Early Nonsurgical Therapy

Early therapy for esophageal disorders included the usual compendium of useless and occasionally life-threatening techniques used for a host of different ailments, including emetics, venesection, leeches, cathartics, enemas, opiates, electrolysis, and immersion in a cold bath. Section of constricting diaphragm muscle was proposed by Bowditch8 for treatment of diaphragmatic hernia, but no surgeon was recorded as being sufficiently adventuresome to undertake such an operation for almost half a century. Similarly, surgery for esophageal stricture or perforated esophageal ulcer was not successfully undertaken until well into the 20th century. In the absence of reliable anesthetic techniques and the ability to artificially ventilate patients, thoracic operations were nearly always doomed to failure. As a result, conservative management, such as esophageal dilation, grew increasingly popular in the 19th century.

Esophageal Dilation

During the early 19th century, dilation therapy for esophageal obstruction was performed by a variety of physicians including urologists, who expanded their practice of dilating urethral strictures to encompass the esophagus. Early dilators included a swallowed bullet attached to a string, bougies made from cloth and wax, a probang (an egg-shaped ivory ball attached to a flexible shaft made from whale baleen), and gum elastic bougies. After some initial enthusiasm, caustic bougies, originally proposed in 1803 by Erasmus Darwin,16 grandfather of Charles Darwin, were rapidly abandoned because of their propensity to cause inflammation and worsen a stricture. Although bougi-nage often resulted in days, if not weeks, of relief from dysphagia, the risk was high. Perforation occurred with relative frequency, to the extent that Trousseau17 remarked that "sooner or later all cases of stricture of the oesophagus die of the bougie."

Dissatisfaction with bougies led to the development of mechanical devices that appeared (and were) dangerous. Fletcher18 designed an instrument with blades at its tip that could be deployed to lacerate an esophageal stricture after the device had been positioned across the stricture. Other bladed devices for internal esophagotomy were subsequently introduced by Maisonneuve19 in 1861 and used by Lannelongue20 in 1868. This method was not very satisfactory in opening strictures and resulted in a high mortality rate.21,22 Lerche23 developed an improved device for use during esophagoscopy (Figure 2.1) and reported good results in a few patients in 1910, but the technique failed to generate a following.

Dilators were continuously modified to improve outcomes and lessen the risk of perforation. In 1915, Hertz24 introduced a flexible

HISTORY OF MEDICAL AND SURGICAL ANTI-REFLUX THERAPY

Tucker Retrograde Dilators

Figure 2.1. This endoluminal device introduced by Lerche in 1910 was designed to be inserted through a rigid esophagoscope with the blade in a holder in a relaxed (straightened) orientation. Pulling on the trigger flexed the blade holder, extending the blade into the esophageal lumen to enable cutting of a short stricture. (Reprinted from Lerche,23 with permission from the American College of Surgeons.)

Figure 2.1. This endoluminal device introduced by Lerche in 1910 was designed to be inserted through a rigid esophagoscope with the blade in a holder in a relaxed (straightened) orientation. Pulling on the trigger flexed the blade holder, extending the blade into the esophageal lumen to enable cutting of a short stricture. (Reprinted from Lerche,23 with permission from the American College of Surgeons.)

weighted rubber bougie, the forerunner of the Maloney dilator,which substantially reduced the risk of perforation. Use of a swallowed thread with a weight attached at the distal end helped avoid errant passage of bougies when used as a guide over which the bougie was passed25'26 or when attached to either end of a bougie and brought out the mouth and a gastric stoma (Figure 2.2).27'28 This combination of the string-guided technique and the tapered bougie eventually led to the development of guidewire-aided techniques including the olive (Eder-Puestow) system in the 1950s.29 These subsequently gave way to the hollow-core polyvinyl bougie (Savary-Gilliard and American Endoscopy) systems that originally became popular in the 1980s.30 Because of continued concern over the risks associated with forceful dilation of benign strictures, particularly because of the shear forces generated within the esophagus, pneumatic dilators were adopted for use for treating peptic strictures. Their theoretical advantage was the controlled delivery of radial forces that would reduce the risk of esophageal injury. Recent randomized studies have demonstrated that both systems have similar efficacy and are equally safe (Figure 2.3).31'32

Esophageal Stents

Stents were first introduced in the management of peptic esophageal stricture in France in the mid-19th century.17,33 Until the late 19th century, the only effective treatment for an obstructing esophageal stricture was passage of a gum elastic tube that spanned the stricture and protruded through the mouth. The protruding end was so uncomfortable that most patients coughed it out or removed it to relieve the dis-tress.34 Symonds35 tailored the tube by cutting off the protruding end of the tube, retaining it in position through use of a loop of silk passed around the patient's ear. This was a popular device for maintaining luminal patency after dilation that probably worked by inducing pres-

sure necrosis.35

MANAGING FAILED ANTI-REFLUX THERAPY

MANAGING FAILED ANTI-REFLUX THERAPY

Figure 2.2. Early dilators, such as this string-guided bougie designed by Tucker, were guided by a string that was passed down the mouth, through the esophageal stricture, and out a gastrostomy.The string was left in place between dilations. (Reprinted from Tucker,28 with permission from Annals Publishing Company.)

Figure 2.2. Early dilators, such as this string-guided bougie designed by Tucker, were guided by a string that was passed down the mouth, through the esophageal stricture, and out a gastrostomy.The string was left in place between dilations. (Reprinted from Tucker,28 with permission from Annals Publishing Company.)

The development of endoscopy led to the application of stent technology primarily for malignant esophageal obstruction rather than peptic esophageal stricture, relegating the use of stents for benign esophageal disease to unusual and highly selected cases. Technical developments in stenting in the early 20th century included the use of guides and dilators, which directly led to the introduction of the Souttar tube in the 1920s. This spiral of silver wire was positioned using an introducer, which considerably increased the safety of stent placement.36 This so-called pulsion-type stent was subsequently modified to include much softer versions made from rubber or silicone. Tapered introducers were adapted to traction-type stents that were drawn down into regions of obstruction through a temporary gastrotomy, including the Mousseau-Barbin and Celestin tubes.37,38 The introduction of self-expanding

Mousseau Barbin Tube Insertion

wire-mesh stents in the 1990s revolutionized the use of stents in esophageal obstruction (Figure 2.4). However, their tendency to create inflammation and fibrosis, despite the increasingly nonreactive nature of their component materials, makes them unsuitable for long-term use in peptic esophageal strictures except under unusual circumstances.

Palliative Surgical Therapy

Before endoscopy and radiography were able to delineate the cause of esophageal obstruction, there were few surgical options for its management, all of which were palliative. Gastrostomy was first performed by Sedillot39 in 1849 as a means for providing nutrition. The first successful use of gastrostomy as an access for retrograde dilation was by von Bergmann in 1883.40 Cervical esophagostomy was also used in cases of high-grade obstruction as means for expelling saliva but provided no other palliative benefits. Trendelenburg devised a long extension tube for the gastrostomy tube, into which the patient expelled masticated food directly from his mouth and propelled the food into the stomach by blowing into the tube.41 This idea was subsequently modified so that a cervical esophagostomy tube connected to the gastros-tomy tube transmitted swallowed food directly into the stomach via an extracorporeal route (Figure 2.5).42 This concept was embraced for

Figure 2.3. Four generations of esophageal dilators. At the top is the olive-tipped (Eder-Puestow) system and below it is a Maloney bougie. The latter dilators were originally filled with mercury to weight them, but now are filled with a tungsten gel. The third and fourth dilators from the top are elements of wire-guided systems, made of polyvinyl chloride. A pneumatic dilator that can be used through the endoscope is pictured at the bottom. (Reprinted from Ferguson M. Chest Surg Clin N Am 1994;4:679, copyright 1994, with permission from Elsevier.)

Figure 2.4. Nitinol self-expanding mesh stents are useful for temporary palliation of benign strictures, but the resultant surrounding tissue inflammation can lead to additional scarring if the stent is left in place too long.

Figure 2.4. Nitinol self-expanding mesh stents are useful for temporary palliation of benign strictures, but the resultant surrounding tissue inflammation can lead to additional scarring if the stent is left in place too long.

HISTORY OF MEDICAL AND SURGICAL ANTI-REFLUX THERAPY

How Insert Mousseau Barbin Tube

Figure 2.5. This patient underwent the first successful transthoracic esophagectomy for cancer, performed by Franz Torek in New York City in 1913. The patient's alimentary tract continuity was established with an external rubber tube, and reconstruction was never attempted. (Reprinted from Torek,42 with permission from the American College of Surgeons.)

Figure 2.5. This patient underwent the first successful transthoracic esophagectomy for cancer, performed by Franz Torek in New York City in 1913. The patient's alimentary tract continuity was established with an external rubber tube, and reconstruction was never attempted. (Reprinted from Torek,42 with permission from the American College of Surgeons.)

palliation of esophageal cancer by Akiyama and Hatano43 and was subsequently introduced for management of failed anti-reflux surgery by Skinner and DeMeester.44

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Responses

  • bilcuzal
    How to insert a mousseau barbin tube?
    8 years ago
  • Amaranth
    How to insert stentil vent in the oesophagus with a tumor?
    6 years ago

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