Cicatricial Stenosis Of The Esophagus


Categories: DISEASES OF THE ESOPHAGUS
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

Etiology.--The accidental swallowing of caustic alkali in solutions

of lye or proprietary washing and cleansing powders, is the most

frequent cause of cicatricial stenosis. Commercial lye preparations

are about 95 per cent sodium hydroxide. The cleansing and washing

powders contain from eight to fifty per cent of caustic alkali,

usually soda ash, and are sold by grocers everywhere. The labels on

their containers not only give no warning of the dangerous nature of

the contents nor antidotal advice, but have such directly misleading

statements as : Will not injure the most delicate fabric, Will not

injure the hands, etc. Utensils used to measure or dissolve the

powders are afterward used for drinking, without rinsing, and thus the

residue of the powder remaining is swallowed in strong solution. At

other times solutions of lye are drunk in mistake for water, coffee,

or wine. These entirely preventable accidents would be rare if they

were as conspicuously labelled Poison as is required by law in the

case of these and any other poisons, when sold by druggists. The

necessity for such labelling is even greater with the lye preparations

because they go into the kitchen, whereas the drugs go to the medicine

shelf, out of the reach of children. Household ammonia, salts of

tartar (potassium carbonate), washing soda (sodium carbonate),

mercuric chloride, and strong acids are also, though less frequently,

the cause of cicatricial esophageal stricture. Tuberculosis, lues,

scarlet fever, diphtheria, enteric fever and pyogenic conditions may

produce ulceration followed by cicatrices of the esophagus. Spasmodic

stenosis with its consequent esophagitis and erosions, and, later,

secondary pyogenic infection, may result in serious cicatrices. Peptic

ulcer of the lower esophagus may be a cause. The prolonged sojourn of

a foreign body is likely to result in cicatricial narrowing.



[FIG. 97.--Schematic illustration of a series of eccentric strictures

with interstrictural sacculations, in the esophagus of a boy aged four

years. The strictures were divulsed seriatim from above downward with

the divulsor, the esophageal wall, D, being moved sidewise to the

position of the dotted line by means of a small esophagoscope inserted

through the upper stricture, A, after divulsion of the latter.]



Location of Cicatricial Esophageal Strictures.--The strictures are

often multiple and their lumina are rarely either central or

concentric (Fig. 97). In order of frequency the sites of cicatricial

stenosis are: 1. At the crossing of the left bronchus; 2. In the

region of the cricopharyngeus; 3. At the hiatal level. Stricture at

the cardia has rarely been encountered in the Bronchoscopic Clinic.

Stenosis of the pylorus has been noted, but is rare.



Prognosis.--Spontaneous recovery from cicatricial stenosis probably

never occurs, and the mortality of untreated small lumen strictures is

very high. Blind methods of dilatation are almost certain to result in

death from perforation of the esophageal wall, because some pressure

is necessary to dilate a stricture, and the point of the bougie, not

being under guidance of the eye, is certain at sometime or other to be

engaged in a pocket instead of in the stricture. Pressure then results

in perforation of the bottom of the pocket (Fig. 98). This accident is

contributed to by dilatation with the wrinkled, scarred floor which

usually develops above the stricture. Rapid divulsion and internal

esophagotomy are mechanically very easily and accurately done through

the esophagoscope, and would yield a few prompt cures; but the

mortality would be very high. Under certain circumstances, to be

explained below, gentle divulsion of the proximal one of a series of

strictures has to be done. With proper precautions and a gentle hand,

the risk is slight. Under esophagoscopic bouginage the prognosis is

favorable as to ultimate cure, the duration of the treatment varying

with the number of strictures, the tightness, and the extent of the

fibrous tissue-changes in the esophageal wall. Mortality from the

endoscopic procedure is almost nil, and if gastrostomy is done early

in the tightly stenosed cases, ultimate cure may be confidently

expected with careful though prolonged treatment.



[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.



[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.





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