The most common malformations of the esophagus which are not of the stenotic character are so-called diverticula, which appear in two forms—namely, distention and traction, these being both acquired forms, while congenital formations of this character are also occasionally met.
Congenital diverticula may appear anywhere along the course of the tube, but are probably more common in its upper portion. They constitute more or less irregular tubular sacs which lie alongside of and parallel to the main tube. The openings by which they connect may be large or small. These saccular defects, always small at first, may assume increasing proportions, because of the entrance therein of food and their consequent distention by foreign material, as well as by products of decomposition of the same. Thus slowly and insensibly a very mild form of such defect may in time assume serious proportions.
The acquired diverticula of the distention type are usually met with in the upper part, and are practically hernial protrusions of at least the mucosa through the fibers constituting the muscular portion of the tube, and cannot occur save by some preceding pathological change. Traction diverticula are the results of adhesions to breaking down lymph nodes or other pathological conditions, by which the esophageal wall is first pulled out of position, then gradually sacculated, and the condition still further aggravated by accumulation therein of foreign material. The acquired diverticula attain considerable size, and when emptied one may be astonished at the accumulation which has occurred. Such a tube having been completely emptied may be again filled by the first food which is subsequently taken. After being filled, the balance of the food may then pass into the stomach, with partial or complete comfort or satisfaction to the patient.
The principal indication of an esophageal diverticulum, beside dysphagia, is regurgitation or vomiting of food. When food which has undergone decomposition is occasionally rejected, and when, at the same time, the stomach is shown to be not dilated and not at fault, the suspicion of a diverticulum may be considered well founded. Its opening into the esophagus may be so placed as to always engage the instrument which may be passed down for examination, either bougie or stomach tube. Should this be a constant phenomenon the diagnosis may be easily established. In such a case it may be possible to first empty and then distend the sac with food mixed with bismuth subnitrate, or perhaps to inject it with an emulsion of the same. If this can be done, the fluoroscope or a good radiograph will show a distinct shadow, and in this way a pictorial outline of the condition may be obtained.
Treatment.
—The treatment of these diverticula is of great difficulty, especially when the sac has attained a size which permits of retention of material. Sacs which contain decomposing matter should be emptied by the stomach tube and washed out at frequent intervals. If it be then possible to pass the tube beyond them the patient should be fed through it, or it may be possible to place the patient in the recumbent position, with the head lower than the body, and cause food or fluid to be swallowed in this attitude. It will then probably enter the stomach instead of the sac. Such measures as these failing, and nothing else affording relief, operations are occasionally undertaken. Much will depend upon the location of the sac, especially its height. A diverticulum in the neck may be more easily reached than one in the chest, and Richardson and myself have had remarkable success in the relief of aggravated cases of this kind. Cushing has shown the advantage of the administration of atropine before these operations, in order to limit the flow of saliva and keep the parts dry. The sac having been exposed by a long incision in front of the sternomastoid, it may be filled with a solution containing methyl blue, by which it may be identified, or it may be filled with paraffin, which, solidifying, will serve admirably for its identification. It then may be attacked as would be any solid tumor. The sac having been identified and extirpated its opening into the esophagus is then closed by sutures and the neck wound cared for as usual, with provision for drainage ([Figs. 511] and [512]).
Fig. 511
Diverticulum freed from its attachments and delivered from the wound. (Richardson.)
Fig. 512