[181] CHAPTER XVII—UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES
The limitations of bronchoscopic removal of foreign bodies are usually manifested in the failure to find a small foreign body which has entered a minute bronchus far down and out toward the periphery. When localization by means of transparent films, fluoroscopy, and endobronchial bismuth insufflation has failed, the question arises as to the advisability of endoscopic excision of the tissue intervening between the foreign body and bronchoscope with the aid of two fluoroscopes, one for the lateral and the other the vertical plane. With foreign bodies in the larger bronchi near the root of the lung such a procedure is unnecessary, and injury to a large vessel would be almost certain. At the extreme periphery of the lung the danger is less, for the vessels are smaller and serious hemorrhage less probable, through the retention and decomposition of blood in small bronchi with later abscess formation is a contingency. The nature of the bridge of tissue is to be considered; should it be cicatricial, the result of prolonged inflammatory processes, it may be carefully excised without very great risk of serious complications. The blood vessels are diminished in size and number by the chronic productive inflammation, which more than offsets their lessened contractility.
The possibility of the foreign body being coughed out after suppurative processes have loosened its impaction is too remote; and the lesions established may result fatally even after the expulsion of the object. Pulmonary abscess formation and rupture into the pleura should not be awaited, for the foreign body does not often follow the pus into the pleural cavity. It remains in the lung, held in a bed of granulation tissue. Furthermore, to await the development is to subject the patient to a prolonged and perhaps fatal sepsis, or a fatal pulmonary hemorrhage from the erosion of a vessel by the suppurative process. The recent developments in thoracic surgery have greatly decreased the operative mortality of thoracotomy, so that this operation is to be considered when bronchoscopy has failed. Bronchoscopy can be considered as having failed, for the time being, when two or more expert bronchoscopists on repeated search have been unable to find the foreign body or to disentangle it; but the art of bronchoscopy is developing so rapidly that the failures of a few years ago would be easy successes today. Before considering thoracotomy months of study of the mechanical problem are advisable. It is probable that any foreign body of appreciable size that has gone down the natural passages can be brought back the same way.
In the event of a foreign body reaching the pleura, either with or without pus, it should be removed immediately by pleuroscopy or by thoracotomy, without waiting for adhesive pleuritis.
The problem may be summarized thus: 1. Large foreign bodies in the trachea or large bronchi can always be removed by bronchoscopy. 2. The development of bronchoscopy having subsequently solved the problems presented by previous failures, it seems probable that by patient developmental endeavor, any foreign body of appreciable size that has gone down through the natural passages, can be bronchoscopically removed the same way, provided fatal trauma is avoided.
At the author's Bronchoscopic Clinics 98.7 per cent of foreign bodies have been removed.