In certain cases of impermeable cicatricial stenosis of the lower end of the oesophagus, and in case of cancerous stenosis, whether involving the oesophagus alone or the cardiac end of the stomach along with it, surgery has hitherto been impotent so far as a radical operation is concerned, and such cases have been treated in the past by gastrostomy. Xow that the pneumatic chamber has become a more practicable help to the surgeon, I think we may look forward to accomplishing in man what has been proved possible in the lower animals.
Sauerbruck (1) has published the results of some of these experiments on dogs, which have been carried out with complete success, although the first attempts made by Mikulicz led to scepticism as to the possibility of such operations.
The conditions necessary to success appear to be perfect asepsis and accurate anastomosis, in which the Murphy button has played a part, but which might doubtless be accomplished by simple suture or by the use of continuous sutures over a decalcified bone bobbin. Sauerbruck made a free application of Lugot's solution to the surface to be anastomosed in order to secure rapid adhesion.
The following are the different steps of the experimental operation for establishing an anastomosis between the cardiac end of the stomach and the thoracic oesophagus :
(1) A long incision through skin, muscle, and pleura is made between the fifth and sixth left ribs.
(2) These two ribs are forcibly separated and the oesophagus, aorta, and both vagi are freely exposed.
(3) The pleural arid peritoneal coverings having been divided, a conical portion of the cardiac end of the stomach is drawn through the oesophageal opening of the diaphragm into the thoracic cavity.
(4) Into the lip of this displaced portion of the stomach the female segment of a Murphy's button is inserted through the smallest possible opening.
(5) The male portion of the button is next inserted into that portion of the oesophagus to which it is intended to fix the stomach.
(6) The anastomosis having been made by bringing the two segments of the button together, the base of the prolapsed cone of stomach is fixed by sutures to the margin of the orifice in the diaphragm.
(7) Lugot's solution is applied to the raw surfaces, and the cavity of the wound having been washed out with saline solution is completely closed by sutures.
Of thirteen dogs thus treated, ten recovered, whilst the remaining three died in consequence of complete hernia of the stomach into the thoracic cavity, due to faulty suturing of the small conical prolapse to the oesophageal opening in the diaphragm. Sauerbruck found in these experiments that the stomach could be readily applied to the upper third of the oesophagus, and that the lower half of this canal could be excluded by anastomosis.
Partial resection of the oesophagus was found to be a very difficult and unsatisfactory operation on account of the inelasticity of the canal and its close attachment to surrounding structures, and of the consequent impossibility of bringing the divided ends together and of maintaining them in contact by sutures. It is not difficult, however, after the stomach has been fixed to the upper part of the thoracic oesophagus, to resect the canal below the seat of anastomosis, and finally to invert the lower end into the cavity of the stomach, and to cover it by a row of peritoneal sutures. The upper end of the divided oesophagus is secured by a ligature. This operation was performed on eleven dogs without a single fatal result. For the removal of a close stricture or of a small tumour situated at the lower end, Sauerbruck suggests the following procedure, to be carried out in two stages : In the first stage the affected portion of the oesophagus, after it has been exposed by thoracotomy within the pneumatic chamber, is inverted into the interior of the stomach and retained in this position by sutures. After an interval of about a fortnight, gastrotomy is performed and the inverted portion of strictured or diseased oesophagus excised. That such operations as are here described are practicable on man Sauerbruck has convinced himself by experiments on the human cadaver. The stomach, he states, is sufficiently mobile, the oesophagus can be readily separated from surrounding nerves and vessels, and sufficient exposure can be attained by a single incision in the fourth or fifth intercostal space.
1. Sauerbruck.-Zentralbl. fur Chir., 1905, No. 4.