TREATMENT OF CICATRICIAL STRICTURES

OF THE ESOPHAGUS.

BY GEORGE R. WHITE, M.D., SAVANNAH.

The difficulty met in the treatment of old esophageal strictures by olive-pointed bougies may be readily understood by examining post-mortem an esophagus extensively injured by caustic potash or some other irritant. We find, as a rule, a tube more or less injured throughout its entire extent, and presenting a tortuous canal with eccentric openings surrounded by tough, unyielding scar tissue. The strictures are usually multiple, and if one be successfully passed there are others further down which work in unison with the first to defeat one's efforts at dilation. The strictures are located for the most part at the three narrowest parts of the esophagus; first, at the upper end of the esophagus, back of the cricoid cartilage; second, at the bifurcation of the trachea, where the esophagus bends forward and to the right after passing behind the left bronchus; and, third, about three inches from the stomach, just before the esophagus perforates the diaphragm. The mucous membrane in these strictures is converted into firm, unyielding cicatrices which are not elastic and require considerable force to pass a bougie a little larger than the calibre of the stricture. The mucous membrane above the stricture is thickened, thrown into irregular folds and often ulcerated. Irregular contraction of the mucous membrane draws the opening to one side and makes the entrance

of all instruments difficult. The muscular coats are usually hypertrophied above the stricture, and prevent the formation of pouches, but such a condition may occur from extensive burns, destroying part of the muscular coats when the tissue above the stricture is compared to the tough cicatrix of the stricture itself. It will be seen that the force required to pass a bougie through the stricture would be more than sufficient to perforate the wall of the esophagus if the bougie were misdirected; especially if ulceration is taking place. This accident occurs frequently and with its complicating periesophageal suppuration is one of the chief factors in the high mortality attending these conditions. The prognosis of a severe case of stenosis of the esophagus is unfavorable. A considerable number die soon after the accident from shock, starvation or sepsis, and of those who pass the acute stages there is a mortality of thirty-three per cent. due generally, either to inanimation followed by tuberculosis or periesophageal sepsis, from extension from the ulcers or perforation by a bougie.

Treatment consists in repeated efficient dilation of the esophagus, and the method depends upon the extent of injuries present. In some the stricture undergoes a spontaneous cure, in others, a few dilations with an olive-shaped bougie is necessary; others require prolonged treatment, aided by a gastric fistula, and in others the esophagus is so badly damaged that no human skill can restore it to a functionating organ.

If the cases are seen soon after the accident no attempt should be made to dilate at once, but, on the contrary, every effort should be exercised to keep the injured esophagus at rest, and give nature a chance to save as much as possible of the damaged tissues. Diet should be entirely of liquids and frequent taking of

nourishment or water should be avoided. If there is reason to believe that the injury is extensive it would be well to make a gastric fistula for nourishment of the patient, during the process of repair, and as an aid to the subsequent treatment. After the acute stage has passed, an attempt should be made at dilation, by bougies of different sizes, and if the stricture is once passed by a sound, a little larger than the caliber of the stricture, and the constricting tissue made to yield there is usually no trouble in dilating to near the normal size, and repeating the dilation until the function of the esophagus is restored. One must always remember that an esophageal bougie is a dangerous instrument, and should there be difficulty in getting one through the stricture, too persistent or forceful efforts should not be made, owing to the liability of perforating the esophagus and setting up periesophageal suppuration and death from sepsis. Various attempts have been made to overcome the difficulty in passing an olive-pointed bougie. Passing a tunneled sound over a filiform whalebone bougie after the manner of treating urethral strictures, has been tried with poor success. Eastman screws a filiform into the bulb of a bougie and passes the bougie after the filiform into the stomach. There has also been devised a hollow sound into which passes a metal core after the sound has been passed and numerous other devices. The objection to the passage of a sound along the filiform is that the filiform may bend and allow the bougie to go astray, and the objection to the hollow sound, and to all esophageal dilators and esophagotome is that considerable degree of dilation must be obtained before they can be used. The great difficulty in these badly strictured cases is to get them large enough to admit even a small bougie or other instrument.

Abbé has recently devised a bulbous bougie with a string attached to the bulb, and so arranged that the bougie may be passed through the mouth and forced against the stricture, which is drawn through by pulling the string back and forth. This instrument would be very satisfactory if one could be sure it were directed rightly, but there is a possibility of the bougie entering a pouch and the string sawing through the esophagus. When one is convinced of the futility of attempts at dilation through the mouth by bougies or other devices a gastric fistula should be made for nutrition of the patient and an aid in the treatment. For this purpose the Kader method is the most satisfactory, and is easily and quickly performed with a minimum shock and discomfort to the patient. In this operation a fold of the stomach is drawn out through an inch and a half incision along the border of the left rectus and an opening made large enough to admit a rubber drainage tube. This is held in place by a purse-string suture, and another purse-string suture is applied about half an inch from the tube, and tightened as the tube is pushed into the stomach. In this way a part of the stomach wall is invaginated into the lumen. forming a perfect valve after the tube is withdrawn. The stomach is fastened to the parietal peritoneum and the wound closed about the tube. The tube is clamped to prevent the contents of the stomach from escaping. After about four days the tube can be removed and a perfect valve will be found through which a catheter can be passed for feeding, but no fluid can return after the catheter is removed.

Feeding may be begun immediately after the operation. if the patient is in need of food; otherwise it is well to wait twelve hours before removing the clamp and pouring liquid food into the stomach. The operation can

be done quickly and also free from shock and danger. Retrograde dilatation should not be attempted when the stomach is opened for gastrostomy. While one sometimes succeeds by that procedure when direct dilation fails, it requires a much more extensive operation with a larger opening in the stomach, and is liable to produce considerable shock as the patient does not stand well much manipulation in the region of the solar plexus, moreover, the same difficulty is met in passing an instrument from below as from above. The first stricture is usually met two or three inches up the esophagus and it is no easy matter to pass an instrument through the fistula into the stomach. Send it to a right angle in order to pass up the esophagus and carry out delicate manipulations at the strictures situated well out of reach, and this manipulation is unnecessary, as the same result may usually be accomplished by easier and less dangerous means. After the wound about the gastric fistula has thoroughly healed the treatment proper of the stricture may begin. A string is passed through the mouth into the stomach, and pulled up through the gastrostomy by a blunt hook. This can usually be accomplished by having the patient swallow some cocaine, and pass a whalebone filiform bougie with a thread attached to the lower end. When the end of the filiform is in the stomach, a little traction on the thread will cause it to separate from the bougie like the string of a bow, when it can be easily caught by the hook and brought out. If one is unsuccessful in passing the filiform the patient may be taught to swallow a string according to Dunham's method. An end of thread is passed through a feedingtube, and the patient is instructed to drink through the tube with the end of the thread in his mouth, which is gradually washed down until there is considerable of