1. Dilatation is practised ordinarily with olivary or conical-tipped bougies. The former are usually metal or ivory tips fastened to a firmer handle, while the latter are fashioned like silk catheters having more or less conical tips. These are introduced until they are engaged within the stricture, after which the amount of pressure or force used should be graduated to the character of the trouble, the density of the tissues, and the tolerance of the patient. Daily dilatation may be practised either for the prevention or relief of strictures following cicatrices due to caustic fluids and the like. A small passage may in time be stretched up to nearly the normal diameter, after which instruments may be passed at regular intervals, as the tendency to recontraction is inevitable. These methods of dilatation have taken the place of more complicated mechanical procedures performed with instruments like those intended for use in the urethra. The writer has, however, in one or two instances used with advantage the Otis dilating urethrotome in cicatricial strictures of the gullet.
2. Internal esophagotomy is practised either with instruments carrying concealed blades, like those used within the urethra, or by a method suggested by Abbe, where the stomach is first opened, and a retrograde divulsion effected, or at least a small bougie is pushed upward from beneath. When its tip is felt in the mouth there is firmly attached to it a strong silk thread which, as the instrument is withdrawn, is brought down into the stomach and then out through the stomach opening. With one hand in the stomach and the other in the mouth this thread is then manipulated in such a way as to saw through the strictured passage. It is well, should the surgeon use silk in this way as he would use a Gigli saw, to pass it through a piece of rubber tubing, both above and below, in order that its sawing effect may be limited to the esophagus proper. This is a procedure which should be done with great precaution. The operator should stop at short intervals, and, by using a bougie, satisfy himself whether the strictured passage has been enlarged. When the desired result has been attained the thread is withdrawn, the stomach and abdominal wounds closed, and dilatation resorted to every day or two in order that the benefit gained may be maintained.
The use of the esophagoscope may permit the exposure of a cicatricial band or an annular stricture, so placed that it may be divided by a fine knife directed through the tube. Whatever cutting is done in this region should be done cautiously, so as to avoid injuring adjoining structures.
3. External esophagotomy is easily performed for the removal of foreign bodies. When done from below it may be combined with a gastrotomy, the cardiac end of the esophagus being thus exposed and exploring instruments or those intended for either removal of foreign material or division of stricture being thus introduced. After the measure is complete the stomach is first closed and then the abdomen.
4. Esophagectomy is an operation undertaken from without, and is seldom performed for other purposes than for the removal of malignant growths. A cancer of the esophagus should be seen early and be favorably located in order to be amenable to such a radical measure, yet cases of this kind have been successful. Too often, however, they are done too late. The esophagus is exposed by the same incision as that described for esophagotomy, namely, on the left side along the anterior border of the sternomastoid, the vessels and nerves being retracted to either side in such a way as to permit its clear exposure. The portion to be removed is then isolated by blunt dissection and resected. This leaves two ends of the canal, which can usually be brought together by sutures, after the fashion of an end-to-end intestinal anastomosis. The principal difficulty met with will be adhesions and infiltration caused by extension of disease, and these of themselves in well-marked cases would be contra-indications to operation.
Transthoracic Resection of the Esophagus.
—Bryant and others have shown how the esophagus may be exposed from the posterior aspect of the thorax by a posterior thoracotomy, made in the third and fifth intercostal spaces, where, by resection of the ribs and dissection, the esophagus may be exposed behind the hilum of the lung. The azygos vein which crosses it at about this level should be either retracted or divided after a double ligation. Experimentation has shown that it is possible at this point to stretch the tube in such a way as to permit of restoration of its caliber, if but a small amount have been removed, but great care should be exercised, otherwise tension would be extreme. Because of the doubt regarding the success of such a resection Mikulicz has suggested the following procedure of externalization of the esophagus: After exposure the distal end of the esophagus is closed and dropped back. An opening is next made along the anterior border of the sternomastoid, where the esophagus is exposed, pulled up and out of its situation—i. e., dislocated—and brought out through the upper opening, which can be done because of its loose connective-tissue surroundings. A third incision is then made over the second intercostal space in front, where a bridge of skin is lifted up, the esophagus drawn down beneath it and fastened, the intent being to connect this opening with the stomach through a gastric fistula by means of some special apparatus, thus making it possible to again feed the patient through the mouth. The incisions in the back are closed by layer sutures. The principal objection to this method is that the passage of fluid through the externalized portion of the esophagus would have to be accomplished by massaging the part and forcing it down through the tube. Sauerbruch and others have shown that in animals at least it is possible to make a transdiaphragmatic anastomosis of the stomach and esophagus. By much the same method as that last above described, i. e., through a posterior opening, the esophagus can be exposed near its lower end, resected, and then turned into an opening in the stomach, the latter having been brought up through an opening in the diaphragm. It is hardly necessary to go into details of this operation here, since the occasions which would justify it are almost as rare as the individuals who could be entrusted with its performance.
OPERATIONS UPON THE THORAX.
Exploratory puncture, either of the pericardial sac or of a pleural cavity, is an exceedingly simple matter, the ordinary hypodermic needle sufficing for many instances, while in some cases the contained fluid will be too thick to flow through a finer needle and will necessitate the use of a larger one. Such needles are furnished, with so-called exploring syringes, and their use is a convenient preliminary to the use of the aspirator—i. e., thoracentesis—or open division—i. e., thoracotomy. It is essential that both the patient’s integument, the instrument, and the operator’s hands be absolutely clean. When several points are explored at one time and fluid is found at but one it is well to indicate this with a little nitrate of silver or tincture of iodine, which will make a temporary mark. Thoracentesis implies a withdrawal of fluid through a hollow needle, which will make a small puncture that will promptly close, a vacuum apparatus of some kind being attached to it. The needle may be introduced at various points to enter either the pericardium or the pleura. Ordinarily no harm pertains to exploratory puncture and but little to withdrawal of fluid, providing certain precautions are used, though fatal syncope has been known to immediately follow it. Beyond absolute sterilization the most important feature is to withdraw fluid slowly rather than rapidly, and to desist so soon as symptoms of a serious nature appear, such as faintness or collapse. When a collection of fluid has existed for some time in one of the pleural cavities it may have gradually so displaced the heart that its too sudden withdrawal may permit a too sudden restoration to its normal position—so sudden, in fact, as to place extra stress upon it and perhaps to seriously embarrass or completely check its action. This is always a matter requiring attention. The position of the patient also should be regarded, and a patient who is seated in a chair, in order that fluid may gravitate to the lower part of the chest cavity, should be promptly placed in the recumbent position so soon as alteration in pulse or coughing or serious embarrassment of respiration are noted.
The skin over the point selected for puncture may be anesthetized with the freezing spray or with a sterile cocaine solution. The needle point should be driven in sufficiently to secure fluid and not such a distance as to puncture the heart or the lung within. The better aspirating needles are provided with rounded points rather than with sharp ones, in order that scratching with a sharp end may be thus avoided. When using a more blunt needle of this type it is well to make a trifling puncture in the skin with a small knife-blade. While the more elaborate instrument outfits sold by the dealers are pleasing to use, fluid may be siphoned through a needle and tube with a fountain syringe just as in lavage of the stomach. Consequently it is not necessary in emergency cases to have anything more than a satisfactory needle. Care should always be given that no air is introduced. Thus in managing the last-named expedient the tube and the needle itself should be filled with fluid before the latter is introduced. Then the bag may be lowered in order that no fluid escape into the chest. It is an advantage to have a piece of glass tubing connected with the apparatus, in order that the character of the fluid first withdrawn may be easily ascertained. If the patient begin to cough or to have a feeling of oppression the operator should temporarily cease, and if symptoms are not ameliorated he should withdraw the needle, renewing the procedure a day or two later. A lung too suddenly forced to expand by removal of fluid may not only give distress to the patient, but there is a possibility of hemorrhage.