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

by Alexis Thomson; Alexander Miles

Malignant Stricture—Carcinoma of the Gullet.—This is met with in two forms which present widely different pathological and clinical features.

Cancer of the cervical portion affects the gullet at its junction with the pharynx, and for some unexplained reason is much more common in women, and at the comparatively early age of between thirty and fifty. Cancer of the thoracic portion affects the extreme lower end of the gullet, and is met with almost exclusively in men over fifty.

Cancer of the Cervical Portion.—Difficulty of swallowing may arise suddenly; more often it is slow and progressive over a period of months and, in some cases, even of years. Pain on swallowing is not a constant or prominent feature; it may be referred to the site of the lesion or to one or both ears. In a considerable number of cases, the complaints of the patient are referred to the larynx; coughing, with abundant mucous expectoration disturbing the night's rest, hoarseness, or even loss of voice, which symptoms are due either to direct invasion of the larynx or to implication of one or other recurrent nerve; for the same cause, difficulty of breathing may supervene, sometimes of such a nature as to render tracheotomy imperative. A gurgling noise on swallowing, and regurgitation of food are occasionally observed.

Palpation of the neck, and particularly of the larynx and trachea, should be carried out in all cases presenting the symptoms described; and as bearing on the question of operation, enlargement of the cervical lymph glands and of the thyreoid should be looked for; cancer of the thyreoid is sometimes secondary to disease at the pharyngo-œsophageal junction.

Direct and indirect laryngoscopic examination is then made; if the laryngeal mirror fails to reveal anything abnormal, suspension laryngoscopy, which gives a more extensive view of that part of the pharynx lying behind the larynx, may be employed, or the œsophagoscope may be preferred. A portion of the growth may be removed for microscopical examination.

The use of the œsophageal bougie as a diagnostic agent must be deprecated; it gives no satisfactory explanation of the cause of the obstruction, and its employment when malignant ulceration is present, is not free from serious risk to the patient (Logan Turner).

Treatment.—The surgeon is dependent on the help of the laryngologist not only for the diagnosis of the disease at the earliest stage possible, but also for information as to its extent, especially with regard to involvement of the larynx.

Œsophagectomy, or resection of the cancerous segment of the gullet, in suitable cases, even if it does not yield a permanent cure, not only prolongs life but relieves the patient of her most distressing symptoms. It is rarely possible to secure an end-to-end anastomosis, but the feeding by means of a tube introduced into the open end of the gullet is more satisfactory and the laryngeal symptoms are more efficiently relieved, than by either of the purely palliative operations. In the majority of cases, however, only the palliative measures of œsophagostomy or gastrostomy can be adopted. Œsophagostomy presents the advantage, that by exposing the cervical portion of the gullet, the operator is enabled to investigate the extent of the disease and to revise his opinion on the feasability of its removal if necessary. In advanced cases, when the disease has spread widely in the neck and involved, it may be, the thyreoid and the larynx, it may only be possible to relieve the urgent distress of the patient by gastrostomy. Tracheotomy may also become necessary because of the spread of the cancer to the interior of the larynx.

Cancer of the Lower End of the Gullet.—The remarkable preference of this location of œsophageal cancer for the male sex has already been referred to; it affects the same type of male patients as are subject to squamous epithelioma in other parts of the body. So far as we have observed, its association with chronic irritation of the mucous membrane in which it takes origin, or with any pre-cancerous condition, has not been demonstrated.

The clinical features resemble those of cicatricial stricture; the difficulty of swallowing is usually of gradual onset, it concerns solids in the first instance, then semi-solids like porridge or bread and milk, and finally fluids. As in other forms of œsophageal obstruction, the difficulty of swallowing varies quite remarkably from time to time, presumably from variations in the degree of congestion of the mucous membrane and of spasm of the muscular coat, but also from mere nervousness, the patient having greater difficulty when in a hurry, as in a railway refreshment room, or embarrassed by the presence of strangers.