BOUGIEURAGE (fr. bougie a candle, buzh) — introduction of special tools — buzhy — in some bodies of a tubular form (an urethra, a gullet, an acoustical pipe, etc.) from diagnostic or to lay down. purpose. Most often this action is applied in urology, surgery, pediatrics, otorhinolaryngology.
Bougieurage in urology
by B. both at adults, and at children is carried out at strictures of an urethra of an inflammatory and traumatic origin and is not shown during an aggravation of local inflammatory processes. At the skillful equipment of anesthesia usually it is not required, but at patients with hypersensitivity or with morbidity in the place of a stricture local anesthesia is recommended: in 5 — 10 min. prior to B. carefully, without pressing, enter 15 — 20 ml of 1% of solution of novocaine or 0,3% of solution of Dicainum into an urethra; the entered solution is held imposing of a soft clip on a penis. Administration of these solutions is contraindicated if the day before or in day B. carried out any manipulations in an urethra, in order to avoid a reflux and intoxication. In rare instances recommend B. iod an anesthesia. At B. of an urethra at men (B. at women does not present difficulty) it is necessary to remember about it fiziol, curvature (reminds the lying letter S). The outside bend (spongy part of the canal) easily becomes straight, and internal (the part of the canal bypassing a pubic joint) can be straightened only by the direct metal tool at the expense of stretching of the suspending ligament of a penis when buzh already entered a cavity of a bubble. This part of an urethra passing through a muscular bottom of a small pelvis and a prostate gland is most difficult for carrying out a buzh and more often than other departments can be damaged. B. soft buzha more simply and safely and very seldom causes serious injuries of an urethra among which the main thing is formation of the false course. It is recommended to make B. only elastic buzha; from them it is more preferable capitate, with a neck thinner, than diameter of the buzh. Introduction of buzhy is made usually in position of the patient lying on spin, and the doctor costs to the left of the patient (some prefer to stand on the right). Previously the balanus is rubbed off antiseptic solution. Carefully greased elastic buzh it is necessary to hold in the right hand between big and index fingers for an upper part it (the so-called pavilion), without touching by hands of other part. The left hand, big and index fingers, hold a balanus and delay it perpendicularly to a long axis of a body why the first curvature of an urethra becomes straight, the channel is extended and but to it slides buzh easier. The end of a buzh is entered into the canal then all tool is usually easily pushed to a bladder. It is necessary to begin B. with buzha of big numbers, approximately with No. 16 — 18 at once to define existence and the place of narrowing. If the tool does not pass at once, then it is not necessary to make efforts for its carrying out. A usual obstacle is convulsive reduction of an urinogenital diaphragm and sphincter of a bladder. It is easy to overcome these obstacles careful and permanent pressing.
Special difficulty is presented by narrow cicatricial narrowings, in particular if the entrance is located (owing to scarring) excentricly. In such cases take thin if it is necessary, threadlike, sometimes with the bent end buzh and it is patient, persistently try to find an entrance. B. a bunch of buzhy helps with the most hard cases: 3 — 5 threadlike buzhy grease and enter before narrowing, then everyone in turn try to grope an opening (fig. 1). Usually after several attempts one of buzhy gets to narrowing and passes in a bladder. Got through narrowing buzh leave in an urethra for days, than cause the slight inflammatory irritation softening narrowing and next day easily enter thicker buzh. The patient urinates at the entered cream puff usually easier, than without it. Such B. is continued will not achieve sufficient passability of the channel yet.
At B. metal buzh the ohm is distinguished by three moments (fig. 2 — 4). At the first moment the doctor holds a balanus in the left hand, in right — the pavilion of the buzh directed by a beak up and enters it into an urethra, pulling a penis on buzh and holding the last parallel to the centerline of an abdominal wall. Buzh gets at the same time to a webby part of the canal, and its curvature shall lay down on a pubic joint. At introduction buzh it is necessary to hold between big and index (sometimes an average) fingers of the right hand, densely and softly as hold a bow at playing a violin. The hand shall grope constantly B. V advance the next moment the pavilion lift from a stomach, and buzh gets for a bulb into a hymenoid part of an urethra. Further (the moment the third) the penis is released from the left hand, the pavilion is lowered down, advanced buzh in depth and it gets into a bladder. The second and especially the third the moments are most responsible because of a possibility of an injury. Quite often in the first attempts of introduction of a buzh there is small bleeding. More severe bleeding — always a sign of too rough manipulation. At people with big adjournment of a fatty tissue on a front abdominal wall when it is impossible to carry out buzh by a usual way, use the following method: the left hand take a penis at bottom edge of a head, the right hand take buzh or a metal catheter with the beak turned from top to bottom. At the same time the penis is strongly extended. The end of a buzh in such situation reaches only the place of narrowing. Then turn buzh round its pivot-center so that its end was directed up. At this movement the end of a buzh usually gets to the narrowed opening of an urethra. Along with the last movement lower the handle of the tool from top to bottom. This reception is known in literature under the name «tour meter» (turn of the teacher); the doctors who already have B. V experience very hard cases can apply it B. by metal buzha with elastic conductors of Lefor is recommended. At first enter the elastic conductor, then screws on metal buzh which carry out after it (fig. 5). This manipulation should be made at the filled bladder. The elastic end is curtailed in a bladder a ring, and metal buzh easily passes behind it a stricture without risk of formation of the false course or damage. If urine is infected, for the purpose of the prevention of development of urethral fever, prostatitis or cystitis after B. parenteral administration or intake of antibiotics (penicillin, levomycetinum, erythromycin) or nitrofurans is recommended (furadonin, furagin).
Bougieurage of a gullet at adults
the Beginning and development of a technique of B. of a gullet is connected with early attempts of its expansion after chemical burns which is carried out by introduction of hollow rubber probes in calculation to hold a gleam of a gullet from a smykaniye and the subsequent scarring. At the same time this probe was used for introduction to a stomach of liquid nutritious mixtures. A. Levental used such technique since 1900. Constant sounding of a gullet with leaving of the probe for 4 — 5 days since 1913 began to apply Ts. Ra. At already created cicatricial esophageal stenoses this technique was impracticable because of impossibility of carrying out soft rubber probes. At such patients of a gullet began to apply dense sticks (laminarias) which, remaining in a gleam of a gullet, inflated and expanded narrowing to B.
As the indication serve the disturbances of swallowing caused according to radiological data, a stricture of a gullet at any its level. B. gullet carry out only with the medical purpose at the disease processes in a varying degree breaking its passability. Preferential it is necessary to deal with chemical burns of a gullet and their effects in the form of cicatricial narrowings and impassability. B. can sometimes be applied at cicatricial esophageal stenoses postoperative, traumatic and peptic (at a reflux esophagites) origins.
The expressed accompanying inflammatory phenomena and heavy necrotic can only be a contraindication esophagitis (see), the late started stages of scarring, especially on a considerable extent (chetkoobrazny or multiple defeats), and also a serious general condition.
At treatment of burns of a gullet distinguish early and late B.
Ranney B. it is applied with the preventive purpose with calculation to limit or reduce a possibility of development of massive hems. Concerning optimum terms to start preventive B. of a gullet of the recommendation are contradictory: some authors recommend to begin them with the first (2 — the 3rd) days after a burn, others — at the end of the first week or even in 14 — 20 days from the moment of a burn. Uniform, strictly established periods to start this to lay down. the procedure cannot be, they shall be defined individually depending on a form, degree and weight of a burn, and also expressiveness of the accompanying inflammatory phenomena. It is rational to begin almost preventive B. at once after subsiding of the local acute inflammatory phenomena; in the majority of observations it is 5 — the 7th day after a burn. At heavy burns with a necrotic esophagitis, at a septic state preventive B.'s terms of a gullet increase or it is excluded absolutely.
Late B. is the main method of treatment of cicatricial esophageal stenoses; it is carried out in several ways. For every way there are indications depending on the nature of narrowing. The most widespread way is B. through a mouth blindly conic bougies; it is carried out usually on an empty stomach, the patient is in a sitting position. Need of anesthesia arises seldom — only at the expressed emetic reflex or spasms and 5% solution of cocaine, or 2 — 3% solution of Dicainum in number of 1 — 3 ml, or 2% of solution of Pirromecainum of 2 — 3 ml are reached by greasing of a pharynx and throat (or an instillation through the nasal course). Bougie before introduction needs to be oiled vaseline or another. Begin B. of a gullet always with thin buzha with the subsequent gradation to Bougie of bigger diameter.
In the drawing the steel string with the springing tip entered into a stomach is visible. The string is a conductor for a buzh whose end is visible at the top of the drawing (roentgenogram).
B. gullet carry out daily or every other day, and always begin with a buzh, the Crimea the procedure B. was the day before finished, and two buzh of the increasing diameters carry out only after that. Sometimes for a number of reasons (deterioration in the general state, temperature increase etc.) it is necessary to stop temporarily for the short term of B. and to surely conduct control X-ray inspection of a gullet. Renew B. at normalization of a state. At permanent recovery of a gleam of a gullet and full swallowing of B. carry out less often — 2 times, and then once a week for 3 — 4 months (on an outpatient basis).
At heavy, it is long the existing and widespread cicatricial narrowings with the expressed suprastenotichesky esophagectasia and an eccentric arrangement of an entrance to B.'s stricture of a gullet blindly through a mouth becomes difficult, risky, and often and just impracticable. In such cases of B. of a gullet carry out under control of sight via the esophagoscope. This technique allows to carry out precisely a conic bougie to the canal and in the subsequent easily and surely to advance it further. At the same time anesthesia is necessary: local anesthesia, is more rare — an intubation anesthesia with muscle relaxants and the managed breath. After holding several such procedures usually it is possible to pass to B. of a gullet without esophagoscope. At the double or multiple (chetkoobrazny) strictures which are quite often combined with a shtykoobrazny curvature of the narrowed intermediate channel of a gullet, the way B. under control of sight can ineffectual because of impossibility of carrying out a buzh be lower than the first stricture. In these cases the offered A.S. Itsenko and Gakker (V. Hacker, 1852 — 1933) a way B. on a thread — «bougieurage endlessly» can be used. Previously the gastrostomy (if it is not made earlier) for food is imposed. The swallowed strong thread is fixed outside of and at a mouth, and at a gastrostomy; thread remains in a gullet in the course of all B. For easier swallowing thread on the end it is fixed a bead or a grain. With success apply hollow rubber tubes of various diameter (ordinary rubber catheters) which in the stretched state are carried out through the narrowed site of a gullet to B. When the tube ceases to be stretched, it accepts the initial diameter thanks to what the narrowed site of a gullet smoothly extends. Upon termination of B. thread and a tube are left in a gullet till next days, changing further only a tube. Having reached some esophagectasia, it is possible to pass to usual B. with conic bougies; temporarily control thread remains in a gullet. At a considerable suprastenichesky esophagectasia and an eccentric arrangement of very narrow entrance to a stricture the unit with a grain does not get to it, and gathers in a lump in a venter of a gullet. In similar cases it is retrogradno necessary to try to carry out through a gastrostomy and the cardia to a gullet a thin ureteric catheter. Tie long thread to the end of a catheter which appeared in a drink or in an oral cavity, reduce it in a stomach and remove outside, carrying out further B. on the way described above. It is better to carry out a catheter through a gastrostomy to the cardia under control of an eye (with use of the esophagoscope).
Considerably possibilities of conservative treatment (by B.) the heaviest cicatricial esophageal stenoses in connection with emergence of the new, developed at All-Union research institute clinical and experimental surgery of M3 of the USSR of B.'s technique on a steel string with the springing conductor on the end of its (fig. 6) extend. Use of this technique saves patients from need of gastrostomies and from use of the laborious, often difficult feasible, described above methods B. of a gullet. By this technique the string from stainless steel with the springing tip is preposted to a stomach, and then on it as on the conductor, are easily carried out special plastic by Bougie with a through central hole.
the Most frequent complication — the aggravation of the accompanying esophagitis observed almost at all patients. Emergence of pains behind a breast and in spin, strengthening of the dysphagic phenomena, sometimes a bloody discharge from a gullet (noticed to Bougie) are considered as signs of an aggravation of an esophagitis and force to stop temporarily B. Strengthening of all above-mentioned painful phenomena which is followed by rise in temperature and the accruing leukocytosis speaks about heavier complications connected with an injury or perforation of a wall of a gullet. Perforation of a gullet is the most dangerous and heavy complication; she is possible both over narrowing (more often), and in the channel of a stricture (especially at the chetkoobrazny bent strictures). Saliva and the infected contents of a gullet, getting to periesophagal cellulose, lead to development of a mediastinitis and the accompanying empyema of a pleura, etc.
Prevention of complications — careful carrying out buzhy without use of any violence. If there is a notable obstacle for further carrying out a buzh, it is necessary to try carrying out buzhy smaller diameters; at unsuccessfulness and these attempts — to pass to B. under control of sight (by means of the esophagoscope).
Bougieurage of a gullet at children
Bougieurage of a gullet at children is applied for the purpose of prevention of development of cicatricial narrowings at chemical burns or to elimination of the acquired stenoses.
Early, preventive B.'s method of a gullet at children at chemical burns was offered by Zaltser (H.Salzer, 1920). Various modifications of a method concerning diameter buzhy, duration of their stay in a gullet, B.'s terms, etc. are known.
Early B. of a gullet is shown to children with chemical burns of the II—III degree, and this diagnosis shall be confirmed with a diagnostic ezofagoskopiya (see. Gullet , burns at children). B. begin after subsiding of the acute inflammatory phenomena — with 6 — the 8th day after a burn.
Of a gullet apply to B. plastic Bougie: for children of the first half of the year of life No. 22 — 24, the second half of the year — No. 26 — 28; 1 — 3 years — No. 30-32; 3 — 5 years — 34-36; 5 — 10 years — No. 38, are more senior than 10 years — N ° 40. With the same purpose of M. G. Zagarsky offered tubes from a heterogeneous peritoneum which leave in a gullet on a long term. It is always necessary to begin B. with maximum for this age of a buzh.
B. carry out in a hospital 3 times a week. Recommendations to leave buzh for several minutes and furthermore hours and days, are unreasonable: it is hard transferred by children and is fraught with complications. B.'s duration is defined by depth of a burn. At burns of the II degree it is limited three weeks. If at a control ezofagoskopiya in these terms full epithelization is found, B. stop. At burns of the III degree when by the end of the third week at a control ezofagoskopiya find the granulating surfaces, ulcerations covered with fibrin. A B. gullet carry out during 6 weeks in a hospital, then continue in out-patient conditions — within 2 — 3 months once in week, the next 3 months — once in 2 weeks and, at last, once a month during a floor a favor. Before changing B.'s intervals, previously are convinced of normal passability of a gullet by X-ray inspection with barium.
Only the hardest esophagitis with periezofagity, a mediastinitis can be a contraindication to B. of a gullet. It is necessary to remember that at a burn of the III degree the admission dvukhtrekh B.'s sessions can lead to an esophageal stenosis.
At observance of all rules of a complication (perforation of a gullet, a mediastinitis) stated above at B. are extremely rare, recovery occurs in 90 — 97% of cases (S. D. Ternovsky et al., 1963; A. P. Biyezin. 1966, p other).
Late B. is applied in the presence of a cicatricial esophageal stenosis. The most acceptable for children is so-called bougieurage endlessly. Other techniques of B. (through a mouth — blindly, via the esophagoscope) do not demand an establishment of gastric fistula. however danger of such terrible complication as perforation of a gullet, at them increases.
B.'s technique of a gullet at children for thread has some features: in 2 weeks after an establishment of gastric fistula through a gullet carry out thread. For this purpose to the child allow to swallow usual bobbin thread, to-ruyu it washes down with water. The unit passes in a stomach and during the opening of a gastrostomy is washed away outside. Thread is replaced with a thick silk ligature, top end a cut is removed through the nasal course, the ends connect it and it resides in such situation. During B. change this thread and carry out the second — through a mouth, for carrying out a buzh (fig. 7). At cicatricial narrowings of B. begin with minimum by the size of a buzh. On the end buzh has a loop, for to-ruyu it attach to thread. The lower unit leaving through a gastrostomy is pulled, and buzh follows it on a gleam of a gullet. B. carry out 2 times a week, gradually increasing diameter of a buzh. Some authors consider expedient retrograde carrying out a buzh, i.e. from a gastrostomy (F. N. Doronin, 1961). B.'s duration of a gullet depends on weight and the extent of cicatricial process, time of its existence and varies from several weeks to several months.
After narrowing is eliminated, the reached effect is controlled radiological and an ezofagoskopiya.
Perforation of a gullet at B. for thread are very rare and connected with errors of the equipment (the forced carrying out for one session of several buzhy), are less often caused by weight of cicatricial process. Good results manage to be received approximately at 80% of patients.
Bougieurage in otorhinolaryngology
Bougieurage in otorhinolaryngology is used for definition of the place and the nature of narrowing or expansion of an acoustical (eustachian) pipe, upper respiratory tracts, a trachea. Into an acoustical pipe buzh it is entered very carefully on depth to 35 mm through the ear catheter inserted into a pharyngeal opening of a pipe. A B. acoustical pipe contraindicated at acute inflammations of a middle ear, mucous membrane of a nose and nasopharynx. After B. it is not necessary to do ear inflations that there was no emphysema. A B. nasal cavity and a postnaris it is applied occasionally after excision of skleromny infiltrates and hems. B. nasopharynxes it is also carried out after an ulotomy of a skleromny origin, fixing a soft palate to a back wall of a nasopharynx. Valikoobrazny buzh, soldered to a dentoprosthetic plate, is entered from a mouth.
B. throats it is used for expansion of a gleam of a throat at its cicatricial stenoses. For ensuring breath of Bougie shall be hollow. They are entered into the narrowed gleam of a throat through a mouth. In other cases of B. make through laringo-or a tracheostoma (at this Bougie can be both continuous, and hollow). Anesthesia of a throat is obligatory only in an initiation of treatment by this method; further in process of accustoming of the patient to B. it becomes unnecessary.
B. tracheas it is shown at cicatricial, and also at compression stenoses (a prelum tracheal or tracheobronchial limf, nodes). B. make dense or elastic hollow tubes through a tracheostoma or a tube of the bronchoscope. A repeated trakheobronkhoskopiya, and also long stay in you grind narrowings of the special long or usual artificially extended tracheotomic tube can represent peculiar. tracheas. It is necessary to remember that at the stenoses of a trachea caused by a prelum her aneurism or a mediastinal tumor, long stay of tubes in it threatens with formation of decubituses.
Indications to B. and its methods at children's age same, as well as at adults. However B.'s carrying out at children requires the maximum attention to anatomic features of ENT organs.
See also Bougie .
Bibliography: Baradulin G. I. Elements of urology, M., 1927; And of m and A. N N. Urological tools and a technique of use of it, in book: Operational urology, under the editorship of S. P. Fedorov and R. M. Fronstein, page 97, M. — L., 1934; Goligorskiys. D. Sketches of urological semiotics and diagnosis, Chisinau, 1956; Zaritskiyl. A. Skleroma of respiratory tracts, Mnogotomn, the management on otorinolar., under the editorship of A. G. Likhachev, t. 4, page 320, M., 1963, bibliogr.; L. E. K commandants to a question of a rhinoscleroma, Vestn, rino-laringo-otiat-rii, No. 4-5, page 8, 1926; Mikhayloveny S. V. Scleroma of respiratory tracts, M., 1959, bibliogr.; Michel-with about A. I. Metodik's N of a research of urological patients, page 24, Minsk, 1955; Myakinnikova M. V. Treatment of patients at skleromny defeats in a noso-stomatopharynx, Vestn, otorinolar., No. 3, page 71, 1958, bibliogr.; The guide to clinical urology, under the editorship of. A. Ya. Py-telya, page 154idr., M., 1969; Mitchell-N e g g s F. Drew H, G, R. The instruments of surgery, p. 311 and. lake, L., 1963; Urology, ed. by M. F. Campbel a. o., Philadelphia, 1970.
B. gullet — Biyezin A. Π, Corrosive burns of a gullet at children. M, 1966, bibliogr.; Wangqiang E. N. and T about shch and to about in R. A. K to a technique of bougieurage of esophageal stenoses, Grudn. hir., jsT# 6, page 96, 1968; they, Treatment of burns and cicatricial esophageal stenoses, M., 1971, bibliogr.; Doronin F. N. Cicatricial esophageal stenoses, Saratov, 1961, bibliogr.; Ternovsky S. D. and d river. Treatment of corrosive burns and cicatricial esophageal stenoses at children, M., 1963, bibliogr.; T about shch and to about in R. A., Skobel-kin O.K. and Bashilov V. P. Recovery of passability of a gullet at cicatricial strictures and inoperable crayfish bougieurage on a steel string with the spring conductor, Vestn, otorinolar., No. 1, page 49, 1973, bibliogr.; Feldman A. I. Diseases of a gullet, M., 1949; Hacker V. Zur Technik der «Sondi-erung ohne Ende» bei Speiscrohrenverenger-ungen, Zbl. Chir., Bd 30, S. 178, 1903; S a 1 z e r H. Frtihbehandlung der Speiseroh-renveratzung, Wien. klin. Wschr., S. 30 7,1920.
A. H. Gagman; B. I. Geraskin (it is put. hir.), B. G. Yermolaev (ENT specialist.), B. S. Rozanov (Abd. hir.).