[FIG. 98.—Schema illustrating the mechanism of perforation by blind bouginage. On encountering resilient resistance the operator, having a false conception, pushes on the bougie. Perforation results because in reality the bougie is in a pocket of the suprastrictural eccentric dilatation.]
Symptoms.—Dysphagia, regurgitation, distress after eating, and loss of weight, vary with the degree of the stenosis. The intermittency of the symptoms is sometimes confusing, for the lodgment of relatively large particles of food often simulates a spasmodic stenosis, and in fact there is often an element of spasm which holds the foreign body in the strictured area until it relaxes. Static esophagitis results in a swelling of the esophageal walls and a narrowing of the lumen, so that swallowing is more or less troublesome until the esophagitis subsides.
Esophagoscopic Appearances of Cicatricial Stenosis.—The color of the cicatricial area is usually paler than the normal mucosa. The scars may be very white and elevated, or they may be flush with the normal mucosa, or even depressed. Occasionally the cicatrix is annular, but more often it is eccentric and involves only a part of the circumference of the wall. If the amount of scar tissue is small, the lumen maintains its mobility; opens and closes during respiration, cough, and vomiturition. Between two strictures there is often a pouch containing food remnants. It is rarely possible to see the lumen of the second stricture, because it is usually eccentric to the first. Stagnation of food results in superjacent dilatation and esophagitis. Erosions and ulcerations which follow the stagnation esophagitis increase the cicatricial stenosis in their healing.
Differential Diagnosis.—When the underlying condition is masked by inflammation and ulceration, these lesions must be removed by frequent lavage, the administration of bismuth subnitrate with the occasional addition of calomel powder, and the limitation of the diet to strained liquids. The cicatricial nature of the stenosis can then be studied to better advantage. In most cases the cicatrices are unmistakably conspicuous. Spasmodic stenoses are differentiated by the absence of cicatrices and the yielding of the stenosis to gentle but continuous pressure of the esophagoscope. While it is possible that spasmodic stenosis may supplement cicatricial stenosis, it is certainly exceedingly rare. Nearly all of the occasions in which a temporary increase of the stenosis in a cicatricial case is attributed to an element of spasm, the real cause of the intermittency is not spasm but obstruction caused by food. This occurs in three ways: 1. Actual "corking" of the strictured lumen by a fragment of food, in which case intermittency may be due to partial regurgitation of the "corking" mass with subsequent sinking tightly into the stricture. 2. The "cork" may dissolve and pass on through to be later replaced by another. 3. Reactionary swelling of the esophageal mucosa due to stagnation. Here again the obstruction may be prolonged, or it may be quite intermittent, due to a valve-like action of the swollen mucosal surfaces or folds intermittently coming in contact. Cancerous stenosis is accompanied by infiltration of the periesophageal tissue, and usually by projecting bleeding fungations. Cancer may, however, develop on a cicatrix, favored no doubt by chronic inflammation in tissue of low resistance. Compression stenosis of the esophagus is characterized by the sudden transition of the lumen to a linear or crescentic outline, while the covering mucosa is normal unless esophagitis be present. The compressive mass can be detected by the sensation transmitted to the touch by the esophagoscope.
Treatment.—Blind bouginage should be discarded as an obsolete and very dangerous procedure. If the stenosis be so great as to interfere with the ingestion of the required amount of liquids, gastrostomy should be done at once and esophagoscopic treatment postponed until water hunger has been relieved. Gastrostomy aids in the treatment by putting the esophagus at rest, and by affording the means of maintaining a high degree of nutrition unhampered by the variability or efficiency of the swallowing function. Careful diet and gentle treatment will, however, usually avoid gastrostomy. The diet in the gastrostomy-fed patients should be as varied as in oral alimentation; even solids of the consistency of mashed potatoes, if previously forced through a wire gauze strainer, may be forced through the tube with a glass injector. Liquids and readily liquefiable foods are to be given the non-gastrostomized patient, solids being added when demonstrated that no stagnation above the stricture occurs. Thorough mastication and the slow partaking of small quantities at a time are imperative. Should food accumulation occur, the esophagus should be emptied by regurgitation, following which a glassful of warm sodium bicarbonate solution is to be taken, and this also regurgitated if it does not go through promptly. The esophagus is thus lavaged and emptied. In all these cases, whether being fed through the mouth or the gastrostomic tube, it is very important to remember that milk and eggs are not a complete dietary. A pediatrist should be consulted. Prof. Graham has saved the lives of many children by solving the nutritive problems in the cases at the Bronchoscopic Clinic. Fruit and vegetable juices are necessary. Vegetable soups and mashed fruits should be strained through a wire gauze coffee strainer. If the saliva is spat out by the child because it will not go through the stricture the child should be taught to spit the saliva into the funnel of the abdominal tube. This method of improving nutrition was discovered by Miss Groves at the Bronchoscopic Clinic.
Esophagoscopic bouginage with the author's silk-woven steel-shank endoscopic bougies (Fig. 40) has proven the safest and most successful method of treatment. The strictured lumen is to be centered in the esophagoscopic field, and three successively increasing sizes of bougies are used under direct vision. Larger and larger bougies are used at the successive treatments which are given at intervals of from four to seven days. No anesthesia, general or local, is used for esophagoscopic bouginage. The tightness of the grasping of the bougie by the stricture on withdrawal, determines the limitation of sizes to be used. When the upper stricture is dilated, lower ones in the series are taken seriatim. If concentric, two or more closely situated strictures may be simultaneously dilated. For the use of bougies of the larger sizes, the special esophagoscopes with both the light-carrier canal and the drainage canal outside the lumen of the tube are needed. Functional cure is obtained with a relatively small lumen at the point of stenosis. A lumen of 7 mm. will allow the passage of any well masticated food. It is unwise and unsafe to attempt to restore the lumen to its normal anatomic size. In cicatricial stricture cases it is advisable to examine the esophagus at monthly periods for a time after a functional cure has been obtained, in order that tendency to recurrence may be early detected.
Divulsion of an upper stricture may be deemed advisable in order to reach others lower down, especially in cases of multiple eccentric strictures (Fig. 97). This procedure is best done with the author's esophagoscopic divulser, accurately placed by means of the esophagoscope; but divulsion requires the utmost care, and a gentle hand. Even then it is not so safe as esophagoscopic bouginage.
Internal esophagotomy by the string-cutting instruments and esophagotome are relatively dangerous methods, and perhaps yield in the end no quicker results than the slower and safe bouginage per tubam.
Electrolysis has been used with varying results in the treatment of cicatricial stenosis.
Thermic bouginage with electrically heated bougies has been found useful in some cases by Dean and Imperatori.