[258] String-swallowing, with the passage of olives threaded over the string has yielded good results in the hands of some operators. The string may be used to pull up dilators in increasing sizes, introduced through a gastrostomic fistula. The string stretched across the stomach from the cardia to the pylorus, is fished out with the author's pillar retractor, or is found with the retrograde esophagoscope (Fig. 43). The string is attached to a dilator (Fig. 35), and a fresh string is pulled in to replace the one pulled out. This is the safest of the blind methods. It is rarely possible to get a child under two years of age to swallow and tolerate a string. It is better after each treatment to draw the upper end of the string through the nose, as it is not so likely to be chewed off and is less annoying. With the esophagoscope, the string is not necessary, because the lumen of the stricture can be exposed to view by the esophagoscope.
Retrograde esophagoscopy through a gastrostomy wound offers some advantages over peroral treatment; but unless the gastrostomy is high, the procedure is undoubtedly more difficult. The approach to the lowest stricture from below is usually funnel shaped and free from dilatation and redundancy. It must be remembered the stricture seen from below may not be the same one seen from above. Roentgenray examination with barium mixture or esophagoscopes simultaneously in situ above and below are useful in the study of such cases.
Impermeable strictures of the cervical esophagus are amenable to external esophagotomy, with plastic reformation of the esophagus. Those in the middle third have not been successfully treated by surgical methods, though various ingenious operations for the formation of an extrathoracic esophagus have been suggested as means of securing relief. Impermeable strictures of the lower third can with reasonable safety be treated by the Brenneman method, which consists in passing the esophagoscope down to the stricture while the surgeon, inserting his finger up into the esophagus from the stomach, can feel the end of the esophagoscope. An incision through the tissue barrier is then made from below, passing the knife along the finger as a guide. A soft rubber stomach-tube is pulled up from below and left in situ, being replaced at intervals by a fresh one, pulled up from the stomach, until epithelialization of the new lumen is complete. Catheters are used in children. In replacing the catheter or stomach tube the fresh one is attached to the old one by stitching in a loop of braided silk. Frequent esophagoscopic bouginage will be required to maintain the more or less fistulous lumen until it is epithelialized, and in occasional cases, for a long time thereafter.
In cases of absolute atresia the saliva does not reach the stomach. No one realizes the quantity of normal salivary drainage, nor its importance in nutritive processes. Oral insalivation is of little consequence compared to esophagogastric drainage. Gastrostomized children with absolute atresia of the esophagus do not thrive unless they regurgitate the salivary accumulations into the funnel of the gastrostomic feeding tube. This has been abundantly proven by observations at the Bronchoscopic Clinic. My attention was first called to this clinical fact by Miss Frances Groves who has charge of these cases.
Intubation of the esophagus with soft rubber tubes has occasionally proven useful.
[260] CHAPTER XXXIII—DISEASES OF THE ESOPHAGUS (Continued)
DIVERTICULUM OF THE ESOPHAGUS
Diverticula may, and usually do, consist in a pouching by herniation, of the whole thickness of the esophageal wall; or they may be herniations of the mucosa between the muscular layers. They are classified according to their etiology, as traction and pulsion diverticula.
[FIG. 99.—Traction diverticulum of the esophagus rendered visible in the roentgenogram by a swallowed opaque mixture. Case of H. W. Dachtler, Am. Journ. Roentgenology.]
Traction diverticulum of the esophagus (Fig. 99) is a rare condition, usually occurring in the thorax, and as a rule constituting a one-sided enlargement of the gullet rather than a true pouch formation. It is supposed to be formed by the pulling during cough, respiration, and swallowing, on localized adhesions of the esophagus to periesophageal structures, such as inflammatory peribronchial glands.