Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

Fig. 286.—Diverticulum of the Œsophagus at its junction with the Pharynx.
(Anatomical Museum, University of Edinburgh.)

If an operation is decided upon, and for this it is essential that the pouch should be accessible from the neck, the general condition is improved by feeding through a stomach tube and by rectal and subcutaneous salines. The operation consists in exposing and isolating the pouch by a dissection on the left side of the neck, and either excising it as if it were a tumour or cyst, or if the risk of infection of the deeper planes of cellular tissue is regarded with apprehension, the pouch may be infolded into the lumen of the gullet, or the excision be carried out in two stages. At the first stage, the pouch is isolated and rotated on its pedicle, in which condition it is fixed by sutures; after an interval of from ten to fourteen days it is excised.

Should the diverticulum be inaccessible from the neck, and the difficulty of swallowing be attended with progressive emaciation, gastrostomy may be required to avert death by starvation.

Traction diverticula are due to the contraction of scar tissue outside the gullet, as for example that resulting from tuberculous glands in the posterior mediastinum; they are rarely attended with symptoms, and are rather of pathological than surgical interest.

Innocent Stricture or Cicatricial Stenosis of the Gullet.—The innocent or fibrous stricture follows upon the swallowing of corrosive substances, usually by inadvertence, sometimes with suicidal intent. Having recovered from the initial effects of the corrosive agent, the patient suffers from gradually increasing difficulty in swallowing, first with solids and later with fluids. There is the usual variation or intermittence of symptoms that attend upon all conditions causing difficulty of swallowing, the exacerbations being due to superadded spasm of the muscular coat and congestion of all the coats. As the gullet dilates above the stricture, there is an increasing accumulation of what has been swallowed, and this the patient regurgitates at intervals; this is usually described as “vomiting,” but the material ejected shows no signs of gastric digestion. There is pain referred to the epigastrium or between the shoulder-blades, the patient suffers from hunger and thirst, and may present an extreme degree of emaciation.

The diagnosis is suggested by the history, and is confirmed by the œsophagoscope or by the X-rays after an opaque meal. The use of bougies has taken a secondary place since the introduction of these methods of examination, but, when other means are not available, the passage of bougies having a whalebone shaft and a series of metal heads shaped like an olive, may give useful information regarding the site, number, and size of the strictures that require to be dealt with.

Treatment.—If the patient is in a critical state from starvation, gastrostomy must be performed to enable him to be fed; otherwise he is prepared for treatment of the stricture by rest in bed, sedatives, and suitable liquid or some solid foods to improve his general condition and eliminate the muscular spasm and congestion already referred to. If the passage of bougies with the object of dilating the stricture is difficult or impossible, it may be made easier or possible by getting a silk thread through the stricture. The patient swallows several yards of a reliable silk thread a day or two before the proposed dilatation is carried out; the thread is expected to pass through the stricture of the stomach, and to enter for some distance into the small intestine; the metal head of the bougie, which is canalised in its long axis, is “threaded” on the silk, and the latter acting as a guide, the bougie is passed safely and confidently through the stricture. Larger olive-shaped heads are passed at intervals until the normal calibre of the gullet is exceeded, after which it is usually easy to pass an ordinary full-sized instrument at intervals of a month or so.

In the event of failure, recourse must be had to gastrostomy, and through the stomach it may be possible to dilate the stricture by the “retrograde” route. In aggravated cases, the gastrostomy opening must be retained in order to prevent death from starvation.