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Cicatricial Stenosis Of The Esophagus

Category: DISEASES OF THE ESOPHAGUS
Source: 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.





Next: Diverticulum Of The Esophagus
Previous: Functional Hiatal Stenosis Hiatal Esophagismus Phrenospasm Diaphragmatic Pinchcock Stenosis

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