Advances in endoscopy of infants and children

Advances in Endoscopy of Infants and Children By STEPHEN L. GANS AND GEORGEBERCI

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INCE KUSSMAlrL introduced the first open tube into the gullet, using as illumination the reflected light of a gasoline lamp, the medical profession has been keenly aware of the advantage and need of inspecting the inside of hollow organs and cavities which could be approached through an orifice. Kussmaul studied the technique and position of a professional sword swallower, whom he used as a willing subject for his attempts at esophagogastroscopy in 1868.’ During the next hundred years endoscopes and their optical components have undergone many changes and improvements, but the principles of the system have remained the same: an open tube with a light at one end or the other, and the addition of the traditional telescope where possible. Although this arrangement has been reasonably satisfactory for the examination of adult patients, when this system is reduced in size for pediatric use, the viewing angle becomes very small and the image very dim. As a result pediatric endoscopy has lagged far behind the advances in adult endoscopy. We have nothing but the greatest admiration and awe for the pioneers in the pediatric field who have practiced this art. However, recent important technical advances have so improved endoscopic methods that the time has now come to reevaluate and expand their usefulness. It is now possible to miniaturize these instruments and at the same time obtain a vastly improved view. This report will be divided into two sections, the first dealing with basic principles and fundamentals relating to optics, illumination, photographic documentation, and general instrumentation. The second will detail specific examinations, describing the advanced instrumentation used for each procedure and discussing present and future indications in the light of advanced technology. BASIC PRINCZIPLES AND FUNDAMENTAL INFORMATION

It is interesting to note that despite the fact that among the various specialties approximately six million endoscopic examinations are performed each year in the United States, it is difficult to find basic research activities in the literature. In order to take advantage of the latest technical developments and exploit them to the fullest extent, well organized interdisciplinary communication is necessary between practicing clinicians, research scientists, experimental surgeons, and highly qualified instrument designers. We will briefly review the general and specific principles accumulated through years of study and observaFrom the Department of Surgery, Endoscopic Service, and Pedintric Service, Cedars-Sinai Medical Center, Cedars of Lebanon Hospital, Los Angeles, Calif. STEPHEN L. CANS, M.D.: Chief, Pediatric Surgery Service, Department of Surgery, CedarsSinai Medical Center, Cedars of Lebanon Hospital; Assistant Attending Surgeon, Chitdrens Hospital of Los Angeles; Associate Clinical Professor of Surgery, University of Southern California School of Medicine, Los Angeles, Calif. GEORGE BERCI, M.D.: Director of Surgical Research and Coordinator, Endoscopic Unit, Department of Surgey, Cedars-Sinai Medical Center, Cedars of Lebanon Hospital; Awistant Clinical Professor of Surgery, University of California at Los Angeles School of Medicine, Los Angeles. C&f. JOURNALOFPEDIATRIC

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Optics If one uses a tube with a small diameter, such as the one now used for infant bronchoscopy, for example, with an inside diameter of 3.0 to 3.5 mm and a 200 mm length, the visual field is determined by the diameter of this small tube. The addition of a magnifying loupe attached to the proximal end does not change the size of the visual field. Because of the tiny view and the long focal distance through the tube, only a very small part of the organ is visible and for this reason orientation is very difficult as is illumination. As early as 1875 Nitze recognized the need for a telescopic system which would transmit an image from a deep hole to the examiner’s eye, when properly illuminated. He developed such a lens system and introduced the first cystoscope in 1879.2 This system became a standard over the years. Although there were many modifications and improvements, the basic system remained the same: small lenses placed at intervals with air space between them (Fig. 1)‘ Although the viewing angle was increased, it remained small; but a greater drawback was the enormous light absorption by the lens system, even in instruments designed for adults. When the diameter of such a telescope is decreased for pediatric use, the light absorption becomes even more significantly increased and the image is quite dim in comparison to adults. Endoscopy of all types was given a “new look” because of the invention by Hopkins (Brit. pat. no. 954629; U.S. pat. no. 3257906) of the rod lens system (Fig. 2). Hopkins has reversed the traditional design. Instead of using small lenses with intervening air spaces, he used glass rods to replace the air space, and small air spaces to replace the former lenses. The ends of the glass rods were shaped to the form of a lens.With this ingenious optical system the viewing

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Fig. 2.-Schematic cross section of usual telescope (A) emploved in endoscopic examinations where telescopes can be used. Small lenses are spaced in a tube with air space between them. Hopkins (B) replaced the air interspaces with glass rods, and the lenses with small air spaces. Fiber light transmission (F) is incorporated into the sheath of the optic.

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angle is significantly larger, there is greatly increased light transmission, exceedingly good resolution, and miniaturization is feasible with exceptional performance. The superior illumination is incorporated at no loss in viewing diameter.3 Viewing angle. The viewing angle is 2 to 3 times larger than in conventional systems depending on the object distance. Thus a much greater part of the organ can be seen in a single viewing field. This makes orientation much easier, the view is more realistic and the examination can be accomplished faster. If any suspicious areas are seen, the scope is brought closer and the object is enlarged, allowing more detailed inspection (Figs. 3 and 4). Light transmission. As previously mentioned, the light absorption through a small telescope is very high and this enormous light absorption limits the efficiency of the present conventional systems. The Hopkins system has the distinct advantage, by comparison, of a significant increase in light transmission with a much brighter image.

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together with a catheter deflector and one instrument channel. Illurnination is provided by a distal globe. The broken line represents the Hopkins-Storz pediatric cytoscope. The sheath is Fr. 10 in size and contains in its wall one instrument channel and a catheter deflector. The telescope along with its fiber light is 2.7 mm (Fr. 8.1). The viewing angle is 60”. (B) Two telescopes shown in (A) are plotted against each other comparing size of object (mm) ordinate and object distance (mm) abscissa. A.

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Optical resolution. Optical resolution is excellent and lesions 0.5 mm in size can be detected easily from a distance of 25 mm.3 The physiology of vision imposes a limit on the resolution when looking through the usual infant bronchoscope with such a small lumen (3 mm) and comparatively great length (200 mm). Moreover, if the object distance is 15 mm from the working end of the tube, the size of the field (object) is still no more than 3 mm. Using the Hopkins telescopic system with identical object-objective distance, the object is transmitted to the receptor system under significantly improved conditions. There is enlargement and increased brightness, the size of object seen through the telescope being 18 mm in diameter as compared with 3 mm through the open tube. Miniatur&~tion. The diameter of the telescope is an important factor in determining the outside diameter of an endoscopic instrument. This is of extreme importance when related to pediatric anatomy, where the various orifices and organs are of small size, particularly in the newborn. This outside diameter has been an obstacle in the development of pediatric endoscopy. With the Hopkins lens system the pediatric endoscope can be miniaturized without

Fig. 5.-Close-up of miniature telescope containing rod lens system for image transmission with the half circle fiber threads incorporated for light transmission. The angle of light beam covers wide viewing field of optical system. Total outside diameter is 2.7 mm.

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compared with the conventional systems. We are now able to with an outside diameter of 2.7 mm including the light transdescribed below, and a 1.8 mm telescope incorporating light under clinical trial (Fig. 5).

Illumination In the early years progress was largely dependent on improvement of illumination. In 1879 Nitze introduced a new era by developing a cystoscope with a lens system in conjunction with internal (distal) illumination. Before the discovery of Edison’s electric globe Nitze used a platinum wire which was heated by batteries to provide light. It was possible to use such a system because the production of heat was of little concern working under water. A few years after Edison’s discovery, Nitze developed the first miniature filament globe, based on Edison’s concept, and opened the first chapter of endoscopic examination using a telescope and a distal light.4 Because of the narrow opening and the long tube, as well as the great need for improving illumination in such limited space, several approaches are used. One such is to introduce a light carrier right down to the working end of the endoscope through a small guide tube which is incorporated into the wall of the scope. Only tiny globes can be used, and thus there is greatly limited light output and unilateral illumination. The object seen is not uniformly illuminated, creating significant contrast differences on the object, which can be confusing in assessing small changes. The light globes tend to “burn out” and are easily covered with secretions or blood obscuring the view. In addition the light carrier itself occupies 1.6 mm of the diameter and when recessed in the wall of the scope either decreases the viewing angle or increases the outside diameter a significant factor in a bronchoscope with a 3.0 mm lumen. Another approach is to place the light source outside of the body, near the eyepiece, so that both its size and efficiency can be increased. The light beam is directed into the endoscope by means of a mirror as a light deflector ( Fig. 6). The projector globe is placed near this mirror. This system of “proximal illumination” has several disadvantages: anything inserted into the tube (mirror)

is placed near the eyepiece and beam is reflected into the tube by a

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decreases the already limited diameter for viewing or for the insertion of a telescope or instruments, there are disturbing reflections in the inside of the tube which can be only partly overcome by coating the inside of the metal tube with a black finish coating, vulnerable to autoclaving, cleaning and instrumentation. Another way to cut down reflections is to insert a spiral into the tube but this further decreases the inside diameter so crucial in pediatrics. A significant advance was made by Montreynaud, Edwards, and Gladu, with an instrument designed by Vulmier and Fourestier, using rigid quartz rods which conducted light with minimal loss. Fortunateely, heat transmission is within physiological range .s This approach was the first practical method of increasing illumination significantly enough to obtain color photos through a conventional lens system. The disadvantages of this system were the weight and difficulty in handling the heavy projector and lamp housing, problems in sterilization, the fragility of the quartz rods, and, from the pediatric point of view, significant problems in minaturization. However, the credit in the field of clinical documentation (photography) must be given this method. Almost all of the good color endoscopic photos seen in the literature have been made with this method through adult endoscopes. The most recent and most significant forward step in obtaining improved illumination was the development of small flexible fiberglass threads for the transmission of light. In 1930 Lamms described his first successfu1 experiment in transmitting images through small individual fiber threads which are held together in a flexible bundle. If they are sorted with great care an image can be transmitted even if the bundle is in a bent position. If the individual fiber threads are not assorted appropriately, each individual thread will not transmit its respective part of the image in position and the image will be distorted, although light is still transmitted. These nonassorted fiber threads are called incoherent bundles and can be attached on one end to a light source at some distance from the endoscope (for example, 6 feet). If fiber threads are placed around a telescope and brought out in a bent position or right angle near the eyepiece in a rigid bundle, the flexible lighttransmitting cabIe can then be connected from the light source to the telescope providing transmission of the beam of the remote light source into the body cavity. It is true that by using a 6 foot cabIe the light loss or absorption in the fiber cable is significant (50-70%), but this can be compensated for by using a more powerful light source. Because of the smaller diameter of the Hopkins lens system, it was now possible to place a thin layer of light transmitting optical fiber bundles around the rod lenses, thereby providing even, strong, cold light illumination without occupying significant space in the endoscope itself. Compared with separate light carrier systems this has an inestimable advantage. Not only is the method more practical and troubIe free, but it creates a clear bright view even powerful enough for coIor photography. In addition, the bronchoscopes, esophagoscopes, and sigmoidoscopes are

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provided with a proximal light source by means of a new prismatic light deflector which occupies less space than previous models and can be connected with the fiber light cable. The instrument can thus be introduced with proximal light and as an open tube. As soon as it is in position, the prismatic deflector can be withdrawn into the holding sheath and the telescope with its incorporated light conducting fibers is introduced into the sheath. Of course, this maneuver is not always necessary or desirable and the scope can be inserted with the telescope in place. Flexible fiber optics. In 1930 Lamm first used flexible fiber glass threads for transmitting an image.6 In 1954 Hopkins made the first prototype of a flexible gastroscope’ and Hirschowitz and his co-workers8 produced the first clinical results of the examination of the stomach in 1958. The presently available flexible fiber gastroscopes are a significant advance in the examination of the adult stomach, such as are the new instruments for examination of the duodenum, or the entire colon (total instrument diameter is 13 mm). The image quality of a flexible fiber optic is by no means comparable with a rigid one, and even more so one with the Hopkins lens systems. However one must compromise in regard to those organs where one cannot introduce a rigid system. Moreover, there are serious problems involved in miniaturization of flexible fiber image transmitting endoscopes. By decreasing the diameter for example to 3 mm, the resolution drops considerably because it is in proportion to the number of threads incorporated in the system. In addition, if we intend to add some sort of control for bending of the tip, this mechanism needs space. We also need space for the light-transmitting bundles which are separately placed along the image bundles. In other words, a 3 mm fiber endoscope with remote control tip and instrument channel cannot incorporate more than a 1.5 mm image transmitting bundle, which would give a very poor, small image. No doubt there are indications for the use of an improved version of such an instrument and we have already initiated investigations and experiments in this matter; but there are doubts as to whether the time and enormous capital investment needed are in reasonable proportion to expected clinical results. Binocular endoscopy. Many instruments have been developed to fulfill the desire of man, that his eye see beyond its normal range. Magnification itself is important, but binocular vision is another desirable adjunct. The microscope was originally a monocular instrument but the advantages of binocular viewing (better vision, less fatigue, faster perception, and more accurate interpretation) became apparent and it rapidly became standard in this field of optical instrumentation. Binocular endoscopy has been tried in the past but the high absorption of a beam splitter made the image very dim. This was even more pronounced when miniaturization was attempted and the light absorption was greater. However, with the new lens and illumination systems, model instruments for binocular endoscopic viewing using a rod lens type of beam splitter are promising. Adequate brightness is available so that the same field of vision which can ordinarily be seen through the monocular telescope, can be observed with both eyes, giving a new perspective to endoscopy, particularly pediatric endoscopy.

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Fig. ‘I.-Nitze’s “photocystoscope” Klin. Wschr., 1893.9)

using small black and white film plates. (Berlin

PERMANENTDOCUMENTATION-PHOTOGRAPHY Because of the limitations of visual perception, it is often difficult for one to distinguish normal from abnormal, or to accurately locate a small lesion, if he can obtain only a fleeting glimpse. It is frequently inadequate to describe in words the appearance of a three-dimensional lesion or growth, and even more so for someone else to recreate his own mental picture of it by reading another’s descriptive report. In radiology one of the factors responsible for the high level of diagnostic accuracy is the availability of the radiograph, which can be scrutinized for an unlimited time by, if necessary, a number of observers or consultants. A lesion which may be overlooked on first inspection, may be detected on subsequent review, or by another examiner. Furthermore, great value is obtained in comparing films taken at various intervals in the patient’s progress. Today, one would hesitate to form an opinion or make a decision after reading only the description of a fluoroscopic examination. On the other hand, in present day endoscopic practice, it is not uncommon for the clinician’s assessment of the diagnosis, pathology or function to be based on the examiner’s visual findings. A small but significant abnormality may be overlooked if the examiner’s attention is divided or hurried, a good possibility in small infants in more or less critical condition. The possibility of minutely scrutinizing permanent films of the examination, repetitively if necessary, by multiple examiners, is most attractive, and would be additionally helpful in teaching. Comparison films of the patient’s condition at intervals could also be quite useful. A single still photograph or slide inserted into the patient’s chart, into the file of the examiner, and into the records of the referring physician or next consultant, instead of or in addition to the written description would be an improved method of recording findings. Motion pictures are of obvious interest in studying function. At the same time, demands on the patient are reduced by shorter operative procedures which are also more accurate. The need for a permanent film record is increasingly evident.

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Attempts to record endoscopic examinations (Fig. ‘7) were made as early as 1893 by Nitze,g and in 1894 he completed the first atlas of pathology of the human urinary bladder. 10 Since then others have introduced alternative documentation technics (Hollinger” in 1942 and Fourestier et a1.12 in 1952) and have given undeniable impetus to solving this problem. However, no method has been widely used because special instrumentation and significant capital investment were required. The instruments themselves were heavy and difficult to manipulate and therefore interfered with the routine of the investigation; the examination time was extended, the danger to the patient was increased, and special skills had to be acquired. Our investigations in the photographic aspects of endoscopy, as well as in instrument development, have been guided by the following fundamental principles. 1) The operator must have complete control over the passage and manipulation of his instruments. He is largely dependent on the sensations of resistance conveyed to his hand during manipulations, to avoid the risk of damage to mucous surfaces or perforation of a viscus. No restraint imposed by the investigating instrument must be allowed to interfere with this primary requirement. Even the best CounterbaIancing system imposes certain restrictions. 2) The examination time must not be unreasonably extended, and if possible it should be shortened. 3) There should be no additional risk to the patient, but indeed less. 4) No special outside skill or assistance should be required. 5) The financial investment should be reasonable. At the present time several methods of obtaining a photographic record during examination are available. In those instances where an open tube system is employed, such as bronchoscopy, a telephoto lens is attached to the proximal end of the scope. Sufficient enlargement and good detail can be obtained, but the viewing angle is very small and orientation is difficult because no more than the actual tube diameter can be seen. The telephoto lens is, of course, coupled to a camera, and a tremendous amount of light is required (the telephoto lens absorbs a great deal) to be projected into the open tube. This type of apparatus is big and bulky and needs a counterbalancing system. The introduction of small quartz rods for the transmission of light was a great step forward because enough light was available for use with standard telescopic systems. It was the first really useful way of producing good photographs during an examination .l3 Again, however, the light source in the form of a small projector housing and cooling system was attached beside the sheath making the whole apparatus heavy and clumsy. There were also significant problems with sterilization and in operating costs. Now there is available the combination of an optical system with markedly decreased light absorption (Hopkins), and fiber light transmission from a remote light source. The size and weight of the illumination apparatus is not significant; adequate light is readily available for recording purposes. Still photography. Ordinary photography can be carried out with an internal or external flash. A miniature flash bulb has been developed which is intro-

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Fig. 8.-Plastic housing containing small flash bulb. One fiber light terminal connects to light source (F), the other to the endoscope (E), providing examining light before and after flash is used. When discharged by trigger the flash is thrown into the body cavity through the fibers incorporated in the telescope.

Fig. 9.-Endo-Zoom lens with fast coupling device and special clear viewer. “Robot” camera body is employed because of its small size and automatic rewinding ability. The pistol grip can also be used as a manipulating handle for the endoscope. When the trigger is pressed, the flash is released, the film exposed and the camera rewinds. Arrow indicates connection of the telescope for fiber light cable or flash housing.

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duced through the distal end of the instrument into the inside of the cavity, and to provides excellent illumination with good depth of field and bright image. Despite preventive measures regarding grounding and circuitry, we hesitate to employ this method and regard it as dangerous on the basis of animal experiments conducted in our laboratories. We are currently using a method which employs a small flash bulb in a plastic housing which is attached to the light conducting fibers of the telescope outside of the scope (Fig. 8). The light conducting cable for the examining light is coupled to the other end of the housing so that the examining light, transmitted through the housing, provides the usual illumination. A reflex camera with a suitable viewer is coupled to the eyepiece of the telescope and the examination is continued through the viewer. When the lesion is properly located, a trigger is pressed, discharging the flash bulb, exposing the film and rewinding the camera. The flash is transmitted through the fiber threads incorporated around the telescope. We have tested a variety of cameras and must admit that none has been found to be ideal. Each has to be coupled with the telescope eyepiece, thereby increasing the distance between the eyepiece and the examiner’s eye. There are problems involved in maintaining sterility which we have partially solved by using plastic cover bags, autoclavable metal cases, etc. The reflex and viewing systems of most cameras absorbed too much light, and the coarse grained viewers had to be exchanged for a clear viewer with a focal ring or cross enabling visual adjustment for the eye. We are designing a camera which we hope will solve these several problems inexpensively. Meanwhile, we are using a camera of small size and weight with an automatic spring rewinding system. Its smaller image is adequate for endoscopy. A convenient viewer with an elongated tube made specifically for endoscopy is attached to this camera (Fig. 9). “Endo-zoom system”@. A special zoom lens system has been designed (Storz) for endoscopy. It has the advantage of enlarging the object without advancing the endoscope. There are some instances when a lesion is detected, but then lost by further manipulation, particularly when using an oblique angled lens, resulting in a loss in time and longer manipulation to recapture the object. Additional manipulation may also “dirty” the lens, which is disappointing when a clear view has once been obtained. With the endo-zoom system, the endoscope can be maintained in the position where the lesion is first detected. The first exposure will therefore display the lesion in relation to the topographic anatomy. By rotating the lens (“zooming in”) the object is significantly enlarged for better and more detailed analysis, without advancing the endoscope. Cinematography. In motion pictures, the best results have been obtained using an R 16 mm Beaulieu movie camera coupled to the telescope eyepiece with a through-the-lens light meter. Many difficulties were encountered in designing a light source which would give enough light without the production of excessive heat, which might melt the fibers on the end which is connected to the light source, or might exceed the physiological range on the working end of the scope. We have succeeded in producing such a light source using a

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short-arc lamp with a specially and cooling system, This illuminator provides (Kelvin) compatible with a high speed Kodak ASA 160.

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designed condenser (Storz) optimal color temperature Ektachrome film ( daylight)

Problems related to the size and weight of the camera and to the maintenance of sterility still exist. These are strong arguments in favor of the development of a universal miniature 16 mm movie camera which would obviate these shortcomings. We have developed a camera introducing a radical departure from the usual apparatus: the heavy part (magazine, motor, etc.) is separated from the film gate and viewer. The two are connected by a flexible tube which incorporates the remote film transport mechanism. The same principle is involved as in separating the heavy light source from the useful beam in the endoscope, and connecting them with a fiber light cable. Our object was to produce a camera which would be light and small enough to be used as the handle of the endoscope connected to the instrument throughout the examination. It can be attached to any endoscope and the viewing field (object) is examined through the camera viewer. If pictures are desired, the camera is put into operation by pressing a foot switch.l* To the best of our knowledge, this is the first flexible remote film transport where the heavy part of the camera is separated from the viewer. This apparatus is still in the process of refinement and development and is not available for general use at the present. At the time of development of this 850 g camera, it was used for making moving pictures through adult endoscopes with standard lens systems and quartz rod light transmission. With the advent of miniaturization even this size and weight is too clumsy for pediatric endoscopy and we are in the process of developing a new miniature 16 mm camera based on completely new principles of recording through a telescope and will be most efficient in pediatric use. Teleuision. One shortcoming of endoscopy has always been the restriction imposed by the use of a small monocular eyepiece. The development of television was therefore of great interest to those concerned with improvements of endoscopic documentation and teaching. It offers these advantages over standard viewing methods: the image can be viewed immediately; the image can be seen by several observers, perhaps in different places, thus facilitating consultation and teaching; the image is enlarged many times according to the size of the monitor screen; the viewing of the image is binocular; moreover it can be seen from an optimal distance; the image can be recorded from the television screen using either a still or synchronized movie camera. Despite these great advantages, progress in this medical application of television techniques has been slow. The first televised adult bronchoscopy was of endoscopic reported by Soulas et al. in 1957. 15 For the earliest television procedures studio cameras ( Image-Orthicon) were used. However, their weight and size excluded them from practical use. Later on, industrial camera chains (Vidicon) were employed. Such cameras, however, were still too heavy and unwieldy to allow gentle and accurate handling. With this in mind we developed our first miniature television camera in 1958 and reported our clinical

Fig. 10. - Miniature high-resolution television camera. Weight 860 g, length 170 mm, width 50 mm. It can be coupled with any endoscope provided that enough illumination is available, and it uses any 16 mm C-mount lenses.

in 1962.16 The camera was 45 mm in diameter, 120 mm in length (without lens) and 350 g in weight. It was built around a U-inch Vidicon tube. The resolution did not exceed 350 TV lines (3.5 MHz). Since then, television techniques have been improved significantly and therefore we selected a new type of system which is capable of 1000 lines (10 MHz) resolution, with incorporation of automatic gamma ( contrast ) and brightness control. It weighs 860 g and can be used with 525 and 1023 scanning lines. This special endoscopic camera with its high-quality image produces details never seen on television monitors through an endoscope before” (Fig. 10). We were able, for example, to perform tubal sterilization (division) in the adult, through the peritoneoscope, operating from the screen. Even the picture through mini-scopes can be televised. However, an important question must be considered: Is the monochrome interpretation real enough and satisfactory. 2 In the examination of certain pathological states where inflammation is the most familiar, visualization of the natural color would seem to be of primary importance. In most endoscopic examinations, however, the dominant color is red and the contrast range in the natural colors is not great. In fact, the difference in the appearance of most structures as seen by endoscopy is determined in the main by small variations within the red spectrum. This would be true, for example, in the examination of blood vessels running on the wall of the bladder or bronchial tree. The contrast range of a color photograph is approximately 4:1, whereas the same range on the television screen can be enhanced with ease to 1O:l or even more. The present resolution (10 MHz) is superior when compared with a color camera (5 MHz). To test the point mentioned above, we carried out bronchoscopy in a dog in which we induced a sudden occlusion of the venous drainage of the lung. The color picture of the bronchus showed a striking degree of venous engorgement but the same point was no less evident from the examination of the photograph taken from the television screen. experience

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Fig. Il.-Pediatric telescope with 2.7 mm outside diameter, has light transmission sufficient to expose a 35 mm color slide (ASA 160) or 16 mm cinefilm (16 frames/ set, ASA 160).

It must be admitted that, in general, color photography should be the method of choice in medicine but in this special field the high quality of a black and white image appears to be good enough to make it of value in diagnosis in selected cases and in teaching. The increased contrast available from the television circuit offsets the loss of color differentiation. It is felt, therefore, that the use of television offers definite advantages and we have been encouraged to adapt this technique to endoscopic investigations. The use of television in endoscopy is still largely unexplored and the scepticism and inhibition against monochrome interpretation is based in many instances more on established psychological backgrounds than on fact. For example, no one demands a color X-ray film. The recording of a television picture is another question. If one transfers a normal (resolution) monochrome TV image to a video tape one loses information (resolution). By doing it with the high quality TV-chain the video-taped image is very poor when compared with the original one. At the moment we are engaged in the development of a unit which will film the full output of the high-resolution television monitor, and therefore reproduce the full information seen on the monitor without loss as mentioned in the case of video-taping. Presently available color television chains are in their infancy and are inferior in reproduction compared with our specially designed small highresolution black and white TV chain. Other technical problems (weight, greater light requirement) and the enormous capital investment do not justify use as an adjunct in endoscopy at the present time. We do hope that there will be a breakthrough in this area of interest, where smaller cameras with better image quality and larger light sensitivity (low light level cameras ) will be available for a more reasonable price. Conclusions on photography. We are quite satisfied that excellent quality photographs can be made in most cases, that this will become more consistent

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and easier with experience, and that appropriate apparatus will become generally available soon. This has been made possible by the use of new instrumentation ( Storz ) employing the Hopkins rod lens system, and by the incorporation of fiber optic illuminating principles into the production of high intensity tine-light and flash systems. These principles have permitted miniaturization for satisfactory pediatric use ( Fig. 11). One color slide inserted into the patient’s chart, the physician’s records and the endoscopist’s file should be the significant “document” accompanying endoscopic examinations. A movie film strip should make the study of obscure or functional disorders possible as well as making diagnosis more complete and accurate, with fewer demands on the patient. The teaching value is obvious. Black and white television is becoming an important communications and teaching method, but color television is not yet on the horizon. Znstrumentatiofl This new optical invention, and with it the opportunity of miniaturization, created potentials for pediatric endoscopy never before possible. Because of this a complete new set of instruments had to be designed, developed, and tested to meet the needs and yet retain the previously listed fundamental guidelines. This paper is the result of years of intensive study in coordinating and adapting the various aspects of optics, illumination, and photography just described, into instrument design, while accommodating physiologic requirements. It is a fact that the metal component of most endoscopes used today is 40 or 50 years old. At present alloys are produced where the resistance to stress is many times greater than the old ones and where the wall thickness is only a fraction of what it used to be. In a tubular shape, there is, of course a larger lumen with a better view. It is also much safer to work with a lighter and more sensitive instrument because of the sensation transmitted to the hand. Miniaturization of instruments, for example, biopsy or grasping forceps, increase the usefullness of endoscopy. We now have a biopsy forceps which fits through the instrument channel of a 3 mm bronchoscope or esophagoscope and can be used without altering the view through the telescope (Fig. 12).

Fig. 12.-Close-up of working tip of a “3 mm” bronchoscope newborn (outside diameter 4.8 mm). The biopsy forceps is introduced through the instrument (suction) channel which is incorporated into the entire outside diameter of the instrument. The jaws of the forceps are 1 X 1.8 mm total diameter. With the forceps in place, the telescope is insered into the sheath and tissue samples can be taken under accurate visual control. Wall thickness of the metal sheath is 0.25 mm.

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Fig. 13.-Miniature oto-rhino-laryngoscope. 56.8 mm, direction of view 30”.

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Outside diameter

is 2.7 mm, length

The efficiency of various types of suction apparatus were studied. To our great surprise we found that the vacuum is dropped or increased from time to time by almost 50% in hospitals using central systems supplying several rooms. We also found significant variations among similar vacuum pumps used as mobile units. This variability is particularly dangerous in pediatric use where too high suction pressures produce injury. Many systems showed a significant delay (5 to 7 set per suction maneuver) before required vacuum is obtained. Multiplied by the number of times suction is applied, minutes can be added to the procedure. We have modified a newly designed mobile pump where the vacuum can be preadjusted independent of the central hospital supply. It always runs within the maximum preadjusted (300 to 700 mm Hg ) vacuum values and has a safety valve which does not permit them to be exceeded. When the machine is turned on, suction is immediately available at the working tip of the instrument. This unit will be described in a separate paper, but we would like to take this opportunity to draw attention to an important and neglected aspect of pediatric endoscopy, particularly as related to investigations of the respiratory or upper digestive systems. Attention to such small details can spell the difference between success and failure in delicate situations. New tools are necessary for new technique and new techniques result from creative new tools. Cooperation between surgeon and inventor could produce many new instruments for safer and better examinations. Specific endoscopes and their adjuncts for specific procedures will be described in the next section on special procedures. We must again express our gratitude and admiration for the pioneers who developed this field and who can “see so much” with their familiar open tube systems of tiny caliber dimly lit for endoscopy, particularly in the small infant. Even in their skilled and experienced hands a large number of endoscopic examinations are abandoned, repeated or prolonged unduly. With the new optical systems, even with miniature instrumentation, the view is outstanding, thereby making procedure shorter, safer, and most of all more accurate and dependable.

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EXAhlINATIONS

Included in this section will be detailed descriptions of the instruments, methods, and indications for various endoscopic procedures in infants and children. It will not include such superficial examinations as inspection of the ear, although we would like to mention the use for this purpose of a new miniature optic, 2.7 mm in diameter and 56.8 mm in length, incorporating fiberlight transmission (Fig. 13). With it the ear, particularly in the newborn, can be examined as never before. The same telescope can be used as a rhinoscope or in the new laryngoscope. Photography can be used as described in the previous section. Laryngoscopy Pediatric surgery interest in this field centers around its use in emergency intubation and for possible aid in the introduction of the bronchoscope. Malformations and diseases of the larynx are well described by other authors.ls-20 The introduction of an endotracheal tube in an infant with respiratory distress is often a life-saving maneuver. This task frequently is the responsibility of a house officer who may be short on skill and experience, rather than to an anesthesiologist or endoscopist for whom this procedure is a simple routine. In addition the inexperienced is frequently handicapped by inadequate equipment, sometimes not even in working condition. Good medical care requires that all house officers as well as other physicians and surgeons dealing with infants and children should gain adequate experience and practice with endotrachia1 intubation and should have immediately available proper instruments, in frequently checked working condition, With this in mind, a new Iaryngoscope was developed. The conventional laryngoscopes have distal illumination by a small globe. Even with repeated suction of accumulating saliva and mucous these globes can be obscured and one is often working in semidarkness. The new instrument has a small prismatic light deflector inserted at the proximal end, in the handle itself. Optical technology permitted the development of this miniature light deflector (Fig. 14),

Fig.

14.-Prismatic only need be inserted into adequate illumination

of new design

light deflector. Because a 2.0 mm of the prism the open tube to provide It is connected to a light

source by a fiber cable.

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Fig. 15.-Laryngoscope for newborn or infant. The smallest size has an outside diameter of 12 mm and a length of 81 mm. (A) Larjngoscope with inserted nrismatic proximal light beflector, connected to fiber light cable. Even with excessive secretions, blade end is well illuminated. (B) Same as (A), but miniature telescope has been inserted for closer inspection and distal illumination. Intermittent use of proximal and distal ilhlmination is facilitated by using Yshaped fiber cable.

which occupies a very small part of the tube, but is sufficient to keep the area illuminated. It is connected to an outside light source by a flexible fiber light cable, and provides much more iIIumination than is achieved with any distal light bulb (Fig. 15A). The prism can be partially withdrawn and a miniature telescope with a large viewing angle and built-in fiber optic light threads, can be inserted for a magnified view (Fig. 15B). This laryngoscope is available in various sizes. The blade is now being modified so that it will not only retract the tongue but will keep it from sliding away from the blade. The relatively small size of the larynx in infancy, its great irritability, and the ease with which obstructive edema may be produced, must be indelibly impressed upon all those who engage in endoscopic work. Edema of 1 mm of the mucosal surfaces of the glottic airway will reduce the lumen to only 35% of its original size.lg The infant is positioned with the neck flexed slightly on the chest and the head extended on the neck. The laryngoscope is introduced slightly to the right of the midline, the tongue is retracted and the blade is advanced in the midline to the vallecula, and the epiglottis is visualized. Sometimes, merely lifting the tongue forward, particularly in small infants, also elevates the epigottis, and the vocal cords can be visualized. Intubation is then performed. In some infants, and in older children, the laryngoscope blade must be advanced under the tip of the epiglottis and the epiglottis gently lifted upward to expose the vocal cords and permit intubation. The most common error is to advance the laryngoscope blade too rapidly or too far, passing the epiglottis and entering the laryngopharynx. Another error is to press the tip of the blade too firmly into the vallecula while searching for the epiglottis. Either of these maneuvers may result in shutting off the airway (with the epiglottis) instead of opening it. Both can be avoided by using the new tongue retracting blade and the bright, wide view afforded by the new laryngoscope.

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Bronchoscopy The bronchoscope is quite indispensible in the study of endotracheal and endobronchial conditions for it provides information for diagnosis and a method of treatment that is unattainable in any other way. Familiarity with the technique is essential to the pediatric surgeon because it adds a new depth to his appreciation of the variations of normal, as well as his understanding of the varieties of lesions and malformations which he is called upon to treat. The problem has been to learn the art. In the past because of the “dim view” and limited viewing field, it took a long apprenticeship, a large number and variety of cases, and a particular undefinable aptitude or talent in order to be able to be sufficiently expert to be confident in performing this examination, particularly in the small patient. With the advent of the new miniature lens systems and improved illumination this may no longer be true. Wider angle viewing makes orientation simple and quick, and along with better illumination gives a realistic and true image. When this is coordinated with photographic (still and tine) studies and television, teaching and learning of the art can be vastly improved and expanded. In the gentle hands of the pediatric surgeon, already familiar with the anatomy and diseases of the involved organs, and armed with improved instruments, it does not take long to learn the manipulations and maneuvers which will provide him with this most valuable adjunct to his specialty. Instrumentation. We have been working with infant bronchoscopes having sheaths of three sizes: 2.5 mm X 200 mm, 3.0 mm X 200 mm, and 3.5 mm x 200 mm. The small numbers represent the inside diameters or the lumen of the tube. In measuring conventional bronchoscopes, we find that they are made of thicker metal and the so-called 3 mm scope has a wall thickness of 0.75 mm as compared with our new model’s 0.25 mm. This makes a significant difference by permitting a proportionally larger lumen compared with the outside diameter (Fig. 16). It is just as important to know the outside diameter measurement of an endoscope as the inside diameter. Most manufacturers in describing their instruments use the gross inside diameter. A small prismatic light deflector is inserted near the proximal end of the sheath (Figs. 16 and 17). This is for connection to a flexible fiber light cable from a light source which may be used during introduction of the bronchoscope as well as later manipulations. A wide-bore conic shaped tube incorporated opposite this prismatic illuminator (Figs. 16 and 17) can be connected to an anesthetic machine or respirator to provide ventilation or controlled respiration. This can be made into a closed system by inserting a “window plug” into the end of the bronchoscope. Even with the telescope in position we have found it easy to handle and maintain adequate ventilation and thus decrease the risk of examination in acutely ill infants. In the very unusual event of inadequate ventilation the telescope may be temporarily removed. A small instrument guide channel with a rubber tip is attached obliquely for introduction of a flexible suction catheter, size 4, Fr. After considerable

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Fig. 16.-Compare the usual newborn bronchoscope (0) with the new instrument (N). Both have an outside diameter of 4.8 mm and are called “3 mm” bronchoscopes. Below, note the small insufflation tube (a) which enters at an acute angle, and the light carrier (b) for a tiny globe which occupies about l/3 of the visual lumen. The new model is shown equipped with proximal light prism (c), miniature telescope (d) (each connected with fiber light cables), de-fogging sheath (e), large airwav tube (f), and biopsy or grasping forceps (g) in the instrument channel, with working tip (h) in direct view of telescope. Fig. 17.-Bronchoscopy and esophagoscopy set. Vertically at the left (B) is a 3.0 mm X 200 mm infant bronchoscope sheath with connected ventilation tube. Horizontal position (B) is the next size larger bronchoscope sheath, 3.5 mm lumen, with proximal light prism in place and “window plug” separate and facing forward. Next is 0” telescope (T) and below that is the “antifog” tube (AF) into which (T) is inserted and locked before introducing the (T) the bronchoscope into sheath. Positive air pressure from aquarium pump is plugged into this tube by means of a Luer-lock connector, marked by arrow. Infant esophagoscope sheath (E), 3.0 mm x 200 mm, is same as bronchoscope sheath except that airwav connector and distal perforations are absent, and the working end is more rounded’ and flared. The same telescope and anti-fog sheath are used for both bronchoscope and esophagoscope, as is the miniature biopsy or grasping forceps shown at the bottom.

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trial a miniature biopsy or grasping forceps, 1 mm in diameter, with sharp “spoon” jaws and cutting edge 1.8 mm in diameter has been designed which can be introduced through this channel and used with the telescope in position in 3.0 and 3.5 mm lumen bronchoscopes (Figs. 16 and 17). Tissue samples can be obtained under direct telescopic vision, with a precision never before possible. Foreign bodies can be grasped under direct vision. An electrode for cutting or coagulation may also be inserted. A minature forward vision optic with a wide-angle view and surrounding fiber threads for illumination is inserted into the bronchoscope sheath (Fig. 16). The telescope is surrounded by a very thin tube (Figs. 16 and 17) which is connected to a small air (aquarium) pump. This minimum positive air pressure in front of the lens avoids contact with secretions or fogging of the telescope. In addition to the 0” or straightforward view, a 30” or forward oblique optic is now available. There is no doubt that the miniaturization of this highquality optical system allows the display of the trachea and bronchial tree with details and minute changes never recognized before in small infants. Similar instruments only larger in proportion are available for children. Procedzlre. The technique of bronchoscopy is beautifully described and illustrated by Stradling,sl Becker,18 and more particularly for infants and children by Holingeris~sa and others. We will refer to this only briefly and mainly where relevant to the new instruments. Many of these examinations can be done either with or without a general anesthetic.22 There are a few circumstances where general anesthesia should not be used. However, with the newer and safer general anesthetics, with a well trained pediatric anesthesiologist, and with the better control and facility possible with the new instruments, we feel that the more frequent use of general anesthesia is probably safer and permits a more careful and thorough examination. With the infant positioned as for laryngoscopy, the larynx is exposed and the bronchoscope is gently introduced between the vocal cords, using the lip of the bronchoscope to gently separate the chords. This procedure is usually done with an open bronchoscope sheath (with or without proximal prism light and “window plug”) using the conventional intubating laryngoscope or with the new one herein described. However, the orientation provided by the magnified wide-angle view, the bright illumination, and the air “de-fogging” device of the new instruments, makes it possible, with a little practice, to introduce the bronchoscope with the telescope already in position. The bronchoscope is supported with the fingers of the left hand while the right hand, holding the scope like a pencil, advances it while rotating the head posteriorly. After examining the trachea the advancing instrument can be gently directed into one bronchus then the other by on shifting the head from side to side. Photographs or motion pictures are quickly made when desired. We again wish to emphasize that good motion pictures of questionable areas are extremely useful for later repetitive review without prolonging or repeating the procedure itself in an already critical patient.

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Fig. 18.-(a) Intennediate pediatric esophagoscope: outside diameter 7.5 mm, lumen 6 mm, length 300 mm; instru-

mm, lumen 5 mm, length 300 mm; instrument channel;

ment channel, prismatic deflector, and telescope. (b) Suction catheter (plastic); metal connector; can be introduced through rubber-tipped instrument channel. (c) Metal suction tube with rubber tip. (d) Intermediate pediatric bronchoscope: outside diameter 6.5 mm, lumen 5 telescope inserted.

Indications. In infants and children bronchoscopy is used both for diagnosis and for therapy. s3 The instruments have been proven to be especially useful in diagnosis of H- or N-type trachea-esophageal fistulas and recurrent tracheoesophageal fistulas. The opening can be seen with clarity and precisely documented, an unusual achievement in the past as witnessed by the difficulties described and the numerous methods recommended in the literature.z4~2s Excessive secretions or coughing should make one suspicious of these conditions, particularly if they do not respond to the usual treatment. Dissatisfaction with the conventional bronchoscopes has been evidenced by the use of cystoscopes for bronchoscopy. 24 Other diagnoses we have made while investigating the causes of wheezing, emphysema, or atelectasis are vascular rings, intrinsic webs, tumors or cysts, tracheal or bronchial stenosis, or hypoplasia and tracheoor bronchomalacia. The usual therapeutic indications include the removal of mucous plugs unrelieved by the conventional means. Occasionally in fibrocystic disease mechanical removal of viscid secretions or debris is helpful in reducing the number of episodes of bronchopneumonia and the occurrence of bronchiectasis.ia,ss Webs may be excised with electrocautery particularly with the new forceps and/or electrode under direct telescopic visualization. The removal of foreign bodies is an art in itself and demands the utmost in skill and patience.27vs* For this one should be familiar with the writing and teaching of Holinger1a~20 whose experience is so broad and who has been such an inspiration to the authors. The most common complication of bronchoscopy is laryngeal edema. Its causes are trauma from too large an instrument, too ‘$eavy” a hand, or from prolonged or repeated examinations. We believe this can be reduced by the proper use of the new instruments. Esophagoscopy The general considerations esophagoscopy as well.

described in the section “Bronchoscopy”

apply to

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The sheath of the new esophagoscope is the same as the bronchoscope in size (3.0 x 200 mm and 3.5 x 200 mm) and shape and proximal prismatic illumination. The attachment for controlled respiration is, of course, omitted as are the perforations for ventilation in the sides of the distal end of the sheath. The working end is shaped and finished extremely well to avoid injuries (Figs. 17 and 18). The telescopes with self-contained fiber illumination and “de-fogging” tube are exactly the same as for the bronchoscope and can be interchanged. The same instrument channel can be used for suction, biopsy forceps, for a small Fogarty catheter, and for a long needle for injections. All procedures are performed under direct telescopic vision. The proximal prismatic deflector and the telescope fiber optic thread connections are coupled separately with a reversed Y-shaped fiber cable, the common limb being connected to the light source. Proximal illumination can be used for introduction of the esophagoscope while secretions are being suctioned away. By withdrawing the prismatic deflector a few millimeters into its sheath, the telescope can be inserted with light and antifog device. If the telescope has to be withdrawn because of excessive secretions or for manipulation, the prismatic light deflector is pressed down into position reestablishing illumination immediately. Larger sizes (instrumentation and optics) are available for children (Fig. 18). Telescopes are available with various viewing angles. Photographic techniques are all exactly the same. This would seem to be an ideal situation for the use of flexible fiber esophagogastroscopes. There are existing systems with an outside diameter of 5 mm29 but the disadvantages are significant, as previously described.aa-3s Although improvements are expected, the rigid system is the method of choice at this time. Procedure. Especially in infants and children, the airway must be guarded by endotracheal intubation. The patient is positioned with the neck somewhat flexed on the chest and the head extended on the neck. A laryngoscope may be used, but mainly for elevation of the tongue. It is usually omitted. The esophagoscope is introduced into the hypopharynx to the right of the midline and advanced laterally to the epiglottis into the right pyriform sinus. In many children the cricopharyngeus often relaxes with respiration, revealing the transverse slit-like opening of the esophagus, particularly if the larynx is gently lifted forward by the lip of the esophagoscope, which can then be slipped into the visible orifice. This is beautifully illustrated by Becker.‘* If the opening does not become readily apparent, pressure on the scope is contraindicated. Instead a woven silk esophageal bougie or a rubber tipped suction tube may be gently inserted into the cervical esophagus and be used as a guide, the esophagoscope being advanced over it as the cricopharyngeus relaxes. Inspec tion of the esophagus is completed by passing the scope through the cardia, into the stomach. This may take gentle pressure or a “lumen-finder”, but when the cardia opens, gastric secretions and rugae immediately appear. By blowing air into the stomach and introducing the lateral optic, a limited examination of the stomach may be made. Abnormalities are noted and photographed as desired.

Instrumentation.

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Indications. Dysphagia is the most common indication for esophagoscopy. Dysphagia is the result of obstruction, pain, or incoordination of peristalsis. Causes of obstruction are congenital webs or stenosis, stenosis acquired after surgical procedures or ingestion of caustics or corrosives, foreign bodies, intrinsic or extrinsic cysts or tumors, and vascular rings. 3s Congenital webs or stenosis can ordinarily be cured by dilatation. Webs may be incised by electrocautery through the instrument channel under direct telescopic control. Postsurgical stenosis usually follows operations for esophageal atresia and usually responds to skillful dilatation. Dilatation procedures are well described by Holingeris~sa and other+45 and are usually done through open tubes. However, evaluation is best done with the new telescope, and passage of strings and even a tiny Fogarty catheter can be done more easily through the instrument channel, using the bright, telescopic magnified view. In situations where a gastrostomy is present, retrograde esophagoscopy and instrumentation can be done after inflating the stomach with air. Accurate evaluation of the interior of the esophagus in the early stages of injury caused by ingested caustics or corrosives is now easily accomplished with the new esophagoscope, and photographs for comparison are a valuable adjunct. Wider angle and depth allow for a quicker, less extensive examination while more information is gained. Dilatation is carried out as indicated in the early and later stages along with the use of steroids and antibiotics. There is a sharp division of viewpoints about the use of the latter medications.ss-39 Ashcroft and Holder40 have described experimental and clinical improvement in strictures injected with triaminolone. The experience of Mendelsohn and Maloney41 adds validity to this concept. The former have attributed some failures to inaccurate injection of the steroid into the lesion. If this method has merit, we suggest that with the instruments such injecion therapy can be carried out with greater accuracy and over a larger area, thus, hopefully producing more consistent and satisfactory results. The advantage of the new esophagascope in regard to foreign bodies relates to speedier orientation and location of the object as well as its possible withdrawal by means of the grasping forceps passed through the instrument channel, in clear telescopic view. Failure of this method calls for the traditional manipulation through an open tube, described in detail elsewhere.1a~20*42 Diagnosis of intrinsic cysts (usually duplication) or tumors (leiomyoma) and biopsy where indicated is handily done. Extrinsic cysts and tumors will only show an indentation or compression, while vascular rings will show pulsatile compression. Esophageal diverticula are also easily demonstrated and may be emptied as indicated. In these latter diagnoses, good radiographs are equally useful, and, as indicated in most cases of dysphagia, should precede esophagoscopy. Choking or coughing on swallowing may indicate a neurogenic dysfunction with faulty swallowing or reverse peristalsis. Cine-radiography is of more help in establishing these diagnoses. However, similar symptoms, particularly when associated with episodes of bronchopneumonia or atelectasis, may result from tracheoesophageal communication, either congenital or recurrent following a

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surgical repair. Here the new esophagoscope will perform with great efficiency in locating, evaluating and photographing this lesion. The many various methods of establishing this diagnosis which are found in the literature attest to their failures and inconsistencies.24q2s Pain may be due to esophagitis, hiatal hernia, foreign body impaction, cyst, tumor, or cardiospasm. We have already commented on all but the first two lesions, which frequently appear together. Demonstration of esophagitis or ulceration may well influence the course of therapy for the associated hiatus hernia. Photography allows for a genuine comparison or reevaluation at a later date. Esophagoscopy is also of considerable value in the diagnosis of upper gastrointestinal bleeding. It can rule out the esophagus as a site of bleeding or it may demonstrate hiatus hernia, esophagitis or ulcer, esophageal varices, or a bleeding tumor. Usually these diagnoses can be made radiologically. However, as many as 20% of varices are not demonstrated by X ray alone, and esophagitis is even more elusive particularly in evaluating its extent. Although neither approving or condemning the procedure, the new esophagoscope would make it more accurate and easier to inject sclerosing solutions into esophageal varices. The most serious complication of esophagoscopy is esophageal perforation, and the most common cause of esophageal perforation is instrumentation occurring during esophagoscopy, gastroscopy, or esophageal dilatation.4s-45 In addition to improper and rough technique, perforation may be associated with manipulation in a dimly illuminated area which may be outside of the field of vision, as well as to inadequate evaluation of the condition of the tissue comprising the wall of the esophagus at the site in question. No doubt the incidence of this serious complication can be reduced in the light of the new developments in endoscopy. Sigmoidoscopy This subject will be dealt with only briefly and only improvements in the instruments based on the new technical innovations will be discussed. Despite the fact that endoscopic examination of the anus, rectum, and sigmoid has been quite adequate, mainly because these organs have a large enough lumen for adequate illumination, the new model is even more proficient. Two sizes are available for infants and children: 12 mm and 16 mm in outside diameter; both are 200 mm in length. As soon as the tube is introduced and the obturator removed, a proximal light deflector is attached, which also incorporates a connection for standard air insufflation. With proximal illumination always in this position, several attachments are now of use (Fig. 19). A simple glass window is still available but is considered to be of little value in comparison to a similar screw cap with a magnifying loupe. Under the loupe is an instrument channel which can be used for suction, biopsy, or cauterization. For more detailed inspection of minute lesions or for more accurate tissue sampling, this loupe cap is replaced by a telescope, incorporating the previously described fiber light transmission to its working end, so that both proximal and distal illumination systems are employed simultaneously. Below the telescope,

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Fig. lg.-Pediatric signoidoscope. (a) 12 mm tube with obturator in place. (b) Prismatic light deflector (connected to fiber cable), which is attached to tube after withdrawal of obturator. Air insufflation bulb is connected to this piece. A plain glass window (w) can be screwed on, or a cap with a magnifying loupe and a sealed hole for suction or instrumentation can be attached (c), (d) Telescope with incorporated fibers for distal illumination, “anti-fog” sheath, and instrument channel. All parts are interchangeable within seconds and proximal illumination is continuously provided.

a sealed instrument channel is similarly provided for suction or biopsy. It is of great advantage that proximal lighting is always present, even if the telescope is obscured by accumulation of intestinal contents. Permanent film records can be obtained through the telescope. Vaginoscopy There are a number of congenital anomalies and other abnormalities in which vaginal examination is of use. Abnormal openings and communications, and intersex problems are among the most important. We use vaginoscopy commonly to determine the presence or absence of a cervix, which will give advance notice of possible male pseudohermaphorditism in apparent females with hernias and normal external genitalia.46 The vaginoscope consists of a sheath, 4.8 mm in outside diameter, similar to a cystoscope sheath, and the distal end is rounded to avoid injury to the tissues. A built-in instrument channel facilitates the introduction of a catheter for probing the various orifices or for injection of contrast material for radiological investigations. A telescope with built-in fiber illumination is inserted for a magnified wide angle view. A two-way stopcock system is attached to the proximal end of the sheath to allow in and out flow of air or fluid as necessary for unobstructed vision and documentation. Peritoneoscop y Introduction. Also referred to as laparoscopy or celioscopy, this procedure was first described by Kelling47 in 1902, as a “celioscopic” examination in dogs using an optical instrument. Jacobaeus,4s in 1910, was the first to describe ‘laparoscopy” in the human, using a trochar and cystoscope. Since that time this procedure has been “rediscovered” every few years with the development of new instruments and techniques, with brief flurries of popularity; but accept-

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ante, particularly in pediatrics, has been slow. Gynecologists have obtained the greatest benefits and have made the most progress.“g Now with advances in optics and illuminationsa~51 new instruments incorporating these advantages has been developed and miniaturized so that pediatric peritoneoscopy is now a valuable method with an expanding future. Znstrumentution and procedure. In infants the procedure is performed under general anesthesia with controlled respirations. Experience has indicated that the installation of pneumoperitoneum with increased intraabdominal pressure can be safely done, using proper precautions and aided by cooperative collaboration of the anesthesiologist, so that respiratory or cardiac output problems are prevented. The abdomen is prepared and draped for the appropriate site of entrance, which will depend upon the area to be examined. However, the smaller the infant, the greater is the area that can be covered from any entrance site. The bladder is, of course, emptied prior to the examination. The procedure starts with insufflation of carbon dioxide to produce a protective air cushion between the abdominal wall and the intraabdominal organs. This is initiated with a specia1 needle which contains within it a spring controlled blunt stylet. This needle is inserted into the abdominal wall and as soon as its sharp point pierces the peritoneum, the blunt stylet springs forward because there is no further resistance, and, filling the sharp needle, protects the abdominal contents from injury by further advancement. A side hole in this stylet is conected outside of the needle to a CO, cylinder that has a reducing vaIve, flow meter, and continuous intraabdominal pressure meter. Abdominal pressure should not exceed 10-15 mm Hg. The flow meter indicates continuous inflow and the voiume is also monitored. In newborns or infants it is very important that the insufflation proceed very slowly and with careful attention by the anesthesiologist. When the pneumoperitoneum is adequate, a trochar with stylet and built-in no escape valve (outside diameter 4.0 mm) is introduced through a tiny skin incision with a drilling motion through the abdominal wall and into the air cushion. The stylet is withdrawn and replaced with the miniature foreward oblique telescope (Fig. 20). CO, does not escape during this maneuver hecause of the valve. Inspection of the abdominal organs then begins first with Fig. 20. - Peritoneoscope. Special needle with spring controIled blunt stylet for initiating pneumo-insufflation (P). Trochar with stylet and no-escape air valve, outside diameter 4.0 mm, (TR). Biopsy forceps (b-f) which is inserted through second separate cannula and is used under direct vision of telescope (T) for tissue sampling and/or electro-coagulation.

*~.-------.-.P

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the involved area. A Menghini needle can be inserted separately through the abdominal wall and biopsies made under direct vision. For more involved manipulation, a second valve-containing trochar and canula can be introduced. Through this cannula, biopsy and grasping forceps can be utilized and electrocoagulation or incision can be accomplished. An example of this can be found in the adult where sterilization by tubal division is done quickly, completely, and safely under direct vision. With greater experience and creativeness we are certain that there will be many more useful developments in this field. Indications. Direct vision biopsy of the liver has great advantages. By this means the color, size, induration, presence of cysts, nodules or hemangiomas, or diffuse hepatic involvement can be noted and evaluated before the biopsy needle or forceps is directed into the most promising areas. Metastatic implants may be missed by needling alone, and when hemangiomas are present blind needling may be dangerous. Another safety factor is provided in guiding the needle away from aberrant vessels, dilated bile ducts, cysts, and the gallbladder. If bleeding or leakage of bile persists at a biopsy site, it can be observed and the site coagulated. Peritoneoscopy may have an important role in the differential diagnosis of biliary atresia and choledochal cysts. In addition to direct vision liver biopsy, with experience it might be possible to inject the biliary tree through the liver with radioopaque material for radiographic study. The presence or absence of a gallbladder can be easily seen. Bulging in the porta hepatis or dilatation of the common duct can be noted. We are investigating the possibility of injecting a gallbladder, if present, through the liver substance, with radioopaque material for radiologic study of the ductal system. By this method, the liver itself would block leakage from the gallbladder. The investigation for and evaluation of portal hypertension could be materially assisted. Radioopaque materials can be injected into spleen or omental vessels for vascular studies, under direct vision and with electrocoagulation control if necessary. Varices can be demonstrated directly. Another important dimension lies in determining the nature of the pelvic organs in intersex or gonadal problems. The view is excellent and gonadal biopsies can be made if indicated. We have on occasion done this procedure through a hernia sac (during surgery) and have also been able to demonstrate a hernia on the contralateral side with this method although we do not believe this procedure is indicated as a routine. No doubt peritoneoscopy can be of value in primary diagnosis of some intraabdominal tumors, although it will be limited for deep or retroperitoneal masses, Perhaps it will have greater use as a “second look” procedure, or passibly in the staging of Hodgkin’s disease. Its role in the diagnosis (and even treatment) in intraabdominal trauma is being considered, as are the possible division of adhesions, and drainage of abscesses through a second trochar and cannula properly directed and inserted. As greater experience with these new instruments is accumulated, some of these indications may be changed or discontinued, while no doubt new ones will be conceived, developed and used. Photography and television are equally available for peritoneoscopy.

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Urethra-cystoscopy The large number of congenital and acquired lesions of the urinary system and the great frequency of their occurrence makes the examination of this tract with an endoscope a necessary routine. In addition to inspection of the urethra and bladder, the endoscope is used for biopsy, fulguration, resection, removal of foreign bodies, catheterization of the ureters, retrograde pyelography, etc. none of which need be elaborated upon in this paper, except in their relationship to new developments in instrumentation and technique. In the past century many efforts were made to miniaturize adult instruments for use in pediatrics but they fell far short of being satisfactory. The major drawback was the optical system itself, because when the standard system was decreased in diameter, light absorption became so high that the image was exceedingly dim and the viewing field so small that orientation was quite difficult. With the advent of the Hopkins rod lens system incorporating fiber optic illumination, miniaturization was achieved with a tremendous improvement in viewing angle and brightness of image.3, 52 We are now using an instrument in the newborn the total outside diameter of the teIescope including fiber optic light transmission is 1.8 mm. To the best of our knowledge, this is the smallest available and the view is excellent. The cystoscope sheath is Fr.8. It does not allow the introduction of a catheter but the telescope can be removed for irrigation (Fig. 21). Its bright image, wide viewing angle, and symmetrically round shape make the examination of the newborn, particularly the male, much easier and safer. For larger infants and children other sets are available: Fr.10, 13 and 14. Two telescopes are used interchangeably and with any of these pediatric sets: straightforward, and 30” forward oblique, each 2.4 mm in outside diameter with built-in fiber light. The 10 Fr. sheath is symmetrically round. It has a double irrigation stopcock and a built in deflector for a Fr. 3 catheter. This represents a great advantage in that a ureteral catheter can be introduced with such a small cystoscope. A catheter deflector can be inserted into the Fr. 13 and 14 sheaths. Through the Fr. 13 sheath one can introduce one 4 Fr. or two 3 Fr. catheters, and through the Fr. 14 sheath one can introduce one 5 Fr. or two 4 Fr. catheters. The slightly curved tip of the sheath facilitates its introduction with the tele-

Fig. 2X.-Cystoscope, size 8 Fr. total outside diameter, with irrigation and obturator. Miniature telescope, O.D. 1.8 mm.

228

GANSANDBERCI

I

14

,

Fig. 23.-Miniature resecto&ope, size 13 Fr. Sheath with workin element, telescope, an% cutting loop (CL.). Biopsy forceps (b-f) can be introduced with this sheath for accurate tissue sampling. Obturator (0) for sheath.

Fig. 22.-Pediatric cystoscopy set. On the left, 13 Fr. sheath with two instrument channels. On the right, similar 14 Fr. sheath. Introducable cathsizes (cd.) Below is a 10 eter deflector for these two Fr. sheath with one inchannel and strument built-in catheter deflector. Both telescopes shown, strai htforward and forwari: oblique, can be used with any of these sheaths.

1

Fig. 24. - Resectoscope sheath, 13 Fr., with telescope and biopsy forceps in position.

ADVANCES

IN ENDOSCOPY

OF INFANTS

AND CHILDREN

229

scope as a urethroscope. The posterior urethra can be seen easily and the bladder neck or bladder can be examined with one maneuver without removing the sheath, by interchanging the optics (Fig. 22). For resection of bladder neck obstructions, valves, etc. in small infants a resectoscope, size 13 Fr. was designed having a miniature cutting loop and coagulating electrode (Fig. 23). Our limited experience with this instrument shows great promise and potential for pediatric urology. A miniature biopsy forceps was also developed which can be used through the Fr. 13 sheath with a telescope (Fig. 24). DISCUSSION

Despite the fact that over six million endoscopic examinations are performed per year in the United States alone, very little coordinated basic research has been reported in the literature. We now have a new service in our institution to assess the performance and parameters of the present instruments, and to investigate and develop technical improvements in and clinical application of these newer instruments. This “Endoscopy Service” includes members from all of the specialties represented in a large general hospital. Thus a research center has been set up where new ideas are created and developed, and laboratory and clinical trials carried out when the results looked promising. Close cooperation and constant “feed back” from the experimental surgeons and practicing clinicians on the one hand, and physicists and instrument designers on the other are necessary in such an endeavor. In all investigations the safety and benefit to the patient must be the first consideration. Endoscopy in infants and children has been much inferior to and far behind that in adults despite the brilliant work of a few pioneers and practitioners of this art. With the advent of the new rod lens system of Hopkins, incorporating fiber optic principles for illumination, it became possible to miniaturize endoscopic instruments for use in infants and children, maintaining a brilliant wideangle view and making possible so many of the achievements described above. This paper represents what we hope is a new chapter in a work which will permit specialists to operate under superior conditions, contributing to improved patient care from increased diagnostic accuracy and more usefully applied therapy, with decreased risk. Hopefully, this will be a new chapter in teaching and in learning of the art, and in placing these new tools in the hands of those who need them most. This is materially aided by the photographic techniques, and by live television viewing possible with these instruments. The future holds many new possibilities, some already initiated: examination of the joints, brain cavities, kidney, pelvis, mediastinoscopy, and amnioscopy. In order to exploit them fully, well organized interdisciplinary communication will be increasingly necessary. The profession must assist, cooperate, create, and demand such instruments as are necessary for safer and better examina-

230

CANS AND BERCI

tions. New tools are necessary to employ will result from creative new tools.

new techniques,

and new techniques

Pediatric endoscopy has been less than satisfactory and slow to develop because miniaturization of conventional endoscopes resulted in loss of light and viewing angle. The invention of the Hopkins rod lens system and the incorporation of fiber light illumination has permitted such miniaturization with vastly improved results. On the basis of this new system more satisfactory methods of making permanent records by photography are available. By this means clinicians’ communications and patients records can be improved. Combining this with television, teaching and learning the art and methods of endoscopy are enhanced, while making the procedure shorter, more accurate and less demanding on a critically ill patient. ACKNOWLEDGMENT We are indebted to Dr. L. Morgenstem, Director of the Division of Surgery, for his assistance and continuous encouragement. We gratefully acknowledge the help of the hospital administration and attending staff members in the establishment of the Endoscopic Unit. The invaluable assistance of Mrs. G. Nemethy, Mrs. M. Kosloff, and Mr. W. Jones is greatly appreciated. We thank the Alfred and Viola Heart Foundation and Mr. and Mrs. Samuel Schulman for their assistance in developing this program. We are indebted to Prof. Harold Hopkins who painstakingly designed the new lens system which allowed miniaturization for pediatric use. We are grateful to Mr. Karl Storz who spent years with US in converting laboratory prototype instruments into sophisticated clinical tools and in redesigning the complete armamentarium of instruments to accommodate miniaturization for pediatric use, We are indebted to Dr. C. E. Koop who encouraged us to collect all these facts and thoughts for presentation as a collective review, hoping, as we do, that others will join us in defining the extent and limits of the method.

REFERENCES I. Huizinga, E.: On esophagoscopy and sword-swallowing. Ann. Otol. 78:32, 1989. 2. N&e, M.: Eine Neue Boebachtungs und Untersuchungsmethode fur Hamrohre und Harnblase. Wien. Med. Wschr. 24:650, 1879. 3. Berci, C., and Kont, L.A.: A new optical system in endoscopy with special reference to cystoscopy. Brit. J. Urol. 41:564, 1969. 4. Nitze, M.: Veraenderungen an memem elektro-endoskopischen Instrumenten zur Untersuchung der mannlichen Harnblase. Ill. Monat. arztl. Polytechn. 3:60, 1887. 5. Montreynaud, J. M., Edwards, R. J., and Gladu, A, J.: Cinematography systematique endobronchique en pratique courante. AM. Otol. 73:682, 1956. 6. Lamm, H.: Biegsame Optische Gerate,

Z. Instrumentenkunde. 50:579, 1930. 7. Hopkins, H. H. and Kapany, N. S.: A flexible fiberscope, using static scanning. Nature (London) I73:39, 1954. 8. Hirschowitz, B. I., Curtis, L. E., Peters, C. W., and Pollard, H. M.: Demonstration of a new gastroscope, the fibergastroscope. Gastroenterology 35:50, 1958. 9. Nike, M.: Zur Photographic der menschlichen Harnblase. Klin. Wschr. 31: 744,1893. 10. -: Cystofotographic Atlas. Wiesbaden, 1894. 11. Holinger, P. H.: Photography of the larynx, trachea, bronchi and esophagus. Trans. Amer. Acad. Ophthal. 46:153, 1942. 12. Fourestier, M., Gladu, A., and Vulmiere, J.: Perfectionnements a l’endoscopy medicale. Presse Med. 60:1292, 1952.

ADVANCES IN ENDOSCOPY OF INFANTS

AND CHILDREN

13. Montreynaud, J., Bruneau, Y., and Jomain, J.: Traite Pratique de Photographie et de Cinematographie Medicales. Paris, Monte], 1960. 14. Berci, G., Merei, F., and Kont, L. A.: A new approach to clinical film recording with special reference to endoscopy. Med. Biol. Illus. 41:37, 1966. 15. Soulas, A., Montreynaud, J. M., and Edwards, R. J.: Bronchoscopy and television. Dis. Chest 31:580, 1957. 16. Berci, G., and Davids, G.: Endoscopy and television. Brit. Med. J. 1:1610, 1962. 17. Urban, J., and Berci, G.: A new high resolution miniature television camera. To be published. 1970. 18. Becker, W., Buckingham, R. A., Holinger, P. H., Korting, G. W., and Lederer, F. L.: Atlas of Otorhinolaryngology and Bronchoesophagology. Philadelphia, London, and Toronto, Saunders, 1969. 19. Holinger, P. H.: In Mustard, W. T., Ravitch, M. M., Snyder, W. H., Welch, K. J., and Benson, C. D. (Eds.) : Pediatric Surgery. Chicago, Year Book Medical Publishers, 1969, p. 429. 20. -, and Schild, J. A.: ln Swenson, 0. (Ed. ) : Pediatric Surgery. New York, Appleton Century Crofts, 1969. 21. Stradling, P.: Diagnostic Bronchoscopy. Edinburgh and London, Livingstone; Baltimore, Williams & Wilkins, 1969. 22. Fearon, B.: Anesthesia in pediatric peroral edoscopy. Ann. Otol. 78469, 1969. 23. Abbot, 0. A.: Recommended principles relative to the use of bronchoscopy and tracheotomy in infants and children. Dis. Chest 52:117, 1967. 24. Winslow, P. R., Bryant, L. R., and Hasbrouck, J. D.: Cystoscope endoscopy in the H-type trachea-esophageal fistula. Arch. Surg. 93:520, 1966, 25. Kafrouni, G., Baick, C. H., and Woolley, M. M.: Recurrent tracheoesophageal fistula: A diagostic problem. Surgery 68: 889,197O. 26. Atkins, J. P.: Bronchoscopic problems of infancy and childhood. Arch, Otolaryng. ( Chicago ) 79: 152, 1964. 27. maly, bodies cago) 28. Arch. 29. scone. L

Kollay, F., Hirschberg, J., and CserG.: Treatment of airways with foreign in infants. Arch. Otololaryng. (Chi88:303, 1968. Putney, F. J.: Bronchoesophagology. Otolaryng. (Chicago) 86: 117, 1967. Ikeda, Shigeto.: Flexible bronchofiberAnn. Otol. 79:918. -, 1970.

30. Kont, L. A., and Berci,

231 G.: A compara-

tive assessment of optical and fibre gastroscopes. Med. Biol. Illus. 17:181, 1967. 31. Berci, G., and Kont, L. A.: Fiber gastroscopes-Quo vadis? Endoscopy 1: 160, 1969. 32. Berci, G.: Fiber image transmission for endoscopy. Proc. Sot. Photo-opt. Engn. In press, 1970. 33. Holinger, P. H., Johnston, K. C., and Schild, J. A.: Congenital anomalies of the tracheobronchial tree and of the esophagus. Pediat. Clin. N. Amer. 9:1113, 1962. 34. Emerson, E. B., Jr.: Teflon esophageal dilators for children. J. Thorac. Cardiovasc. Surg. 52:579, 1966. 35. Bikhazi, H. B., Thompson, E. R., and Shumrick, D. A.: Caustic ingestion: Current status. Arch. Otolaryng. (Chicago) 89:770, 1969. 36. Borja, A. R., Ransdell, H. T., Thomas, T. V., and Johnson, W.: Lye injuries of the esophagus. J. Thorac. Cardiovasc. Surg. 57: 533, 1969. 37. Middlekamp, J. N., Ferguson, T. B., Roper, C. L., and Hoffman, F. D.: The management and problems of caustic bums in children. J. Thorac. Cardiovasc. Surg. 57:341, 1969. 38. Kinnman, J. E. G., Lee, B. C., Lee, c. w., and Shin, H. I.: Management of severe lye corrosions of the esophagus. J. Laryng. 83: 899, 1969. 39. Webb, W. R., Koutras, P., Ecker, R. R., and Sugg, W. L.: An evaluation of steroids and antibiotics in caustic burns of the esophagus. Ann. Thorac. Surg. 9:95, 1970. 40. Ashcraft, K. W., and Holder, T. M.: The experimental treatment of esophageal strictures by intralesional steroid injections. J. Thorac. Cardiovasc. Surg. 58:685, 1969. 41. Mendelsohn, H. J., and Maloney, W. H.: The treatment of benign strictures of the esophagus with cortisone injection. Ann. Otol. 79:900,1970. 42. Jackson, C., and Jackson, C. L.: Bronchoesophagology. Philadelphia and London, Saunders, 1950, p. 246. 43. Wychulis, A. R., Fontana, R. S., and Payne, W. S.: Instrumental perforations of the esophagus. Dis. Chest 55:184, 1969. 44. Quintana, R., Bartley, T. D., and Wheat, M. W., Jr.: Esophageal perforation. Ann. Thorac. Surg. 10:45, 1970. 45. Bill, A. H., Jr., Mebust, W. K., and Sauvage, L. R.: Evaluation of techniques of esophageal dilatation in relation to the danger

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of perforation. J. Thorac. Cardiovasc. Surg. 45:510, 1963. 46. Cans, S. L., and Rubin, C. L.: Apparent female infants with hernias and testes. Amer. J. Dis. Child. 104:82, 1962. 47. Kelling, G.: Uber Oesophagoskopie, Gastroskopie und Celioskopie. Munchen Med. Wschr. 49:21, 1902. 48. Jacobaeus, H. C.: Uber die moglichkeit die Zystoskope bei untersuchung seroser Hohlung anzuwenden. Munchen Med. Wschr. 572090, 1910. 49. Cohen, M. It.: Culdoscopy vs. Peritoneoscopy.

Obstet. Gynec.

31: 310,

AND

BERCI

50. Berci, G.: Peritoneoscopy. Brit. Med. J. 1:562,1962. 51. Banche, M., Roatta, L., and Bonardi, L.: Preliminary experiences with the optical system of Hopkins. In Endoscopy of the Digestive System. Base1 and New York, Karger, 1969, p. 88. 52. Berci, G., Getzoff, P. L., and Kont, L. A.: An improved concept in optics applied to cystoscopy. J. Ural. 104:542, 1970. 53. Walter, C. W.: Electrical Hazards in Hospitals. Washington, D. C., National Academy of Sciences, 1970.

1968.

Fig. 25.-Bronchoscopy. Six-month-old infant after repair of tracheoesophageal fistula; examination indicated by recurrent “respiratory distress”. Photo demonstrates view of the carina and entrance to major bronchi. Proximal to this on the posterior wall of the trachea is a blind pouch, the site of the closure of the communication. The patient has been entirely well since dilatation of her esophageal stricture (see Figs. 28 and 29). Fig. 26.-Bronchoscopy. and therefore enlargement Fig. 27.-Right

Same as Fig. 25, but taken with a longer focal range lens is achieved.

main bronchus in same patient; orifice of upper lobe is well visible.

Fig. 28.-Esophagoscopy. Esophageal stricture in 6-month-old infant after repair of tracheoesophageal fistula. She had been eating well, but had bouts of “respiratory distress” which we attributed to possible regurgitation and aspiration although mother denied vomiting. Fig. 29.-Esophagoscopy. symptoms.

Same area in same infant

after dilatation.

No further

Fig. 36.-Peritoneoscopy. Patient with possible glycogen storage disease of liver. Three failures to obtain tissue by percutaneous Menghini needle biopsy. Photo shows site of forceps biopsy on surface of liver done under direct vision. Fig. 31.-Cystoscopy on eight month old infant. Right ureteral bility of minute vessel architecture. Fig. 32.-Cystoscopy, ureteral orifice. Fig.

same patient.

33.-Vaginoscopy.

Two-year-old,

form, having had correction vaginoplastv (method view of cervix.

of indigo

congenital

1 year

Fig. 34.-Sigmoidoscopy. One-year-old moid mucosa (flash photo).

carmine

adrenal

of vagino-urethral

of Hendren),

Fig. 35.-Sigmoidoscopy. position. Photo significantly sigmoidoscope camera.

Photo

coming

hyperplasia,

communication Satisfactory previous.

with ulcerative

orifice. Note visifrom left

salt losing

and reconstructive vaginal vault and

colitis. Appearance

of sig-

Same patient with sigmoidoscope in exactly the same enlarged for more detailed analysis, using zoom lens on

ADVANCES

IN ENDOSCOPY

OF INFANTS

AND CHILDREN

Figures 25 through 33 are each enlargements of single 16 mm movie frames. The original picture size is 2 mm. It should be taken into consideration that the projected movie image is much sharper than one frame viewed as a still. There is also some loss in image quality in enlarging 5 X or 10 X in size and in the printing procedure. Figures 34 and 35 are taken with flash. This page is not meant to be an atlas of pathology, but only to illustrate some of the present ability to see and to document. (See legends on facing page.)