Various methods of external operation have been devised, among which are: (1) Freeing the sac through an external cervical incision and suturing its fundus upward against the pharynx, which has proved successful in some cases. (2) Inversion of the sac into the pharynx and suture of the mouth of the pouch. In a case so treated the pouch was blown out again during a fit of sneezing eight months after operation. (3) Plication of the walls of the sac by catgut sutures, as in the Matas obliterative operation for aneurysm. (4) Freeing and removing the sac, with suture of the esophageal wound. (5) Removal of the sac by a two-stage operation, in which method the initial step is the deliverance of the sac into the cervical wound, where it remains surrounded by gauze packing until adhesions have walled off the mediastinum. The work is completed by cutting off the sac and either suturing the esophageal wound or touching it with the cautery, and allowing it to heal by granulation. External exposure and amputation of the sac has been more frequently done than any other operation. Unless the pouch is large, it is extremely difficult to find after the surgeon has exposed the esophagus, for the reasons that at operation it is empty and that when the adhesions about it are removed the walls of the sac contract. After removal, the sac is disappointingly small as compared with its previous size in the roentgenogram, which shows it distended with opaque material. It has been the chagrin of skilled surgeons to find the diverticulum present functionally and roentgenographically precisely the same as before the performance of the very trying and difficult operation. The time of operation may be shortened at least by one-half by the aid of the esophagoscopist in the Gaub-Jackson operation. Intratracheally insufflated ether is the anesthesia of choice. After the surgeon has exposed the esophagus by dissection, the endoscopist introduces the esophagoscope into the sac, and delivers it into the wound, while the surgeon frees it from adhesions. The esophagoscope is now withdrawn from the pouch and entered into the esophagus proper, below the diverticulum, while the surgeon cuts off the hernial sac and sutures the esophagopharyngeal wound over the esophagoscope. The presence of the esophagoscope prevents too tight suture and possible narrowing of the lumen (Fig. 102).
[FIG. 102.—Schematic representation of esophagoscopic aid in the excision of a diverticulum in the Gaub-Jackson operation. At A the esophagoscope is represented in the bottom of the pouch after the surgeon has cut down to where he can feel the esophagoscope. Then the esophagoscopist causes the pouch to protrude as shown by the dotted line at B. After the surgeon has dissected the sac entirely loose from its surroundings, traction is made upon the sac as shown at H and the esophagoscope is inserted down the lumen of the esophagus as shown at C. The esophagoscope now occupies the lumen which the patient will need for swallowing. It only remains for the surgeon to remove the redundancy, without risk of removing any of the normal wall. The esophagoscope here shown is of the form squarely cut off at the end. The standard form of instrument with slanted end will serve as well.]
After-care.—Feeding may be carried on by the placing of a small nasal feeding tube into the stomach at the time of operation. Gastrostomy for feeding as a preliminary to the esophageal operation has been suggested, and is certainly ideal from the viewpoint of nutrition and esophageal rest. The decision of its performance may perhaps be best made by the patient himself. Should leakage through the neck occur, the fistula should be flushed by the intake of sterile water by mouth. Oral sepsis should, of course, be treated before operation and combated after operation by frequent brushing of the teeth and rinsing of the mouth with Dakin's solution, one part, to ten parts of peppermint water. A postoperative barium roentgenogram should be made in every case as a matter of record and to make certain the proper functioning of the esophagus.
[268] CHAPTER XXXIV—DISEASES OF THE ESOPHAGUS (Continued)
PARALYSIS OF THE ESOPHAGUS
The passage of liquids and solids through the esophagus is a purely muscular act, controlled, after the propulsive usually voluntary start given to the bolus by the inferior constrictor, by a reflex arc having connection with the central nervous system through the vagus nerve. Gravity plays little or no part in the act of deglutition, and alone will not carry food or drink to the stomach. Paralysis of the esophagus may be said to be motor or sensory. It is rarely if ever unassociated with like lesions of contiguous organs.
Motor paralysis of the esophagus is first manifested by inability to swallow. This is associated with the accumulation of secretion in the pyriform sinuses (the author's sign of esophageal stenosis) which overflows into the larynx and incites violent coughing. Motor paralysis may affect the constrictors or the esophageal muscular fibers or both.
Sensory paralysis of the esophagus by breaking the continuity of the reflex arc, may so impair the peristaltic movements as to produce aphagia. The same filling of the pyriform sinuses will be noted, but as the larynx is usually anesthetic also, it may be that no cough is produced when secretions overflow into it.
Etiology.—1. Toxic paralysis as in diphtheria.
2. Functional paralysis as in hysteria.
3. Peripheral paralysis from neuritis.
4. Central paralysis, usually of bulbar origin.
Embolism or thrombosis of the posterior cerebral artery is a
reported cause in two cases. Lues is always to be excluded as the
fundamental factor in the groups 3 and 4. Esophageal paralysis is not
uncommon in myasthenia gravis.
Esophagoscopic findings are those of absence of the normal resistance at the cricopharyngeus, flaccidity and lack of sensation of the esophageal walls, and perhaps adherence of particles of food to the folds. The hiatal contraction is usually that normally encountered, for this is accomplished by the diaphragmatic musculature. In paralysis of sensation, the reflexes of coughing, vomiturition and vomiting are obtunded.