CARDIOSPASM (grech, kardia heart, inlet opening of a stomach + spasmos a spasm) — the disease which is followed by disturbance of normal sokratitelny ability of a gullet and reflex disclosure of the cardia.
The first clinical description To. T. Villizy (1674), and anatomic — Purton gave (Purton, 1821). In domestic literature the wedge, a picture of a disease were described for the first time by N. V. Ekk in 1852 S. P. Botkin (1884) in detail stated symptomatology, differential diagnosis and treatment of «spasmodic or paralytic» an esophageal stenosis.
There are various names of a disease. In Russian it is also mute. to literature use the term «cardiospasm», in English - an amer. to literature of «an achalasia of the cardia» (lack of reflex disclosure of the cardia is meant); in fr. literature it is possible to meet the name «dolichoesophagus», «megaezofagus», «cardiostenosis» more often, etc. The disease and under other names is described: idiopathic esophagectasia, S-shaped gullet, ezofagealny dyssynergia etc. Despite abundance of terms, any of them does not reflect completely essence of a disease.
According to Mayngot (R. Maingot, 1944), I. T. Tyshchenko (1949), frequency To. in relation to other diseases of a gullet makes from 3 to 20%; To. meets at any age, it is almost equally frequent at men and women. The disease has various character of a current. At one typical the wedge, a picture develops for several months, at others — for several years.
The etiology and a pathogeny
the Aetiology and a pathogeny are finally not found out therefore there is a set of various theories. The bard (To. Bard, 1919), etc. consider To. inborn pathology; they reason the theory with the fact that the disease occurs at newborns and children of early age. This theory is spoken well also by cases family To.
According to the organic theory which is put forward by Mosher (N. Mosher), To. develops owing to a mechanical obstacle in the field of the cardia. Here, and also in a zone of an esophageal opening of a diaphragm find fibrous and sclerous changes. Expansion of a gleam of a gullet occurs for the second time.
The theory of an essential spasm of the cardia offered by I. Mikulich (1904) explains To. dominance of a sympathetic innervation over parasympathetic. Reduction of circular muscle fibers in the field of the cardia creates an obstacle to a passage of food that causes strengthening of a vermicular movement of a gullet, the gleam to-rogo afterwards extends because of a decompensation of sokratitelny ability.
The beginning To. often connect with a mental injury. Experimentally the method of a sshibka at dogs received disturbance of motility of a gullet, and more expressed changes are noted at animals with weak type of nervous activity. At patients To. disturbances of normal interaction of bark, a subcortex and internals come to light. Psychological frustration are found out in 70% of patients of K. Ustanovleno that at To. bulbodientsefalichesky departments in which there are centers of swallowing therefore excitement covers all neurons which are at the same time participating in carrying out impulses are surprised.
The theory of defeat of vagus nerves won many followers. At pilot studies and a wedge, observations it is revealed that inflammatory, dystrophic processes in vagus nerves, their tumors, hems increased limf nodes can lead a prelum to the changes described at To. However at the expressed cicatricial and sclerous and inflammatory processes in cellulose of a mediastinum extending to vagus nerves and also at injuries with crossing of nervous trunks of rife always develops To. At the same time it is often observed in the absence of signs of defeat of vagus nerves. N. K. Bogolepov et al. (1960), etc. showed that. at To. are damaged not only wandering, but also sympathetic nerves and a ganglion.
According to the theory of the achalasia offered by Eyngorn (M. of E inhorn, 1888), a basis To. not the spasm of the cardia, but lack of its reflex disclosure is. Hurst (A. Hurst, 1914), etc. changes in intermuscular neuroplex which, in their opinion, are the reason of disappearance of a reflex of disclosure of the cardia paid attention on patol.
According to Trauns (Trounce) et al. (1957), etc., cells of neuroplex in the field of the cardia at To. are not damaged and are in an active state, but owing to damage of overlying departments they do not receive the corresponding impulses.
Some researchers find damage not of cholinergic, but adrenergic receptors of muscular layers of a cardial part of a stomach or muscle fibers of a wall of a gullet. This theory is most popular since it is based on an established fact — the degeneration of ganglionic cells of an intramural texture observed at this disease that K.
Elnor is, apparently, the main reason of development (Alnor, 1958) created model K. by impact of low temperature on area of the cardia that led to an anoxia and a degeneration of nervous cells of an intermuscular texture. Similar results were received by Korelli (H. N of Corelli) et al. (1957) which by a mechanical prelum caused ischemia of ezofagokardialny area. Keberle, Penkh (F. Koberle, Penha, 1959) proved a possibility of development To. in the dogs infected with Crous's trypanosome. Toxin of this parasite caused in intermuscular neuroplex of change, characteristic of K. Znacheniye of dystrophic changes in a pathogeny of a cardiospasm confirms the mekholilovy test: after administration of cholinergic drugs reductions of a gullet considerably amplify. Such processes are characteristic for. so-called autonomous denervation when in denervated structures sensitivity to the corresponding mediators increases (U. Kennon, 1939).
The theory of an achalasia was confirmed also by researches of intra esophageal pressure. In the field of esophageal and gastric transition the sphincter which at healthy people at rest is in a condition of tonic contraction was found, and after swallowing relaxes. This zone received the name fiziol, cardias. At patients To. this postdeglutitory reflex reaction of the cardia is absent, i.e. the picture of an achalasia is observed. Sometimes even instead of relaxation additional reduction, as if a spasm of the cardia is observed. The term «cardiospasm» approaches these cases more, than others. Also the peristaltics of a gullet changes: instead of the peristaltic reductions extending to a stomach waves appear not propulsive (not providing a passage), segmented reductions join them. Diskoordination of sokratitelny ability of a gullet and the cardia is caused, apparently, by disturbance of the correct spread of activation in connection with patol. changes in intramural neuroplex. The reasons of these changes can be various — inborn and acquired, endogenous and exogenous, caused infectious and parasitic diseases, different types of an injury, endocrine or other exchange frustration and intoxications.
The pathoanatomical picture depends on duration and a stage of process. Usually allocate four stages (fig. 1) during a disease (B. V. Petrovsky). In the I stage visible macroscopic changes are absent. In the II stage the gleam of a gullet extends to 2,5 — 3 cm, and the cardia is narrowed. Microscopically note a hypertrophy and hypostasis of muscle fibers (fig. 2), clear changes in an intraparietal texture. In structure of the majority of nervous trunks their sharp thickening with the chetkoobrazny swellings caused by vacuolar focal dystrophy (fig. 3) is visible. Some trunks have a branchy, acanthoid appearance. In the III stage the gleam of a gullet extends to 3 — 5 cm. All layers of a wall of a gullet are thickened, in a muscular coat preferential circular layer, a mucous membrane plethoric is hypertrophied. In a submucosa focal lymphoid infiltrates are found. Walls of some arteries are sclerosed, their gleam is slightly narrowed. Further progressing of vacuolar dystrophy of nerve fibrils with loss of their structure (fig. 4) is noted. In intermuscular layers — growth of connecting fabric (fig. 5), edge divides muscle fibers into separate complexes. In neuroplex disintegration and fragmentation of axial cylinders is observed, the quantity of ganglionic cells considerably decreases. In the IV stage expansion of a gleam can be over 5 cm. The gullet is extended and gets S-shaped, or serpentine, a form. His mucous membrane becomes the rough, deprived folds. Microscopic changes become even more expressed, in nervous network find full aganglioz.
The mediastinal pleura in the last two stages, especially in IV, becomes dense, quite often spliced with the surface of a gullet and during operation hardly separates from it. The cellulose of a mediastinum surrounding a gullet from friable in initial stages gradually turns into dense. In a diaphragm, in close proximity to edges of an esophageal opening, changes of muscle fibers, their swelling, vacuolation, a basophilia, loss of striation, hypostasis of connecting fabric come to light.
Thus, anatomic and gistol, data demonstrate that sclerous processes in a mediastinum at To. are secondary and depend on intensity of an inflammation in the gullet.
A clinical picture
Klin, a current To. it is divided into four stages: I \a non-constant spasm of the cardia, II — a stable spasm, III — cicatricial changes of the cardia and an esophagectasia, IV — sharp cicatricial changes of the cardia and the expressed esophagectasia. Some authors divide To. on the compensated, dekompensirovanny and complicated forms.
Usually patients connect emergence of a disease with some mental injury, a nerve strain. In the beginning they feel awkward during the swallowing, feeling of the slowed-down passing of food on a gullet, «causeless» retrosternal pains. Such phenomena of discomfort at some patients can proceed months or even years. In other cases more bystry progressing of a disease is observed, and from the very beginning of the patient sees a doctor with the main complaint on dysphagy (see), cover with idiosyncrasy in an initial stage To. character is its intermittent. Sometimes patients feel a delay only of the first drinks of food, especially if it is cold. Cases when the dysphagy is caused only by products of a certain taste, a smell, a look meet. The feeling of a dysphagy amplifies at bystry food. It can proceed from several minutes to several days and then suddenly disappear. In certain cases a dysphagy at To. can be paradoxical: dense food passes well, and liquid and semi-fluid is late. Eventually the dysphagy amplifies, unpleasant feelings behind a breast, feeling of a prelum and raspiraniye, retrosternal pains appear. For simplification of a state, trying to help passing of food, patients use various methods increasing intra esophageal and intrathoracic esophageal pressure, quite often wash down each drink of dense food with water.
At the further course of a disease and disturbance of sokratitelny ability of a gullet food in it is late a long time, being exposed to fermentation and disintegration. In far come cases for emptying of a gullet patients cause vomiting. This sign, according to various authors, is observed at 50 — 90% of patients. Vomiting can arise and involuntarily, especially during sleep or in horizontal position of the patient, at inclinations of a trunk and t; item.
From 50 to 80% of patients at To. pains in an anticardium, behind a breast, in interscapular space disturb. On character they can remind stenokardichesky. At the beginning of a disease (the I—II stage) pain arises along with feeling of a delay of food, i.e. is connected with spastic reductions of a wall of a gullet; it has passing, incidental character. In the started cases (the III—IV stage) pain is caused by stretching of a gullet the food accumulating in it therefore happens more constant and disappears after emptying of a gullet.
Sometimes in the III—IV stages of a disease when the capacity of a gullet is considerably increased, the feeling of a dysphagy decreases that, perhaps, is caused by defeat of an afferent part of a reflex arc and death of sensory nervous cells. Apparently, has value and lack of reductions of a gullet.
The general condition of patients at To., as a rule, suffers slightly, the expressed lose of weight seldom develops. Exhaustion as the reason of lethal outcomes is casuistry and it is possible only in the absence of treatment. Because of a dysphagy patients try to eat separately, avoid society, their mentality is fixed on painful feelings. Available prior to the beginning of specific a wedge, manifestations To. asthenoneurotic reactions amplify in process of progressing of a disease, the general weakness, decrease in working capacity appears.
Complications as the general, and local, develop in the started cases. First of all congestive concerns to them esophagitis (see), manifestations to-rogo vary from an easy hyperemia of a mucous membrane of a gullet before formation of ulcers in a wall of a gullet. The most terrible general complications To. — the pneumonia, abscess of lungs caused by aspiration of contents of a gullet.
Especially often these complications occur at children. Quite often at To. diverticulums and cancer of a gullet meet. B. V. Petrovsky and O. D. Fedorova (1963) observed cancer of a gullet at 2,8% of patients To., Santy et al. (1958) — in 3,2% of cases. If diverticulums of a gullet at To. develop in connection with disturbance of a nervous trophicity of a muscular coat and increase in intra esophageal pressure, most likely the congestive esophagitis is the reason of cancer.
Timely diagnosis To. allows to begin early the corresponding treatment and by that to avoid possible complications.
X-ray inspection at suspicion on To. begin with careful survey raying of bodies of a thorax. At a sharp esophagectasia and availability of liquid in it it is possible to see a homogeneous shadow of an expanded gullet.
The contrast research of a gullet is conducted by portion reception of 1 — 2 glasses of a baric suspension of a usual consistence. At polyposition research (see) define contours and walls of a gullet, a relief of a mucous membrane of suprastenotichesky department of a gullet, and also degree of its smeshchayemost. For the purpose of possible improvement of passability of cardial department of a gullet it is possible to allow to the patient to drink a glass of «sparkling mix», with the help the cut is also possible to define a form, the sizes and elasticity of a gas bubble of a stomach.
The basic rentgenol, a sign To. narrowing of terminal department of a gullet with accurate, equal and elastic contours is. Folds of a mucous membrane in the field of narrowing are not destroyed. The gas bubble of a stomach is absent. Suprastenotichesky expansion, sometimes with an overhang of walls of a dilatirovanny gullet over its narrowed department (fig. 6) is noted. At To. the first two drinks of barium can freely come to a stomach. However then there comes sharply expressed spasm of terminal department of a gullet, and the gullet looks as if amputated due to lack of a shadow of the contrasted its abdominal department.
Disclosure of the cardia can come at the heavy «empty» deglutitory traffics, i.e. during the forcing of air in a gullet or at reception of additional quantity of a baric suspension.
During roentgenoscopy it is possible to observe the expressed segmented reductions of a gullet as a result of which contrast weight makes the pendulum movements. Evacuation of a baric suspension in a stomach happens regardless of intra esophageal pressure.
Ezofagoskopiya carry out for the purpose of confirmation of the diagnosis To., detection of its complications and carrying out the differential diagnosis. Examining the mucous membrane collected at To. in cross folds in the form of 15 — 20 rings, specify degree of an esophagitis and expansion of a gleam of a gullet, expressiveness of stagnation of food in it. In cases of sharp dilatation of a gullet cross folds of a mucous membrane disappear, and walls have an appearance of a leathery flabby bag. At further carrying out the esophagoscope examine carat the diya having at To. a type of the point or a crack located vertically or horizontally. As a rule, the end of the esophagoscope at To. it is possible to carry out through the cardia that confirms data on a preferential funkts, the nature of changes in a gullet.
Ezofagomanometriya — a valuable method of early diagnosis To., since changes of sokratitelny ability of a gullet and the cardia appear typical a wedge, symptoms much earlier. The research is made by means of the special multichannel probe with rubber barrels or «open» catheters, on the Crimea fluctuations of endoluminal pressure are transferred to the chart recorder.
Normal after swallowing (fig. 7, 1 and 2) on a gullet the peristaltic wave (fig. 7, 3) begins to extend, and the cardia opens at this time and pressure falls (fig. 7, 4). After passing of peristaltic reduction the cardia is closed again. At an achalasia of the cardia after swallowing (fig. 8, 1 and 2) reflex relaxation of an ezofagokardialny sphincter is absent, and endoluminal pressure remains on former figures (fig. 8, 4) which absolute values differ from those at healthy people a little. At To. after swallowing (fig. 9, 1 and 2) instead of the pressure drop reflecting opening of the cardia there is a build-up of pressure (fig. 9, 4), i.e. the perverted reflex reaction is registered. Between these typical states depending on a stage of a disease there are transitional forms. In certain cases after separate deglutitory movements there can occur relaxation of the cardia, but it insufficiently either on amplitude, or on duration. With the course of a disease undergoes changes and sokratitelny ability of a gullet: in the beginning postdeglutitory reductions (fig. 8, 3) amplify, then segmented reductions join them. Both types of reductions at To. have no propulsive ability therefore they are not enough to push food through the closed cardia. Gradually there comes the decompensation of sokratitelny activity, and in a gullet any reductions (fig. 9, 3) cease to be registered.
Thus, the main difference To. and achalasias of the cardia the nature of reflex reaction of the cardia in response to swallowing, and also sokratitelny ability of a gullet is. Initial pressure in the cardia at rest a little in what differs from the level registered at healthy.
In doubtful cases for diagnosis To. sometimes use the special test consisting in intramuscular administration of cholinomimetic drugs. Selectively stimulates motility of a gullet mekholit (karbokholit). Injections of these drugs at other diseases of a gullet and the cardia which are followed by disturbance of their passability do not lead to strengthening of reductions of a gullet.
Differential diagnosis. In initial stages at atypical development the disease on a wedge, can remind a picture stenocardia, hernia of an esophageal opening of a diaphragm, a diverticulum of a gullet, an initial stage of cancer of cardial department of a gullet and stomach. At To. pains are usually connected with meal, match on time feeling of a dysphagy that distinguishes To. from stenocardias (see) when pains are generally provoked physical. loading. At hernias of an esophageal opening diaphragms (see) patients heartburn, an eructation disturb, vomiting, but, unlike is possible To., the food digested in a stomach. The corresponding anamnesis and clinic a reflux esophagitis is inherent in peptic strictures (see. Esophagitis ). An additional argument in favor of the diagnosis To. — duration of a current and young age of patients, its communication with a mental injury. It is much more difficult to otdifferentsirovat initial stages To. from the disease known in literature under the name «esophagism». At this disease there is a disturbance of motive function and passability of a gullet out of its terminal piece; the mechanism of disclosure of the cardia is not broken, than the esophagism essentially differs from To. The alternating character of a dysphagy is characteristic of an esophagism, edges is followed by the pain arising at the time of swallowing and passing of food on a gullet. Regurgitation, as a rule, not plentiful, at the same time contents of a gullet are almost not changed.
Rentgenol, a research finds at an esophagism an esophageal stenosis more often in its nizhnegrudny department. It comes to light at the deglutitory movements better and usually has the wedge-shaped form and big extent (3 — 6 cm). In the course of the research it is possible to observe change of spasmodic reductions by good passability of a gullet. At the same time patients note feeling of a delay of a baric suspension. The Suprastenotichesky esophagectasia at an esophagism moderate, liquid and slime in a gleam is a little, the gas bubble of a stomach is expressed well. It is also extremely important to mean that To. can accompany an initial stage of cancer of cardial department gullet (see) and stomach (see).
Treatment and the forecast
Conservative therapy pursues the aim to normalize the disturbances inherent To. and being its reason. The great value is gained by actions of fortifying character. Patients should be protected from excessive experiences, to convince of high quality of a disease and that their state will surely improve. It is necessary to create to patients such conditions of food that they did not feel constraint from people around. In conservative treatment the dietotherapy has a certain value. The eaten food shall be mechanically and chemically sparing. Food shall be fractional. The last meal shall be in 3 — 4 hours prior to a dream.
Conservative treatment provides obligatory intensive vitamin therapy, especially a complex of vitamins of group
of V. Nek-ry of reduction of a dysphagy in I and II stages of a disease it is possible to achieve reception before food or during food of spasmolysants. Drugs of nitrogroup — nitroglycerine, amyle nitrite belong to the most effective spasmolysants. In late stages spasmolysants oppress motility of a gullet that can have an adverse effect on passability of the cardia. However, they render short-term effect. Apply to relaxation of the cardia also other spasmolysants (Platyphyllinum, Nospanum, Halidorum, a papaverine, etc.). Hopes for therapeutic effect at administration of antikholinesterazny adrenolytic and adrenomimetichesky drugs, according to numerous data of literature, did not come true.
In far come cases, at the expressed stagnation in a gullet and an esophagitis it is possible to apply washing of a gullet weak solution of antiseptic agents. It is necessary to treat this procedure with care at the complicated forms of an esophagitis (hemorrhagic, ulcer). Considering the expressed disturbance of passability of a gullet in III and IV stages of a disease, it is not recommended to apply the medicinal substances per os in tablets, especially if they possess local irritant action.
Sometimes the therapeutic effect occurs after various physiotherapeutic procedures.
Modern conservative therapy in the isolated look is applied practically only in an initial stage To., and in most cases she uses during the training of patients for operational treatment or as addition to the cardiodilatation which is the main method of treatment To.
Surgical treatment is directed to elimination of an obstacle to advance of food in the field of the cardia by its expansion by means of anemic or operational methods. For the first time cardiodilatation was made in 1898 by J. G. Russel using the dilator created by it for this purpose. However only in 20 century the method gained recognition and began to be used in the USA, England, the USSR and other countries.
In the USSR in 1930 P. A. Herzen, and then A. I. Savitsky used the mechanical dilator of Stark.
All dilators for expansion of the cardia divide on pneumatic, hydrostatic and mechanical. There are also various combinations of devices. The devices designed by Plummer belong to the first two types of dilators (H. S. Plummer, 1906). V. Bryunings (1906) offered a mechanical dilator, and in 1924 H. Starck modified it.
The principle of stretching of an elastic cylinder by air or liquid is put in a basis of a design of pneumatic and hydrostatic dilators. In a mechanical cardiodilator expansion of the cardia is carried out by the metal branches connected by means of hinges to the lever located on the handle of the dilator. During the use of a dilator of H. Starck there are various complications more often — anguishes and ruptures of a wall of a gullet, bleeding, there are difficulties with introduction and extraction of the tool. So, according to Ventsel (Wenzel, 1970), on 47 dilatation by H. Starck's device registered 6 complications, quite often life-threatening (a short-term cardiac standstill — 1 case, a rupture of a gullet — 2). At the same time H. Starck on 1118 expansions only in one case had a rupture of the cardia.
In 1964 in the All-Russian Research Institute of clinical and experimental surgery the pneumatic cardiodilator which is applied to treatment more than at 500 patients is created (O. D. Fedorova, G. K. Melnikov). The method of cardiodilatation became method of the choice at treatment To. also it is applied in many clinics of the USSR. The dilator (fig. 10) consists of a X-ray contrast rubber tube probe 120 cm long and to dia. 15 mm with the rounded-off end. At distance of 5 — 6 cm from the end the cylinder 15 cm long and to dia is strengthened a gantelevidny form. 4 cm. The wall of a cylinder consists of three layers (covers): internal and outside — rubber, and average — naylonovy. Rubber covering provides tightness, and naylonovy — the constant diameter and a form of a cylinder during the forcing of air in it. On the end of the probe the channel going in the slanting direction to an axis and intended for thread or strings conductors opens. Cardiodilators have various sizes: to dia. 25, 30, 35, 40, 45 mm.
Cardiodilatation can be carried out in any stage of K. Obychno patients do not need special preparation. The procedure is made in the morning on an empty stomach, as a rule, without anesthesia.
Success of expansion of the cardia in many respects depends on correctness of an arrangement of the dilator. His «waist», i.e. the center of a cylinder, shall be in ezofagokardialny area, approximately at the level of a gas bubble of a stomach (fig. 11). Installation of a cylinder is made under control of the x-ray screen. During the forcing of air in a cylinder of the dilator its shift towards a gullet or a gleam of a stomach is possible.
Begin a course of dilatation by means of dilators of the smaller size; pressure in them is increased also gradually — from 180 — 200 to 300 — 320 mm of mercury. Duration of the procedure of expansion — apprx. 1/2 — 1 min., an interval between sessions of 1 — 2 day. In some cases, if after dilatation severe pain behind a breast or in epigastric area develops, temperature increases or traces of blood on the tool are found, extend an interval between dilatation. Usually during expansion patients feel moderate pain behind a breast and in an anticardium. In 2 — 3 hours after disappearance of pains reception of liquid food is allowed.
Contraindications to cardiodilatation are limited: portal hypertensia with a varicosity of a gullet, an ulcer and ulcer and hemorrhagic esophagitis, diseases of blood which are followed by the raised bleeding, etc.
The patients who are already operated earlier concerning a cardiospasm, dilatation) need to make extremely carefully. About efficiency of dilatation it is necessary to judge not only by feelings of the patient, but also according to objective methods of a research (rentgenol. and ezofagomanometrichesky control).
At rentgenol, a research find improvement of passability of a contrast agent on a gullet, return of a relative propulsivnost of motility of a gullet, approach to the normal size of diameter of its gleam, formation of a gas bubble of a stomach (fig. 12).
Ezofagomanometriya in case of effective dilatation reveals pressure decrease in a cardial sphincter. Extent of this decrease depends on a condition of motility of a gullet, its propulsivnost, functional reaction of the cardia to swallowing.
Cardiodilatation is a highly effective method of treatment of K. Pochti at 94% of patients it is possible to achieve excellent and good results. Preference should be given to expansion of the cardia by means of pneumatic or hydrostatic dilators. Unsatisfactory results are caused most often by insufficient or excessive dilatation. In the first case the dysphagy decreases slightly, and in the second — the clinic a reflux esophagitis develops.
Indications to operational treatment: 1) impossibility to make cardiodilatation); 2) lack of therapeutic effect after repeated courses of kardiodilatation; 3) early the diagnosed ruptures of a gullet which arose during expansion of the cardia; 4) the expressed peptic strictures which developed as a result of restretching of the cardia and not giving in to conservative therapy and bougieurage.
The most part of the operative measures offered for treatment To., is of only historical interest. Among them: 1) the operations on a venter of a gullet directed to reduction of a gleam of a gullet by excision of a part of its wall or an ezofagoplikation; 2) operations on a nervous system (vagisection, sympathectomies, excision of a phrenic nerve, intervention on submucosal neuroplex); 3) operations on a diaphragm (a diaphragmotomy, a krurotomiya, ezofagoliz); 4) operations of switching off of the cardia (subphrenic ezofagogastroanastomoz, transthoracic ezofagogastroanastomoz, cardiectomy and parts of a gullet); 5) operations on the «physiological» cardia (transgastralny expansion, a cardioplasty). All these interventions are not applied in view of small efficiency, a frequent recurrence of a disease and frequent development of an incompetence of cardia and peptic a reflux esophagitis.
From a various arsenal of the offered operational methods only the interventions on the «physiological» cardia based on the idea of extramucosal cardiomyotomy are applied.
Gottstein (G. Gottstein, 1901) suggested to cut longwise only a muscular coat in ezofagokardialny area. Geller took advantage of this offer (E. Heller, 1913). The Ekstramukozny cardioplasty according to Geller (fig. 13) is carried out from abdominal access and consists in a longitudinal section of a muscular coat of terminal department of a gullet of front and back walls throughout 8 — 10 cm. On extent the myotomy shall extend partially to a venter of a gullet, a zone of narrowing and a cardial part of a stomach where cut group of slanting muscle fibers. Edges of a dissect muscular coat part in the parties, and in the formed defect the unimpaired mucous membrane begins to prolabirovat.
According to data of most of authors, good results after this operation are observed in 70 — 95% of cases. However V. V. Utkin (1966), O. D. Fedorov (1973) found the unsatisfactory results caused by a recurrence of a disease, an incompetence of cardia, a peptic esophagitis etc. in 20 — 50% of patients.
According to aggregated data, the lethality after Geller's operation is equal on average 1,5%, sometimes reaches 4%. The unnoticed injuries of a mucous membrane of a gullet leading to a mediastinitis, pleurisy, peritonitis are the main reason for lethal outcomes. These damages are observed in 6 — 12,8% of operations. In the place of a section of a muscular coat after Geller's operation development of diverticulums, the hems deforming the cardia is described.
For the prevention of a recurrence Lorta-Jacob (J. L. Lortat-Jacob, 1951) suggested not to cut, and to excise a strip of a muscular coat.
If injury of a mucous membrane is revealed, it shall be taken in. It is more dangerous if this wound remains unnoticed. Therefore various methods for cover of a mucous membrane are offered: epiploon, front wall of a stomach etc. Methods of closing of defect of a muscular coat with various synthetics, are not recommended.
It is very important to keep as much as possible anatomic relationship of a diaphragm, a gullet and stomach for prevention of an incompetence of cardia and ref a luxury esophagitis. For these reasons B. V. Petrovsky et al. (1972) began to combine Geller's operation with an ezofagofundorafiya or fundoplication across Nissen (fig. 14).
The cardioplasty a phrenic rag according to Petrovsky (fig. 15) which is a kind of an ezofagofrenoplastika is developed in an experiment; since 1956 its implementation in a wedge, practice is begun. Access — a thoracotomy in the VII mezhreberye at the left; cut a mediastinal pleura over expanded nizhnegrudny department of a gullet and allocate the last from a mediastinum. Under a gullet carry out a rubber or gauze tape and make the T-shaped myotomy 8 — 10 cm long. In the acute and stupid way methodically otseparovyvat and excise a strip of a muscular coat of a gullet and the cardia of 10 X 3,5 cm in size. Especially carefully it should be made in the narrowed site since here as a result of inflammatory and sclerous changes the muscular coat not always easily separates from a submucosa and it is possible to injure a mucous membrane.
In initial option of operation of an integrity of edges of an esophageal opening of a diaphragm did not attach essential significance, and afterwards it led to disturbance of barrier function of the cardia, gastroesophagal a reflux at and to an esophagitis. In a final version the muscular and connective tissue elements forming an esophageal opening are not damaged. A rag create, of a diaphragm, otstupya 2 — 3 cm from edges of an esophageal opening. After cutting out of a rag through the arisen defect in a diaphragm make additional expansion of the cardia a finger through the invaginated wall of a stomach and complete excision of a muscular coat. The rag of a diaphragm is hemmed at first on an inner edge of area of a myotomy, beginning from below, and then on outside. After that recover an integrity of a diaphragm.
It is possible to refer preservation of locking function of the cardia at good passability of a gullet to positive sides of the last modification, and also a possibility of reliable cover of a mucous membrane. Besides, defect in a muscular coat is covered with the fabric close on the structure and function to muscles of a gullet.
According to O. D. Fedorova (1973), in the analysis of the long-term results of a cardioplasty the phrenic rag turned out that from 98 the operated excellent and good results are received at 84 patients, at 12 — satisfactory and only at 2 — unsatisfactory.
According to aggregated statistical data, on 296 operations there were 4 lethal outcomes. Success of operation is provided with an effective myotomy, the correct cutting out and a podshivaniye of a rag of a diaphragm, and also sewing up of the defect formed in it. It is very important that blood supply of a rag was full, at a podshivaniye it is necessary that it was not bent, otherwise there can come insufficiency of its blood supply and the subsequent scarring. The muscular rag from a gullet and the cardia should be excised from area where there do not pass branches of vagus nerves,
In 1960 T. A. Suvorova reported about operation of the ezofagokardiogastroplastika (fig. 16) which is that after an ezofagokardiomiotomiya the front wall of a stomach is hemmed to edges of defect in a muscular coat and to a mediastinal pleura. This operation in a smaller measure interferes with a gastroesophagal reflux, than a combination of an ezofagokardiomiotomiya to an ezofagofundorafiya or fundoplication across Nissen therefore it did not find broad application.
The cardiospasm at children
the Cardiospasm at children was for the first time described by G. Gottstein in 1901. In domestic literature one of the first observations belongs to H. To N. Petrov (1926). To. at children's age — rather rare disease (4 — 5% in relation to adult patients).
The main patol, phenomena at To. at children, as well as at adults, disturbance of passability of the cardia and expansion of overlying departments of a gullet with frustration of their tone and motility is. It is characteristic that at children at To. the organic stricture in a belly part of a gullet and a myopachynsis of this area is not found.
Gistol, by researches it was established that in genesis To. at children inborn deficit of neurons in gangliya of an intermuscular texture of a gullet both in cardial, and in overlying departments (fig. 17) with the secondary dystrophic changes in smooth muscle fibers caused by motive denervation matters.
Wedge, picture K. at children it is characterized by two main symptoms: regurgitation and dysphagy. Regurgitation is noted not after each feeding, and its frequency fluctuates on days, vomiting can be during sleep. In emetic masses not changed food without signs of gastric contents is found (esophageal vomiting). The senior children define a dysphagy as feeling of a stop, delay of food after the act of swallowing. In chest and babyhood the dysphagy is determined by a number of indirect signs and microsymptoms (failure from a breast and periodic vomiting, the child it is long chews food, «chokes», meal is slowed very down). Children often resort to a zapivaniye of food water. Regurgitation quite often leads to aspiration and pulmonary complications (recurrent bronchitis and pneumonia). Hron, disturbance of food results in deficit of weight and lag in physical. development, anemia of an alimentary origin is possible. Complaints to stethalgias or in epigastric area are shown by some patients of school age.
The disease occurs at any age, including and at babies, however the basic group is made by children of preschool and school age. The beginning of a disease usually gradual, the periods of deterioration alternate with «light intervals», but its current with a tendency to stabilization or progressing patol, symptoms is characteristic hron.
Crucial importance in diagnosis has contrast rentgenol, a research of a gullet. At the same time barium or does not come to a stomach at all, filling an expanded gullet, or is squeezed out from it by a narrow stream, and narrowing in cardial department has equal contours. Suddenly, through various time slices, there occurs bystry evacuation of barium from a gullet a wide stream as fall. This phenomenon at children easily is reproduced at a zapivaniye of barium water. At children two types rentgenol, changes are observed. At the first type an esophagectasia moderate (no more than twice), the tone of walls is kept, after swallowing chaotic and brisk reductions of a gullet which as if break against the closed cardia are noted. At the second type the gullet is sharply expanded and atonichen. Among additional researches the ezofagoskopiya is reasonable, at a cut expansion of a gleam to food of sweat with an excess skladchatost comes to light; inflammatory changes of a mucous membrane are not observed. It is characteristic that the tube of the esophagoscope freely passes through the cardia in a stomach.
Differential diagnosis is carried out with inborn and acquired (postburn and peptic) stenoses of distal department of a gullet. These ezofagoskopiya, and also lack of a symptom of fall of a baric suspension at a contrast rentgenol, a research at patients with organic strictures are of great importance.
At children, as well as at adults, for treatment To. apply cardiodilatation and surgical interventions. From the last are most widespread extramucosal cardiomyotomy on Geller or a diafragmokardioplastika on Petrovsky.
Some surgeons give preference to a myotomy in combination with an ezofagokardiofundoplikation, edges can be executed by both transpleural, and abdominal access. After a wide longitudinal extramucosal ezofagokardiomiotomiya the formed muscular defect is closed, hemming a wall of a greater cul-de-sac to edges of defect. Similar reception reduces a possibility of cicatricial wrinkling of the cardia and increases reliability of operation. The short-term and long-term results of operational treatment at children good. As a rule, symptoms of a disease are liquidated, however at sharply expressed atony and dilatation of a gullet the last quite often remains expanded.
See also Gullet .
Bibliography: Berezov Yu. E. and Grigoriev of M. S. Hirurgiya of a gullet, page 56, M., 1965; In and N of c I am E. N. N and d river. Treatment of a cardiospasm cardiodilatation, Surgery, No. 2, page 19, 1974, bibliogr.; Vasilenko V. of X., r e e of N of e in A. L. and Salman M. M. Diseases of a gullet, page 84, M., 1971; Vasilenko V. of X., Suvorova T. A. igrebenev A. L. Akhalaziya of the cardia, M., 1976; In both l yav and N G. D., Solovyov V. I. and Timofeeva T. A. Kardiospazm, M., 1971, bibliogr.; Vorokhobov L. A. both Geraskin V. I. Klinika and treatment of a cardiospasm at children, Surgery, jvft' 6, page 54, 1967, bibliogr.; Geraskin V. I. and Lindenberg L. K. About a pathogeny of a cardiospasm (an achalasia of a gullet) at children, Vopr. okhr. mat. also it is put., t. 12, No. 12, page 48, 1967, bibliogr.; Kagan E. M. Radiodiagnosis of diseases of a gullet, M., 1968; To e in e sh L. E. a X-ray-cinema research of a gullet, M., 1970, bibliogr.; The multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 6, book 2, page 214, M., 1966; Morgenstern A. 3. Achalasia of a gullet, M., 1968, bibliogr.; Petrovsky B. V., To and N sh and N N. N. and Nikolaev N. O. Hirurgiya of a diaphragm, L., 1966, bibliogr.; P and Bq and N And. X., Arablinsky V. M. and Daniyelyan G. A. Rentgenotelevi-zionnaya cinematography of a gullet, M., 1969, bibliogr.; Rusanov A. A. Cancer of a gullet, L., 1974, bibliogr.; Modern methods of researches in gastroenterology, under the editorship of V. of X. Vasilenko, M., 1971; Utkin V. V. Cardiospasm, Riga, 1966; Fedorova O. D. Cardiospasm, M., 1973, bibliogr.; Sh and l and m about in A. A., Saenko V. F. and Shalimov S.A. Surgery of a gullet, page 67, M., 1975, bibliogr.; E f f 1 e of of D. B. and. o. Primary surgical treatment for esophageal achalasia, Surg. Gynec. Obstet., v. 132, p. 1057, 1971; E 1 1 i s F. H. a. o. Esophagomyotomy for esophageal achalasia, Ann. Surg., v. 166, p. 640, 1967; Rossetti M. Osophagocardiomyotomie und Fundoplica-tio, Schweiz, med. Wschr., S. 925, 1963, Bibliogr.; Spiro H. M. Clinical gastroenterology, L., 1970; SteichenP. M, Heller E. Ravitch M. M. Achalasia of the esophagus, Surgery, v. 47, p. 846, 1960; Wenzel K. P. u. S a nide r E. Zur Therapie der Achalasia oesophagi, Zbl. Chir., Bd 95, S. 945, 1970.
B. V. Petrovsky; V. I. Geraskin (it is put. hir.), And. X. Rabkin (rents.).