices retain their shape during the examination. The operating principle of such devices is based on the transmission of light from a source (an incandescent lamp located at the working end of the device) through a lens optical system.
Flexible devices are capable of changing the configuration of the working part in accordance with the shape of the organ being examined. The optical system of plastic fiber endoscopes is similar to a lens one, but the supply of light and images is realized through fiber light guides. Thus, the lighting system is placed outside the endoscope, which allows for sufficient illumination of organs without heating the tissues.
Rigid endoscopes equipped with fiber optics (thoracoscope, mediastinoscope, laparoscope, cystoscope, rectoscope) are simplified in design, while increasing the safety of the examination.
After the examination, the working part of the endoscope and its channels must be washed, cleaned and dried. Endoscopes are sterilized in special chambers in vapors of certain drugs that have antimicrobial properties (ethylene oxide, formaldehyde, etc.). Plastic endoscopes are subjected to special treatment in certain antiseptic substances (ethyl alcohol, formic alcohol, etc.).
Endoscopic devices are classified into the following categories:
By purpose (examination, biopsy, operating rooms);
Age modifications (for children and adults);
Structural features of the working part (rigid, flexible).
Examination of the esophagus, stomach and duodenum
It is carried out for diagnostic and/or therapeutic purposes for diseases of the esophagus, stomach, and duodenum.
Contraindications for this study:
Cicatricial changes in the esophagus;
Traumatic injuries:
Esophagus;
Stomach;
Duodenum.
The nurse instructs the patient in advance about the scheduled examination, the time and place of its conduct. The study is carried out on an empty stomach; you cannot take food, water, medicine, or smoke. A nurse accompanies a patient to the endoscopy room. The patient must have a towel with him.
Colon examination
Colonoscopy is performed for diagnostic and/or therapeutic purposes in the presence of probable pathologies of the large intestine. Contraindications may include traumatic intestinal injuries and scar changes in the rectum.
The patient is instructed three days before the study:
Exclude foods rich in fiber from your diet (legumes, fresh milk, brown bread, fresh vegetables and fruits, potato dishes);
The day before the test, exclude solid foods;
Also, the day before the study, the patient is given laxatives (castor oil 60-80 ml, magnesium sulfate 125 ml of a 25% solution, senna decoction - 140 ml);
The night before, two cleansing enemas are performed with a volume of about 300 g at an interval of 1.5-2 hours;
In the morning, two cleansing enemas with a volume of 2.5-3 liters are also prescribed, but no later than 2 hours before the procedure.
Bladder studies
Cystoscopy is used for diagnostic and/or therapeutic purposes in diseases of the bladder. Contraindications to this study: traumatic injuries to the urethra, cicatricial changes in the urethra.
The nurse prepares a sterile kit for cystoscopy in advance:
Cystoscope;
Syringe Janet;
Rubber catheters;
Napkins;
Towel;
Two pairs of rubber gloves;
Vaseline oil or glycerin;
Two trays;
Gauze swabs;
Oilcloth;
Antiseptic solution;
Anti-shock kit;
Containers with disinfectant solution.
The patient is notified in advance about the time and place of the study.
The procedure technique is as follows:
The nurse puts on sterile gloves;
Treats the patient's external genitalia with an antiseptic solution;
Removes gloves and places them in a container with a disinfectant solution;
Performs bladder catheterization;
Endoscopy - (from the Greek endon - inside and scopeo - looking) - a visual instrumental diagnostic method that allows you to look inside a hollow organ without resorting to a scalpel.
Endoscopy is an indispensable method for the differential diagnosis of neoplasms of the gastrointestinal tract, esophagus, stomach or duodenum, because These diagnoses are extremely difficult to confirm using the main diagnostic methods - radiography and ultrasound scanning of the abdominal cavity.
Esophagogastroduodenoscopy
Esophagogastroduodenoscopy (EGDS) refers to endoscopic research methods (examination of internal organs using endoscopes), in which the upper parts of the gastrointestinal tract are examined: the esophagus, stomach and duodenum. From the mouth, food enters the esophagus, through which it passes into the stomach and then into the duodenum.
Gastroscopy will help make the correct diagnosis for many conditions, including stomach pain, bleeding, ulcers, tumors, difficulty swallowing and many others.
How to prepare forresearch?
Regardless of the reason you are scheduled for testing, there are important steps you should take to prepare for and undergo the procedure. First of all, be sure to tell your doctor what medications you are taking and about any allergies to medications, if you have one.
Also, the doctor should know what diseases you suffer from that you need to pay attention to before the procedure.
It is very important in preparation for the study that you should not eat for 8-10 hours before gastroscopy. Food in the stomach will make it difficult to examine it and make a correct diagnosis.
During the procedure, everything possible will be done to make it as easy as possible for you. The office staff will closely monitor your condition.
To reduce sensitivity when swallowing, you will be treated with a local anesthetic solution in the back of your throat. You will be asked to hold a mouthpiece between your teeth, through which the endoscope is passed.
The doctor will carefully examine the inside of the stomach and, if necessary, remove a piece of the mucous membrane for further examination (biopsy). This is also a painless procedure (Fig. 1). Sometimes, you may undergo therapeutic measures, for example, stopping ulcer bleeding and removing a polyp.
What to expect after gastroscopy?
An unpleasant sensation in the throat for some time after the examination is common. It usually disappears after 30–60 minutes.
Fibercolonoscopy
Colonoscopy- endoscopic examination, during which the condition of the colon mucosa is visually assessed, that is, under visual control. The examination is performed with flexible endoscopes. The light source is an illuminator operating on a halogen or xenon lamp, that is, the so-called “cold” light is used, which eliminates burns to the mucous membrane.
How to prepare forcolonoscopy?
In order to examine the mucous membrane of the colon, it is necessary that there is no feces in its lumen.
The success and informative content of the study is determined mainly by the quality of preparation for the procedure, so pay the most serious attention to the implementation of the following recommendations: If you do not suffer from constipation, that is, the absence of independent bowel movements for 72 hours, then preparation for the study (endoscopy) is as follows: On the eve of the study at 16:00 you need to take 40–60 grams of castor oil. Other laxatives (senna preparations, bisacodyl, etc.) lead to a pronounced increase in the tone of the colon, which makes the study more labor-intensive and often painful. After independent bowel movements, you need to do 2 enemas of 1–1.5 liters each. Enemas are given at 20 and 22 hours. In the morning on the day of the study, it is necessary to do 2 more of the same enemas (at 7 and 8 o’clock). There is no need to fast on the day of the test
Recently, in our country, the scheme of preparing for colonoscopy WITHOUT ENEMA with the drug “Fortrans” has become popular. If you have a tendency to constipation, then to prepare for a colonoscopy you need to additionally follow several recommendations:
3-4 days before the examination (endoscopy), it is necessary to switch to a special (slag-free) diet, excluding from the diet fresh vegetables and fruits, legumes, black bread, cabbage in any form (both fresh and cooked).
At the same time, you need to take the laxatives you usually use every day. It may be necessary to increase their dose - to resolve this issue, consult your doctor. Further preparation does not differ from the above.
What to expect during a colonoscopy?
Endoscopic examination of the colon is a rather technically complex procedure, so try to help the doctor and nurse as much as possible - strictly follow their instructions. You may experience discomfort during the examination, but the doctor will take all measures to reduce these discomforts. In many ways, following the instructions exactly can reduce discomfort. You will be required to remove all clothing from the waist down, including underwear. They will help you lie on the couch on your left side, with your legs bent at the knees and pulled towards your stomach.
The endoscope is inserted through the anus into the lumen of the rectum and gradually moves forward with a moderate supply of air to straighten the lumen of the intestine. During the examination (endoscopy), as directed by your doctor, you will be helped to turn on your back or again on your left side. In some pathological conditions, to clarify the diagnosis, a microscopic examination of the changed areas of the mucous membrane is necessary, which the doctor takes with special forceps - a biopsy is performed, which extends the examination time by 1–2 minutes.
What will you feel during a colonoscopy?
A feeling of fullness of the intestine with gases, which causes the urge to defecate. At the end of the study, the air introduced into the intestine is sucked out through the endoscope channel. Moderate pain as the intestine stretches when air is introduced into it. In addition, at the moment of overcoming the bends of the intestinal loops, tension occurs in the richly innervated fold of the peritoneum, through which individual loops of the intestine are attached to the walls of the abdominal cavity. At this point, you will experience a short-term increase in pain.
How to behave after the study?
You can eat and drink immediately after the procedure. If the feeling of fullness of the abdomen with gases persists and the intestines are not emptied of remaining air naturally, you can take 8–10 tablets of finely crushed activated carbon, stirring it in 100 milliliters (half a glass) of warm boiled water. It is better to lie on your stomach for several hours after the examination.
Colonoscopy is a highly informative examination method that helps maintain and increase your health.
Fig.2. View of healthy colon mucosa through an endoscope
Fig.3. Malignant colon polyp (endoscopic radical treatment is possible)
In the absence of significant reasons explaining jaundice, or when the bile ducts are dilated, fibroesophagogastroduodenoscopy (FGDS) is performed following ultrasound. With its help, the pathology of the upper gastrointestinal tract is determined: varicose veins of the esophagus, stomach tumors, pathology of the major duodenal papilla (MDP), deformations of the stomach, duodenum due to compression from the outside. In this case, it is possible to perform a biopsy of the area suspicious for cancer. In addition, the technical feasibility of performing ERCP is assessed.
A 
B 
IN
Figure 3– FEGDS with inspection of the observatory: A – normal observatory;
B – driven stone into the BDS; B – BDS cancer
X-ray contrast methods
Methods that allow visualization of the bile ducts using their contrast. These include two main methods: endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTCHG)
Endoscopic retrograde cholangiopancreaticography (ERCP)
Diagnostic ERCP is a retrograde contrast of the bile ducts and pancreatic duct performed through the major duodenal papilla (or sometimes through the minor duodenal papilla). Along with the possibility of contrasting the bile ducts, the method allows you to visually assess the condition of the stomach and duodenum, the major duodenal papilla and the periampullary region, as well as determine the fact of bile entering the intestinal lumen. In addition, when performing ERCP, it is possible to take material for a biopsy from the pathologically altered duodenal papilla and from stenotic areas of the bile ducts, as well as scrape the mucous membrane for cytological examination. Invasive research methods associated with direct or retrograde contrasting of the biliary tract allow one to determine the level of obstruction, but do not allow one to judge the nature and extent of the pathological process to surrounding organs and tissues, which is especially important in patients with suspected tumor obstruction.
ERCP technique
To perform ERCP, a duodenoscope is required - an endoscope equipped with lateral optics to create optimal conditions for manipulation of the BDS (located on the postero-inner wall of the descending part of the duodenum, therefore difficult to visualize with end scopes) and a cannula for introducing contrast through the BDS into the bile and pancreatic ducts
ERCP is a complex, invasive procedure that requires special endoscopist skills, can take a long time and is often poorly tolerated by patients. Therefore, before undergoing ERCP, patients need to undergo medication preparation, on which the success of the study largely depends. The purpose of premedication is to reduce pain, reduce secretion, relax the sphincter of Oddi and create hypotension of the duodenum. For this purpose, narcotic (promedol), antispasmodic and antisecretory (atropine, metacin), sedative (seduxen, relanium) drugs are used. Recently, information has appeared on the use of the drug Dicetel, selectively blocking calcium channels of smooth muscle cells of the intestines and bile ducts. It has a complex effect: relieves spasms, reduces motor activity, has an analgesic effect, and selectively relaxes the sphincter of Oddi.
ERCP is performed in an X-ray room. The doctor inserts the duodenoscope into the duodenum and visualizes the BDS. After this, the BDS is cannulated and a radiopaque substance is introduced into the ducts. In this case, fluoroscopy and visualization of the state of the contrasted ducts on the screen of the electron-optical converter are performed.
Contraindications and restrictions
Carrying out ERCP contraindicated at:
1) acute pancreatitis;
2) acute myocardial infarction, stroke, hypertensive crisis, circulatory failure and other severe patients;
3) intolerance to iodine preparations.
The use of ERCP is limited after previous surgery on the stomach, when the major duodenal papilla (MDP) is inaccessible for endoscopic manipulation, the location of the MDP in the cavity of large diverticula, a technically insurmountable obstacle in the outlet of the common bile duct (stricture, calculus, tumor). In general, it is not possible to obtain information about the state of the bile ducts during ERCP in 10–15% of patients with choledocholithiasis, which requires the use of other diagnostic methods.
Figure 4– Carrying out ERCP
AB
Figure 5– A – duodenoscope; B – cannulation of the BDS
A 
B
Figure 6– ERCP: A – gallstones without duct pathology;
B – picture of choledocholithiasis (choledochus is dilated, stones are visualized)
A 
B
Figure 7– ERCP: A – choledocholithiasis, a Dormia basket was inserted for lithoextraction; B – stricture of the distal common bile duct with prestenotic expansion
Complications of ERCP
Invasive diagnostic methods associated with contrasting the biliary tract have an operational risk and are unsafe in terms of the development of complications, which occur in 3–10% of cases. The most common complications of diagnostic and therapeutic ERCP are the development of acute pancreatitis (2–7%) and cholangitis (1–2%). Bleeding and duodenal perforation rarely occur during diagnostic ERCP, but are common during therapeutic ERCP when performing papillotomy (about 1%).
Percutaneous transhepatic cholangiography (PTCH)
For puncture of the intrahepatic bile ducts, special thin needles are used, the design of which allows one to avoid the complications inherent in this study (blood and bile leakage into the abdominal cavity). If a patient has dilated intrahepatic bile ducts, percutaneous transhepatic cholangiography allows one to obtain information about their condition in more than 90% of cases, in the absence of dilation in 60% of cases.
Using PCCG, the bile ducts are identified in the direction of the physiological flow of bile, in contrast to ERCP, so the localization and extent of obstruction is visible. The use of a thin Chiba needle with a diameter of 0.7 mm allows one to puncture the dilated hepatic ducts and obtain information about the condition of the extra- and intrahepatic bile ducts when non-invasive methods do not provide clear diagnostic criteria. Sometimes PCCG complements ERCP.
The optimal point for puncture is the 8th–9th intercostal space along the mid-axillary line. After treating the skin and infiltrating the abdominal wall with novocaine, with held breathing, the needle is inserted to a depth of 10-12 cm towards the XI-XII thoracic vertebra. The direction and stroke of the needle is controlled on the TV screen. The position of the needle when injecting is horizontal. After placing the end of the needle approximately 2 cm to the right of the spine, the needle is slowly withdrawn. Negative pressure is created using a syringe. When bile appears, the tip of the needle is in the lumen of the bile duct. After decompression, the bile tree is filled with a water-soluble contrast agent (40–60 ml) and fluoroscopy is performed.
A safer method is to puncture the bile ducts under ultrasound guidance, especially in real-time three-dimensional reconstruction (4D ultrasound).
A 
B
Figure 8– A – special “Chiba” needle for hCG; B – scheme for conducting PCCG
Indications for PCCG:
Differential diagnosis of cholestasis with dilated bile ducts and ineffective ERCP (most often with a “low” block of the common bile duct);
Suspicion of an abnormality of the bile ducts in childhood;
Extrahepatic cholestasis during biliodigestive anastomoses.
Contraindications:
Allergy to contrast agents;
General serious condition;
Violation of the coagulation system (PTI less than 50%, platelets less than 50x10 9 / l);
Hepatic-renal failure, ascites;
Hemangiomas of the right lobe of the liver;
Interposition of the intestine between the liver and the anterior abdominal wall.
Complications:
Biliary peritonitis;
Bleeding into the abdominal cavity;
Hemobilia - the entry of blood into the bile ducts along a pressure gradient (manifested by pain in the right hypochondrium, symptoms of obstructive jaundice and bleeding from the upper gastrointestinal tract);
The formation of fistulas between the bile ducts and liver vessels with the penetration of bacteria from the biliary system into the bloodstream and the development of septicemia.
A 
B
Figure 9– PTC: A – Cholangiolithiasis (presence of a filling defect with clear
smooth contours, dilation of ducts);
B – BDS cancer: narrowing of the terminal part of the common bile duct like a “cigar”
Contrast through the gallbladder (fistulocholecystocholangiography).
One of the common methods of contrasting the biliary tree is the use of cholecystostomy, applied directly (surgically) or by puncture under ultrasound or laparoscopy control. A necessary condition for performing such a study is the patency of the cystic flow. This is usually evidenced by bile flowing through the drainage. Most often, the need for external drainage of the gallbladder occurs when obstructive jaundice is combined with acute destructive cholecystitis or with tumors of the head of the pancreas (distal ducts), when the extremely serious condition of the patient does not allow palliative or radical intervention to be performed in the traditional way.
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In oncology, one of the leading places in the diagnosis (visualization) of malignant tumors is occupied by endoscopic (Greek endo - inside and skopeo - looking) research methods that allow you to examine the internal surface of hollow organs and body cavities, diagnose a tumor and determine its location, size, anatomical shape and growth boundaries, as well as identify early, without clinical manifestations, cancer (tumor up to 0.5-1 cm).
Targeted biopsy during endoscopy allows for morphological verification of the diagnosis.
In some cases, endoscopic examination can be combined with therapeutic effects (for example, stopping bleeding from a tumor, removing a polyp, etc.). The study is carried out using special devices - endoscopes.
Depending on the design of the working part, endoscopes are divided into flexible and rigid. The most common are endoscopes with fiber optics, represented by fiber light guides with a diameter of several tens of microns, forming the fiber-optic system of the device. A single fiber transmits part of the image, and many fibers combined into a single bundle transmit a complete image of the object under study.
Endoscopic methods in oncology allow solving the following main problems:
1) primary and differential diagnosis of tumors of the thoracic and abdominal cavities;
2) clarifying diagnostics: determining the location, size, anatomical shape, boundaries of the tumor and its histological form;
3) identification of pre-tumor diseases and their dispensary monitoring;
4) dynamic monitoring of treatment effectiveness, diagnosis of relapses and metastases:
5) endoscopic therapeutic interventions;
6) detection of early cancer using chromoscopy (0.2% indigo carmine, 0.25% methylene blue, Lugol’s solution, Congo red, etc.) and laser puminescence using hematoporphyrin derivatives.
Collection of material for morphological research can be carried out in various ways. A targeted biopsy is performed using special biopsy forceps (farcept) from the areas most suspicious for a tumor for histological examination.
Its effectiveness increases in proportion to the number of pieces taken from the study area. Brush biopsy - sampling (scraping) of material for cytological examination using a special brush - is widely used in bronchoscopy. A puncture biopsy is performed using a special needle at the end of a catheter inserted through the biopsy channel of the endoscope.
Aspiration of the contents of hollow organs and/or washings from the surface of the affected area using a catheter allows one to obtain material for cytological examination. It is obvious that histological and cytological studies are not competing, but complementary diagnostic methods.
Thus, if a targeted biopsy allows one to examine only a small piece of the mucous membrane, then by scraping or washing off, material for examination is obtained from a much larger surface area of the organ wall.
Therapeutic endoscopy is used in oncology to remove polyps of the gastrointestinal tract using a diathermy loop or laser therapy. The latter allows you to remove wide-based polyps (more than 2 cm), large-area (creeping) polyps, for which loop polypectomy is usually contraindicated.
However, with laser coagulation, complete evaporation of polypoid formations is achieved, which. naturally excludes their subsequent histological examination. Subject to strict indications, endoscopic treatment of early cancer is possible (electrosurgical method, thermal and laser tumor destruction, photodynamic therapy, etc.).
Endoscopic methods are highly effective in the diagnosis and treatment of gastrointestinal bleeding, the source of which is often malignant tumors and polyps. For such bleeding, when it is immediately impossible to perform radical surgery or it is contraindicated, active conservative therapy is carried out.
Under visual endoscopic control, through the biopsy channel, the walls of the organ with the source of bleeding are washed with ice water, irrigated with hemostatic solutions, cryotherapy (chlorethyl carbon dioxide), and the mucous and submucosal layer in the area of bleeding is infiltrated with vasoconstrictor and thrombus-forming drugs.
In some cases, diathermocoagulation of a bleeding vessel is performed with a special electrode or photocoagulation of the bleeding area using a laser and a quartz light guide. In this way, it is possible to stop bleeding in more than 90% of patients. In cases of bleeding from a benign polyp, the most radical treatment is polypectomy or laser coagulation.
A number of endoscopic research methods can be used in combination with X-ray (retrogradehy) or in combination.
An example of complex diagnostics is transillumination of the walls of the abdominal organs (stomach, colon, bladder) using an endoscope inserted into the organ under study and a laparoscope inserted into the abdominal cavity.
When transilluminating the walls of organs, shadow images of tumors are revealed, their intraorgan boundaries and features of the blood supply are clearly visible. Most often, the need for transillumination arises during operations when the tumor is small and cannot be detected by palpation by the surgeon.
Endoscopy in gastroenterology
Esophagogastroduodenoscopy is used when a tumor is suspected, to determine the cause of bleeding, assess the effectiveness of chemotherapy and/or radiation therapy, and perform surgical endoscopic interventions.The study is contraindicated in acute myocardial infarction, stroke, stage III cardiovascular decompensation, mental illness, severe kyphosis, lordosis, acute inflammation of the tonsils, stage III hypertension, significant dilatation of the esophageal veins. In some cases, 2-3% solutions of dicaine, lidocaine, xylocaine are used to anesthetize the pharynx and mouth of the esophagus, or even anesthesia is indicated.
The endoscopic picture of tumors of the gastrointestinal tract is quite diverse and is determined by the characteristics of the anatomical form of growth and the stage of the tumor process.
Esophagus
The early form of cancer is usually defined as a focal infiltrate or polypoid formation, the mucous membrane over them is unchanged or eroded (ulcerated). In the area where the tumor is localized, the wall of the esophagus loses elasticity and becomes rigid; with instrumental palpation, the tumor is easily injured and can bleed.When the esophagus is inflated with air, its lumen appears asymmetrical and does not expand evenly in all directions, as is normal. As the tumor develops, the following endoscopic forms of cancer can be observed.
Saucer-shaped - characterized by a dense roll-shaped edge and the presence of gray or yellow necrosis in the center.
Ulcerative-infiltrative - is an irregularly shaped ulcer with unevenly thickened, dense, pale pink edges, covered with a fibrous-necrotic coating. The mucous membrane around the ulcer is infiltrated and rigid. Infiltrative-stenotic - there is a funnel-shaped circular narrowing of the lumen of the esophagus, with dense walls that bleed when touched.
The mucous membrane in the affected area is hyperemic, edematous, and non-displaceable. Submucosal (periesophageal) - the mucous membrane may not be externally changed, and a characteristic endoscopic sign of a malignant process in this case will be rigidity of the esophageal wall.
Benign tumors (leiomyomas, fibromas, lipomas) are localized in the submucosal layer and endoscopically detected as a protrusion of the mucous membrane (usually on one of the walls), the surface of which is usually smooth, and mild hyperemia is rarely observed.
The same forms of benign submucosal tumors are found in the stomach and duodenum, but there they are much more likely to become infected (peiomyo-fibro-liposarcoma). In addition to mesenchymal tumors, endothelial tumors (hemangiomas, lymphangiomas, endotepiomas, etc.) and less commonly cysts, dermoids, and hamartomas are also often found in the gastrointestinal tract.
Stomach
Endoscopic semiotics of gastric cancer depends on its stage and anatomical form. There are exophytic (polypoid and saucer-shaped). transitional (ulcerative cancer) and endophytic tumors (ulcerative-infiltrative, flat-infiltrative and diffuse-infiltrative).Polypoid cancer from 0.5 to 10 cm in diameter are most often found in the antrum and body, usually round in shape, have a lobulated or villous structure with an eroded, easily bleeding surface. Tummy-shaped cancer measuring from 0.5 to 15 cm is usually localized in the antrum and body, somewhat more often along the anterior wall.
The tumor borders are represented by pronounced ridge-like edges; an area of necrosis is usually observed in the center. The ulcerative form of cancer from 0.5 to 4 cm in diameter is most often localized in the area of the angle and the lower third of the body along the lesser curvature. It is an ulcer with uneven borders without convergence of folds to its edges, one of which is usually lumpy, the other flat.
The bottom of the ulceration is uneven, often covered with a dirty gray or brown coating, rigid and bleeds profusely during a biopsy from the edge of the ulcer. Ulcerative-infiltrative cancer has the same endoscopic signs as ulcerative cancer, only the size of the ulceration is larger and there is a complete absence of the inflammatory shaft.
The edges of the ulceration immediately transform into the mucous membrane infiltrated by the tumor with smoothed rigid folds. The bottom of the ulceration is deep, sometimes ingrowth into a neighboring organ is visible. Excessive contact bleeding often occurs. There is no peristalsis in the tumor area.
Flat infiltrating cancer is most often localized in the antrum along the lesser curvature and posterior wall. It is very difficult for endoscopic diagnosis, as it appears in the form of flat areas of gray mucosa, somewhat pressed into the wall of the stomach due to the absence of folds, which break off at the edge of the tumor.
Grayish-white glassy mucus often accumulates over the tumor, sometimes imitating fish scales. There is no rigidity of the stomach wall, since tumor infiltration spreads throughout the submucosal layer and only in advanced cases affects the muscular layer.
Therefore, this form of tumor can be detected only when the stomach is completely inflated with air. The diffuse-infiltrative form is equally common in all parts of the stomach and is very difficult for endoscopic diagnosis, since tumor development occurs in the submucosal layer.
In the early phase of its development, it appears in the form of a plaque, rising 3-5 mm above the level of the mucous membrane, with foci of submucosal hemorrhage, sometimes necrosis and depressions. With further growth, the mucous membrane above it becomes uneven, lumpy, grayish-pink in color, with erosions and numerous hemorrhages. The folds do not straighten when inflated with air, the walls of the stomach are rigid, and there is no peristalsis.
Sarcomas of the stomach are relatively rare (0.5-5%) and their endoscopic appearance resembles hyperplastic gastritis (Menetrier's disease), benign ulcers, and submucosal tumors. Polyps are most often hemispherical or spherical in shape with a flat, smooth surface of the mucous membrane of orange, pale pink or bright red color, the base of the polyps is wide or pedunculated. The size of benign polyps most often does not exceed 1 cm.
Lymphogranulomatosis most often appears in the form of multiple ulcers in various parts of the stomach.
Gastric stump cancer
In case of relapses, endophytic forms of tumor growth predominate, most often localized in the area of the anastomosis and spreading mainly in the submucosal layer of the wall of the gastric stump. Endoscopic semiotics in general terms does not differ from that of carcinoma of the unoperated stomach and is determined mainly by the anatomical shape of the tumor.It should be noted that fibrogastroscopy allows more often than other research methods to identify early forms of relapse and primary cancer of the gastric stump and in this regard it can be considered as a screening method for examining patients who have undergone gastrectomy.
Duodenal cancer is rare (0.3-0.5%), its diagnosis does not cause any particular difficulties, and only in advanced cases in the presence of obstruction of the organ is it difficult to distinguish it from a pancreatic tumor. In these cases, morphological examination of the biopsy material helps.
Sigmoidoscopy is the leading and most effective method for diagnosing cancer of the rectum and distal part of the sigmoid colon. The study makes it possible to give a reliable visual assessment of the nature and extent of the tumor process along the mucous membrane, to perform a targeted biopsy or take material for cytological examination over a distance of up to 30 cm from the anus.
Sigmoidoscopy is used to monitor the effectiveness of treatment and to remove polyps. Despite the simplicity and good tolerability of the method, complications are possible with sigmoidoscopy. Trauma to the tumor with the distal end of the instrument can cause bleeding. The danger of perforation of the pathologically altered intestinal wall cannot be excluded due to careless insertion of a proctoscope or excessive insufflation of air. Anoscopy is a technique for examining the anal canal and lower rectum using a special instrument - an anoscope. It is a tube 8-12 cm long with a diameter of 2 cm with a handle and an obturator. The anoscope is convenient for performing small-scale diagnostic manipulations: examination of the anal canal and biopsy in its area, performing medical procedures.
Examination with a rectal mirror - examination of the anal canal and rectum to a depth of 12-14 cm. A biopsy or therapeutic manipulations may be performed.
Fibercolonoscopy allows you to visually examine the condition of the mucous membrane of all parts of the colon and establish the nature of the pathology in 90-100% of cases through targeted biopsy and/or collection of material for cytological examination.
However, a total colonoscopy is possible only in 53-75% of cases. The reasons for possible failures of carrying out a colonoscope to the dome of the cecum may be the peculiarities of the anatomical structure of the large intestine (pronounced looping, sharp bends in the splenic and hepatic angles, significant sagging of the transverse colon), adhesions in the abdominal cavity, a negative reaction of the patient to the examination, unsatisfactory preparation intestines.
Contraindications to fibrocolonoscopy can be absolute and relative, due to both general and local reasons. Absolute contraindications are the severe general condition of the patient, coagulopathy, mental illness, cardiac decompensation, acute myocardial infarction and stroke, advanced pregnancy, the presence of obvious signs of inoperability of the patient, acute inflammatory processes and severe stenosis of the anus, the immediate period after surgery on the rectum and colon. , acute inflammatory and adhesive processes in the abdominal cavity, severe forms of ulcerative colitis and Crohn's disease.
Relative contraindications include old age and childhood, heart and pulmonary insufficiency, pronounced neurasthenia, severe post-radiation atrophy of the intestinal mucosa, and severe diverticulitis.
Among the complications of colonoscopy, the most serious are intestinal perforation and massive intestinal bleeding (0.1-0.2% of cases). Other complications include acute dilatation of the colon due to excessive introduction of air, collapse of the colonoscope in the intestine, and intussusception of a section of the intestine during its rapid removal.
Colonoscopy successfully performs endoscopic removal of colon polyps for diagnostic and therapeutic purposes. Such operations are low-traumatic, organ-saving and safe, provided that contraindications to them are observed: coagupopathy of various origins, associated with the threat of bleeding; the presence of a pacemaker in patients; the size of the polyp is more than 4 cm and its base is more than 1.5 cm.
Of all the methods of colonoscopic removal of polyps, the most preferable is loop electroexcision, which makes it possible to preserve their entire mass for morphological examination.
In this case, the most common complications are bleeding from the bed of the removed polyp and perforation of the intestine directly during coagulation or later due to transmural necrosis of the wall in the area of the base of the polyps. Such complications occur in 0.5-0.8% of cases.
Endoscopy of the respiratory tract
Endoscopic methods for studying the upper respiratory and alimentary tract make it possible to diagnose the pathological process and collect material for morphological examination. If the tumor formation is completely removed, then if it is benign, the biopsy in this case will be curative.Examination of the oral cavity, middle and lower parts of the pharynx. First of all, the vestibule of the oral cavity, alveolar processes, and then the floor of the mouth, hard palate, and anterior tongue are examined. After pressing the tongue down with a spatula, the tonsils, arches, soft palate, and lateral and posterior walls of the pharynx become visible.
The most common sign of tumor and pre-tumor diseases of the oral cavity and pharynx is the presence of superficial or deep ulcerations, whitish or grayish plaques on the mucous membrane, asymmetry of the pharynx and pharynx, the presence of tuberous growths that bleed easily upon probing.
Laryngoscopy (mirror endoscopy of the larynx)
Most often, malignant tumors of the larynx are localized on the vocal folds, somewhat less often - in the vestibular and, rarely, in the subglottic regions. The appearance of laryngeal cancer in the early stages is not much different from chronic non-tumor and pre-tumor processes. Therefore, the final diagnosis is made after histological examination.Posterior rhinoscopy - mirror endoscopy of the nasopharynx and posterior sections of the nasal cavity - is one of the most technically difficult manipulations performed using small mirrors. In the nasopharynx, neoplasms with a lumpy surface and pink color of varying intensity are most often localized in the fornix and on the lateral walls.
On instrumental palpation they bleed easily. In the posterior parts of the nasal cavity, tumors are often located on the nasal turbinates or in the posterior parts of the ethmoidal labyrinth, protruding into the lumen of the nasopharynx and sharply narrowing or completely closing the passages.
Anterior rhinoscopy is performed using a nasal speculum. Most often, tumors are found in the area of the middle nasal passage in the form of tuberous or papillary growths of a grayish-pink color, narrowing or completely obstructing the nasal passages.
Fibropharyngoparyngoscopy is the most advanced method of endoscopy of the upper respiratory and alimentary tract. The flexibility of the device, the small diameter of its distal end, convenient for carrying out in any of the studied sections, and good illumination greatly facilitate the examination of all hard-to-reach places.
Bronchoscopy (FBS)
An endoscopic examination is carried out with a fiber-optic bronchoscope, which allows one to examine the bronchi up to the subsegmental bronchi inclusive, as well as perform a pinch or brush biopsy and targeted washings from small bronchi, which allows in 93% of cases to clarify the nature of the pathological process in the lungs.In addition, the condition of the carina and tracheobronchial angle on the affected side is assessed. Rigidity, hyperemia and swelling of the mucous membrane, expansion of the carina, flattening of the slopes of these anatomical structures indicate a widespread tumor process and are usually caused by metastatic lesions of the tracheobronchial or paratracheal lymph nodes. If such pathological changes are detected, transtracheal or transbronchial puncture biopsy is indicated.
The endoscopic picture of lung cancer depends on the form of growth of the lung tumor. Endobronchial tumors (6%) have the appearance of a tuberous polyp with clear boundaries, often grayish-brown in color, often with necrotic deposits. With a mixed growth form (14%), the tumor spreads both into the pulmonary parenchyma and into the lumen of the bronchus.
Identified on the basis of direct (presence of a tumor in the lumen of the bronchus) and indirect (rigidity, narrowing, bleeding of the mucous wall of the bronchus) signs of tumor growth. Peribronchial tumors (over 80%) grow predominantly in the pulmonary parenchyma around the affected bronchus, which is often compressed by this node.
The bronchoscopic picture is characterized only by indirect signs of tumor growth. In case of peripheral tumors, bronchoscopically reveals them only in cases where there is tumor growth into an accessible bronchus (cancer with centralization).
X-ray negative cancer (occult carcinoma) is lung cancer in which there is only cytological verification of the tumor process obtained by examining sputum. In this situation, bronchoscopy on both sides with separate sampling of material (washes or brusn biopsies) from all segmental bronchi is the only method to determine the localization of the tumor.
Endoscopy in gynecological oncology
Endoscopic diagnostic methods with sampling of material for morphological examination are the main ones in identifying dysplasia. pre- and microinvasive cervical cancer.For this purpose, colloscopy with targeted biopsy with a conchotome is used, since the final diagnosis can only be established after histological examination. The patient does not need special preparation for the study.
Colposcopic examination can be performed at 15-30x magnification. Colpomicroscopy is an original intravital pathohistological study intended for intravital study of tissues of the vaginal part of the cervix.
Hysteroscopy is used to diagnose pathology (tumors, polyps, endometriosis) of the uterine body and perform therapeutic procedures.
Endoscopy in oncourology
All parts of the urinary tract can be examined using endoscopic methods for the primary diagnosis of tumors (or tumors growing in them), monitoring during chemotherapy and radiation therapy, and timely recognition of tumor relapses after radical treatment.The use of endoscopy in oncourology also makes it possible to perform numerous transurethral operations: biopsy, diathermocoagulation, electroresection, cryodestruction of affected areas of the bladder, prostate and urethra.
Cystoscopy
Conditions for performing endoscopic examinations in urology significantly depend on the gender and age of the patient. In women, cystoscopy, as a rule, does not present technical difficulties, while any transurethral manipulation in men can lead to urethritis, prostatitis, epididymitis, and urinary retention.With cicatricial strictures of the urethra, sclerosis of the bladder neck, prostate adenoma, inserting the instrument into the bladder is sometimes impossible. In such cases, cystoscopy is preceded by urethral dilation or internal urethrotomy.
Cystoscopy is most often performed to clarify the source of hematuria both at the time of bleeding and after it has stopped. The most common finding is bladder tumors.
The discharge of blood from the mouth of the ureter observed during cystoscopy gives reason to assume the presence of a tumor of the kidney, renal pelvis or ureter and determine the side of the lesion.
Inspection of the bladder is carried out after filling it with liquid, which straightens the folds of the mucous membrane and ensures that the required distance is maintained between the bladder wall and the optical system of the cystoscope. To fill the bladder, a warm solution of furatsilin or a 3% solution of boric acid (250 ml) is usually used.
With a bladder capacity of less than 80 ml, cystoscopy is almost impossible. In women, cystoscopy can be performed without anesthesia. In men, passing an instrument through the urethra is often painful. Therefore, examination of the bladder and other endoscopic manipulations in men should be performed under local anesthesia (instillation of a lidocaine solution into the urethra).
To perform lengthy and painful endoscopic interventions, the use of anesthesia or epidural anesthesia is indicated. During cystoscopy, catheterization of the ureters can be performed with a diagnostic (retrograde ureteropyelography, obtaining urine from the kidney for cytological examination) and therapeutic (drainage of the pelvis) chain.
Cystoscopy makes it possible to determine the anatomical form of growth and size of the tumor, to clarify the degree of involvement of the most functionally important formations in the process (Lietaud's triangle, ureteral orifices, bladder neck area). There are exophytic (papilloma and papillary cancer) and endophytic tumors.
In papillary (villous) cancer, the tumor has short, thick and opaque villi. Villous-free forms during cystoscopy appear as tuberous formations, slightly protruding into the lumen of the organ and covered with edematous infiltrated mucosa, often with areas of ulceration and necrosis.
The wide base of the tumors indirectly indicates infiltration of the deep layers of the bladder wall. Primary endophytic bladder cancer does not have strictly pathognomonic endoscopic signs. The mucous membrane looks hyperemic, edematous, without clear boundaries of the lesion.
Characterized by a significant decrease in the capacity of the bladder, due to the rigidity and wrinkling of its walls. Such changes must be differentiated from pathological processes similar in endoscopic picture (chronic and radiation cystitis, tuberculosis).
Chromocystoscopy is used to assess the excretory function of the kidneys and identify disturbances in the passage of urine through the ureters. Intense discharge from the ureteric orifices observed through a cystoscope 3-6 minutes after intravenous administration of indigo-carmine (5 ml of 0.4% solution) indicates the free outflow of urine from well-functioning kidneys.
Weakening or complete absence of dye release on one side indicates a decrease in the function of the corresponding kidney or obstruction of the ureter (tumor or stone), compression by scar tissue, pathologically altered lymph nodes or a tumor of the retroperitoneal space.
Urethroscopy
Endoscopic examination of the urethra in urological oncology practice is used relatively rarely and more often in men (in women, the urethra is short and accessible for palpation through the vagina along its entire length). Primary urethral cancer is endoscopically determined either in the form of a villous exophytic tumor or in the form of a tuberous infiltrating formation with significant swelling of the mucous membrane and areas of ulceration.Mediastinoscopy
Mediastinoscopy [E. Carlens, 1959] - a method of surgical endoscopic examination of the anterior mediastinum for visual assessment and biopsy of paratracheal and tracheobronchial (upper and lower) lymph nodes, trachea, initial parts of the main bronchi, large vessels.Mediastinoscopy is indicated to clarify the spread of the tumor process in the lung, when there are assumptions about the presence of metastases in the lymph nodes of the mediastinum and roots of the lungs, to clarify the nature and cause of adenopathy of the intrathoracic lymph nodes with radiographic expansion of the mediastinal shadow of unknown etiology (sarcoidosis, lymphomas and other systemic diseases).
The mediastinoscopy technique is as follows: A transverse skin incision is made above the jugular notch, the trachea is bluntly and sharply exposed, a canal is formed with a finger into which the mediastinoscope is inserted. The paratracheal areas, the tracheal bifurcation zone are examined, and lymph nodes are taken for examination.
At the end of the study, the wound is sutured. Mediastinoscopy can be accompanied by quite severe complications, so it is contraindicated in the general serious condition of the patient, severe cardiovascular and respiratory failure, acute inflammatory process in the mediastinum or lung. The operation is performed under general anesthesia using a non-explosive drug.
In the absence of a mediastinoscope, parasternal mediastinotomy can be used to diagnose mediastinal lymphadenopathy located anterior to the superior vena cava or in the area of the “aortic window” [E. Stemmer, 1965].
In this case, by making a skin incision from the 1st to 3rd ribs, the subperichondrial cartilage of the 2nd rib is exposed and resected for 2.5-3 cm, the posterior layer of the perichondrium and intercostal muscles parallel to the sternum are dissected, the internal mammary vessels are ligated and transected, after which a revision and biopsy is performed.
Thoracoscopy
Thoracoscopy - a method of endoscopic diagnosis of malignant tumors of the thoracic cavity - is performed with a fiber thoracoscope passed through the trocar sleeve into the pleural cavity in the fourth intercostal space anterior to the mid-axillary line.In oncology, thoracoscopy is indicated for:
1) suspicion of the presence of a primary (meeothepioma) or metastatic tumor of the pleura and the impossibility of their verification using transthoracic punctures;
2) the presence of disseminated changes in the visceral pleura or tumor formations localized subpureurally;
3) empyema of the pleural cavity that arose after pneumonectomy or lobectomy, to assess changes in it, the condition of the bronchial stump and subsequent decision on treatment tactics.
Laparoscopy
Endoscopic examination of the abdominal cavity using an optical instrument allows for examination, biopsy and surgical interventions. Laparoscopy (peritoneoscopy) in oncology is indicated in cases where, based on clinical, radiological and laboratory data, it is not possible to establish the true nature of the process in the abdominal cavity.Contraindications to the study are the general serious condition of the patient, the presence of diffuse peritonitis or severe intestinal bloating, and pustular lesions of the anterior abdominal wall.
Laparoscopy is performed both under local anesthesia and general anesthesia. The study begins with the application of pneumoperitoneum (oxygen, air, nitrous oxide) using a trocar at one of the classic points. Then the abdominal organs are examined using standard methods. After examination, the air is evacuated and sutures are placed on the skin incision. Failures and complications during laparoscopy occur in 2-5%, mortality is about 0.3%.
Laparoscopy can reveal tumor dissemination throughout the peritoneum (carcinomatosis); establish the initial signs of ascites; diagnose primary cancer and metastases in the liver when they are located close to the surface; identify pathological changes in the pancreaticoduodenal zone, stomach, and intestines. However, in common cases, it is not always possible to determine the source of the primary tumor.
Laparoscopy is informative in the diagnosis of neoplasms of the genital organs (uterine fibroids, cysts, primary and metastatic ovarian tumors). Currently, laparoscopic operations on almost all organs of the abdominal cavity have become widespread.
Uglyanitsa K.N., Lud N.G., Uglyanitsa N.K.
