ESOPHAGUS, Stricture of.
Spasmodic stricture has been dealt with in the preceding article. and the treatment of malignant will be found detailed in the article on Cancer.
Cic.atricial stricture is nearly always the remote effect of swallowing corrosive liquid, and is to be met by mechanical dilatation.
The patient should be fed' upon liquid diet to minimise catarrh and spasm in the neighbourhood of the stricture before resorting to dilatation where the narrowing is very advanced. Various forms of boogie are recommended. Whilst the olive-headed instrument mounted upon a whalebone stem is preferable for diagnosis, the writer believes that a graduated firm gum-elastic bougie is better for dilating. purposes. This should be passed through the stricture two or three times a week, leaving the instrument in situ for the brief moment during which its presence can be tolerated, employing a larger instrument every time till the fullest size is reached.
The passage of the instrument must be resorted to once every 4 or 6 weeks as long as the patient lives. Where the stricture whilst easily dilatable shows a tendency to contract rapidly between the operations, continuous dilatation may be employed (as in the treatment of resilient strictures of the urethra) by inserting a Symonds' tube. After 2 or 3 days the tube is withdrawn and replaced by a larger till the largest size can be left in, hut this method is obviously unsuitable where the narrowing is situated high up near to the pharynx. The writer successfully em ployed partially dried sea-tangle as a dilator in an obstinate narrow cicatricial stricture as long ago as 1879.
Internal cesophagotomy was an unjustifiable operation till the intro duction of the perfected cesophagoscope; by means of this aid in suitable and select cases good results will be doubtless forthcoming.
Various devices may be employed when the narrowing will not admit any form of dilating Bougie. The simplest procedure is to perform a gastrostomy, and through the artificial opening in the stomach wall to feed the patient for the remainder of his life.
In some cases, after several days' complete rest to the gullet has been secured by the gastrostomy, it Nvill lie found that the spasm which has been added to the organic narrowing has subsided so as to permit the passage of a fine bougic. Abbe's operation may then be carried out; he introduces the bougie„ armed with a stout thread, through the stomach opening, and directs it from below into the gullet and through the stric ture till it appears in the pharynx. The string or thread is employed to
divide the stricture by pulling it up and down to imitate the action of a saw. As soon as the narrowed portion has been cut by the string a series of graduated bougics may be passed down the gullet through the mouth, after which the opening in the stomach should be closed and a Symonds' tube worn for a time.
In some cases it may be possible to carry out Abb6's method by getting the patient to swallow a few yards of fine silken cord where the gullet cannot be entered from below. If a steel bead attached to the end of the thread can he got to pass through the stricture, after a preliminary gastrostomy the bead will he easily attracted to the stomach opening by a magnet. Having now got the thread in situ, it may either be. used as a saw or as a guide by which bougies can be drawn up from below through the stomach till the requisite degree of dilatation has been secured. In a case of impassable stricture where gastrostomy had been performed four years previously, and the patient was living on nourishment injected through the fistula, Bernays cut down upon the site of the stricture at the inner edge of the sterno-mastoid and opened the gullet above the stricture. Later on he perforated the stricture by a pointed bougie introduced from below through the gastric fistula, and eventually inserted a funnel, through which the patient was able to swallow food, which entered the stomach for the first time in five years through the gullet.
Strictures at the lower end of the gullet may be dilated by the methods of treating cardio-spasm, and impassable narrowings in the thoracic zone promise to fall under the method of posterior mediastinal cesophagotomy carried out in Sauerbruch's chamber under increased atmospheric pres sure or by Torek's operation mentioned on p. 613. Lexer has suc ceeded in supplying the patient with a new extra thoracic gullet by an elaborate cesophagoplastic operation in which a coil of jejunum was transposed and fixed under the skin of the thorax, and Jianu has utilised the great curvature of the stomach in a similar manner.