GULLET

From Big Medical Encyclopedia

GULLET [esophagus (PNA), oesophagus (JNA, BNA)] — a part went. - kish. a path between a throat and a stomach, representing the muscular channel which is beginning at the level of bottom edge of the VI cervical vertebra and coming to an end with transition to a cardial part of a stomach at the level of XI of a chest vertebra.

As the separate body of P. was allocated by doctors of Ancient Greece.

EMBRYOLOGY

Fig. 1. Germ of the person 9 mm long: 1 — a trachea, 2 — a gullet, 3 — a stomach, 4 — a liver, 5 — heart.

The item manages to be distinguished on cuts of a germ of the person 4 — 5 mm long. It represents the short wide tube consisting of two rows of the epithelial cells coming from an entodermalny vystilka of primary intestinal tube. At first the epithelium single-layer prismatic, and then becomes multilayer flat. As a result of registration of a neck at an embryo 10 mm of Item long it is extended, and diameter it relatively decreases (fig. 1). The item on cross section round or oval. With formation of longitudinal folds of a mucous membrane P.'s gleam on a section gets a star-shaped form.

Differentiation of a mesenchyma by surrounding P. leads to emergence of muscular elements in its wall. The embryo 12,5 mm long has a circular muscular layer, and at an embryo 17 mm long — longitudinal is allocated. By the time of the birth P.'s length equals 11 — 16 cm, width of 7 — 8 mm. It is the thin elastic tube flattened in the dorsoventral direction. At the newborn it begins at the level of IV — the V cervical vertebra.

ANATOMY

At the adult P.'s length on average 25 cm. In it distinguish three parts: cervical, chest and belly.

Cervical part P. begins at the level of VII of a cervical vertebra behind a cricoid of a throat and lasts throughout 5 — 6 cm to an upper aperture of a thorax, in front of a backbone and behind a trachea. The fascial leaf shrouds a trachea, a throat, P. and separates these bodies from a prevertebral fascia. On the right and to the left of P. shares of a thyroid gland are located.

Chest part P. 17 — 19 cm long is located in back mediastinum (see) at first between a trachea and a backbone, and then between heart and a chest part of an aorta which pushes aside it a little to the left. The item, adjoining to a back wall of a pericardium, prilezhit to the left auricle. From sides it is influenced by fluctuations of the pleural bags connected to P. a plevropishchevodny muscle. Similar muscle bundles between P. and the left primary bronchus are called a bronchoesophageal muscle. Muscle bundles of a lumbar part of a diaphragm limit an esophageal opening in the form of a loop; at their tension (e.g., at a deep breath) there is almost full occlusion of the Item.

Belly part P. is at the level of XI — the XII chest vertebrae. Its length from a diaphragm to a stomach fluctuates within 2 — 4 cm. P.'s gleam is closed in the place of transition to a cardial part of a stomach and opens only at the movement of food. Throughout P. its diameter changes. In P. there are three narrowings. The first narrowing is caused by a tension of the lower constrictor of a throat and pressure of a cricoid of a throat; the second at the height of IV of a chest vertebra — pressure of an aortic arch which presses it to the left bronchial tube. The third narrowing is located in the field of an esophageal opening of a diaphragm (tsvetn. fig. 1, 2).

Fig. 2. The diagrammatic representation of arteries of chest department of a gullet (the back view is located in the center), according to Fedorov: 1 — the lower thyroid artery, 2 — the right back bronchial branch, 3 — branches to a gullet from bronchial branches of a chest aorta, 4 — an esophageal branch of a chest aorta.

Blood supply The item in a cervical part is provided with the lower thyroid artery, in chest — 4 — the 5th esophageal branches of a chest part of an aorta, in belly — branches of the lower phrenic and left gastric artery (fig. 2). Outflow of blood happens hl. obr. in unpaired and semi-unpaired veins. The main distributor of a venous blood — a submucous plexus.

Limf, the system P. is presented by network limf, capillaries of a submucosa and network of a muscular coat. Longwise going limf, vessels take away a lymph or to gastric limf, nodes, or in the ascending direction to lateral cervical nodes near a throat. In a chest part the lymph from P. flows to tracheobronchial and back mediastinal limf, to nodes.

Fig. 1. Topography of a gullet, its vessels and nerves (anterior aspect). Fig. 2. Diagrammatic representation of cross and longitudinal cuts of a gullet. Fig. 3. Topography of a gullet, its vessels and nerves (back view): 7 — a cervical part of a gullet, 2 — the left recurrent guttural nerve, 3 — a trachea, 4 — tracheal lymph nodes, 5 — the left general carotid artery, 6 — the left vagus nerve, 7 — an aortic arch, 8 — the left pulmonary artery, 9 — the left primary bronchus, 10 — the left pulmonary veins, 11 — a chest aorta, 12 — a chest part of a gullet, 13 — the left sympathetic trunk, 14 — a semi-unpaired vein, 15 — a belly part of a gullet, 16 — a stomach, 17 — a diaphragm, 18 — a back mediastinal lymph node, 19 — the right sympathetic trunk, 20 — a chest channel, 21 — an unpaired vein (it is cut off at the place of falling into an upper vena cava), 22 — an esophageal texture, 23 — the right pulmonary veins, 24 — the lower tracheobronchial lymph nodes, 25 — the right pulmonary artery, 26 — the right vagus nerve, 27 — a brachiocephalic trunk, 28 — the right general carotid artery, 29 — the right recurrent guttural nerve and esophageal branches, 30 — the right internal jugular vein, 31 — an upper vena cava, 32 — heart, 33 — an esophageal branch of a chest aorta, 34 - an esophageal branch of the lower thyroid artery, 35 — the left internal jugular vein, 36 — a muscular coat, 37 — a mucous membrane, 38 — a muscular plate of a mucous membrane, 39 — a submucosa.
Fig. 3. The diagrammatic representation of an arrangement of a gullet in relation to vagus nerves: 1 — an esophageal opening of a diaphragm, 2 — the front wandering vagal trunk, 3 — the lower cervical cordial branch of a vagus nerve, 4 — a bronchial branch of a vagus nerve, 5 — the right subclavial artery, 6 — an upper cervical cordial branch of a vagus nerve, 7 — the right vagus nerve, 8 — the left recurrent guttural nerve, 9 — the left vagus nerve, 10 — an aortic arch, 11 — an esophageal texture of a vagus nerve, 12 — a diaphragm, 13 — a stomach.

Sources innervations The item — vagus nerves (fig. 3) and branches of nodes of a sympathetic trunk. From an adventitious esophageal texture nervous bunches get into deep layers of P. where form intermuscular and submucosal textures. Afferent conductors in a wall P. bulbar (The X couple) and the spinal nature (axons of neurocytes of spinal nodes) come to an end with receptors, especially numerous in a belly part (tsvetn. fig. 1, 3).

HISTOLOGY

P.'s Wall is formed by a mucous membrane, a submucosa, a muscular coat and adventitious (in a belly part — serous). From within P. is covered by a multilayer flat not keratosic epithelium.

P.'s epithelium forms 20 — 25 layers. Closer to a gleam layers of the tearing-away epithelial cells are located. Scaly epithelial cells accumulate on them, and layers of epithelial cells outside adjoin to them, to-rye gradually become scaly. Further from a gleam acanthceous cells and, at last, the basal layer, most remote from a gleam, leaning on a thin basal membrane are localized.

Fig. 4. Microdrug of a wall of a gullet: 1 — a multilayer flat epithelium, 2 — a channel of own gland of a gullet, 3 — own plate of a mucous membrane, 4 — a muscular plate of a mucous membrane, 5 — a submucosa, 6 — own gland of a gullet, 7 — a muscular coat; coloring hematoxylin-eosine; x 200.
Fig. 5. Microdrug of a mucous membrane (with a submucosa) a gullet: 1 — secretory department of gland, 2 — an output channel; coloring by methylene blue.

Knaruzhi from it is own plate of a mucous membrane of P. V to it fibroblasts meet, macrophages, scattered lymphocytes and are very numerous collagenic and elastic fibers (fig. 4). Here the small branched tubular glands producing slime (fig. 5) are localized. Distinguish own glands of a gullet and cardial — on border with a stomach. Submicroscopic folds of own plate of a mucous membrane are implemented into epithelial layers, removing a basal membrane. The thinnest circulatory and limf, capillaries of a mucous membrane are also localized here.

The muscular plate separates a mucous membrane from a friable submucosa. Sliding on it at reduction of smooth muscle cells, the mucous membrane gathers in longitudinal folds therefore on cross section of P. has the star-shaped form (tsvetn. fig. 2, and, b). During the passing of food of a fold finish, P.'s gleam extends.

For active advance of food the muscular coat of a wall of P. consists of two layers: outside longitudinal and internal circular (circular). Their reduction causes P.'s peristaltics, and the wave of reductions follows from a throat to a stomach. Upper 2/3 gullets consist of cross-striped muscles, lower 1/3 — 113 unstriated muscles.

On all length of P. in a submucosa, except vessels and nerves, the set of lymphoid follicles lies. Here trailer departments of microglands of tubular and tubular and alveolar character are found. The extima of P. is constructed of friable connecting fabric in which there are a lot of fibrous structures.

PHYSIOLOGY

Fig. 6. The scheme of change of pressure in various departments of a gullet during the swallowing: 1 — in distal department of a throat, 2 — in a pharyngoesophageal sphincter, 3 — in initial department of a gullet.
Fig. 7. Curve of rate of propagation of primary peristaltic wave of a gullet: on ordinate axis speed, and on abscissa axis — distance from cutters is noted.

The item carries out food from a throat to a stomach, participating in a concluding phase swallowing (see). In sites of transition of a throat to a gullet and a gullet in a stomach there are fiziol, sphincters separating a zone of weak negative pressure in P.'s gleam from a zone of positive pressure in a throat and a stomach. Out of swallowing P.'s sphincters are closed that prevents aspiration of air and getting of a gastric juice into the Item. Circular muscle fibers of the upper sphincter which is located at distance of 15 — 20 cm from cutters are in a condition of tonic contraction thanks to what in a gleam of a sphincter zones of supertension are created (20 cm w.g.). At a proglatyvaniye of food pressure in a zone of an upper sphincter of P. increases during the tenth fractions of a second, then during 1 sec. falls below atmospheric. Pressure in the field of an upper sphincter goes down almost along with build-up of pressure in a throat, created by primary peristaltic wave (fig. 6) extending lengthways according to the Item. The maximal pressure developed by primary peristaltic wave makes 70 — 90 cm w.g. Primary peristaltic wave at the person passes all P. for 8 — 12 sec. As it moves ahead according to P., its speed progressively decreases (fig. 7). Speed of primary peristaltic wave is equal in initial part P. to 50 cm/sec., at distance of 25 — 30 cm from cutters it decreases to 3 cm/sec. and falls to 1 cm/sec. and less in the field of the lower sphincter of P. located in the place of transition of P. to a stomach. At the person who is in vertical position, liquid passes P. for 1 — 2 sec. with a speed exceeding the speed of primary peristaltic wave. It is caused by force developed by reduction of constrictors of a throat and gravity. Having passed through P., the swallowed liquid is late in its lower part before distribution of peristaltic reduction. During a series of bystry deglutitory movements, napr, at reception of a glass of water, liquid passes through the lower sphincter and gets into a stomach in 1 — 2 sec. after the beginning of drink. Except primary peristaltic wave arising in a drink local stretching of a wall of P. food excites secondary peristaltic reductions of smaller amplitude, but also extending according to P. V of the bottom of P. local irregular tertiary reductions are observed. Ability of all parts P. to reduction, irrespective of the act of swallowing, promotes removal of the remains of food from it or foreign bodys. The delay of food excites a series of rhythmic peristaltic reductions in P. The lower sphincter of P. possesses a row fiziol, features. Changes of pressure in connection with peristaltic reductions in upper part P. are less expressed here. The sphincter and other departments of P. react to cholinergic and anticholinergic influences exactly the opposite. The zone of supertension is located 1 — 2 cm above and lower than an opening in a diaphragm. Pressure in this site P. exceeds pressure in a stomach upon 10 — 11 cm w.g. During swallowing high initial pressure in the place of transition of P. to a stomach falls and during 7 — 10 sec. becomes lower than atmospheric. In same it is a high time pressure in site P. located above a sphincter that creates a pressure gradient between the bottom of P. and the place of its transition to a stomach increases. Disclosure of the lower sphincter is carried out reflex under the influence of brake impulses of not adrenergic nature, and the pressure gradient moves a food lump to the area of a sphincter. After this the sphincter is slowly reduced, and pressure in the segment P. lying above a diaphragm exceeds pressure in the subphrenic site that provides emptying of the Item. Function of the lower sphincter is controlled gastrin (see) and secretin (see). Introduction of small doses of gastrin to blood or increase in pH in antral department (a lesser cul-de-sac, T.) a stomach, caused by endogenous intake of gastrin, raises a tone of a sphincter. The injection of secretin or increase in acidity in a duodenum lowers intra sphincteric pressure. In motor function P. the large role is played by the intraparietal neuroplexes supporting a peristaltics of the Item. Reductions of muscles of P. are controlled by the centers of a myelencephalon through vagus nerves. Atsetilkholin (see) and Eserinum (see. Fizostigmin ) strengthen P.'s reductions

METHODS of the RESEARCH

P.'s Auscultation has limited value. At healthy faces during a proglatyvaniye of liquid in the field of a xiphoidal shoot in front or the X—XII chest vertebrae two noise behind are usually listened (see. Deglutitory noise ): one directly after a drink, another — in 7 — 9 sec. after it (the moment of approach of a peristaltic wave to the cardia). Absence or delay of the second noise can be a consequence of an organic or functional esophageal stenosis.

Fig. 8. Roentgenograms: and — a gullet at hard filling with a contrast agent; — drinks and a cervical part of a gullet after reception of a contrast suspension of barium.

In diagnosis of diseases of P. contrast is of great importance X-ray inspection (see). In all cases the contrast research P. is made after preliminary survey raying of a neck, a thorax and an abdominal cavity. Researches P. begin with giving to the patient of a liquid water suspension of barium sulfate. In the beginning during roentgenoscopy or X-ray television raying study features of passing of a contrast suspension on a throat. More or less long delay of a suspension of barium in a drink shall guard the radiologist. If after emptying of a throat to make Valls's test lions (see. Valsalva experience ), the throat enough considerably stretches that allows to judge elasticity of its walls. Then consistently study parts P., paying attention to character of contours and elasticity of walls, examine areas fiziol, narrowings. Researches carry out at various turns of the patient (fig. 8, a).

Having studied features of passing of a liquid suspension of barium, start detailed examining of walls of P. by means of a double contrast study. For receiving «pneumorelief» to the patient suggest to gulp a liquid suspension of barium quickly. On roentgenograms it is possible to see a konturiro-bathing inner surface of walls of P. filled with air. After that start a research P. by means of a dense baric suspension. At the same time the patient is turned around a vertical axis for the purpose of a review of all walls of the Item. If necessary to achieve the slowed-down passing of a contrast agent according to P. of the patient investigate in horizontal position or in situation with the raised basin.

Fig. 9. Roentgenogram of a gullet: thin longitudinal folds of a mucous membrane are visible.

Important ethane of a research P. is studying of a relief of a mucous membrane. In normal conditions it consists of 2 — 4 longitudinal folds (fig. 9) parallel each other. It is recommended to make a X-ray analysis of a relief of a mucous membrane in position of the patient lying on one side, most often in one of slanting provisions. All phases of a research fix on roentgenograms. The Smeshchayemost, a peristaltics and sokratitelny ability of walls of P. are documented by means of a video, X-ray television (see. Television in medicine ), rentgenokimografiya (see), polygraphies (see), X-ray cinematographies (see).

To judge whether sprouted a tumor in cellulose of a mediastinum and in the next bodies, and also for the purpose of differential diagnosis of a tumor of P. and vkepishchevodny educations apply mediastipografiya (see). P.'s pneumorelief can be studied on a pariyetogramma (see. Pariyetografiya ), on which wall thickness P.

Protivopokazany to a contrast rentgenol is visible, to a research P. is almost not present, even at the general serious condition of patients. At suspicion on perforation or a rupture of a wall of P. it is necessary to use water-soluble contrast mediums (like Gastrografinum, Urografinum, ve ro a decanter, etc.).

At a research of the patient in vertical position with the posteroanterior direction of a bunch of x-ray emission P.'s beginning is projected at the level of Cv. Here and below P. holds almost median position, being slightly bent at the level of Thni_lV to the left and to the right aortic arches (ThVl_VlI) are lower. At the level of Thx P. passes through a diaphragm and comes to an end at the level of Thxl.Tolko the distal piece of P. sharply is turned to the left.

In process of rotation of the patient around a long axis P. comes out of the shadow of heart, large vessels and a breast and its considerable part is located in light space between a shadow of a backbone and a shadow of heart and large vessels. In such provisions well come to light not only fiziol, narrowings and expansions, but also various options of an arrangement.

Position of a body of the patient, functional and anatomic features of separate bodies of chest and belly cavities, and also various phases of breath and swallowing can significantly affect a form and all P.'s position or its separate parts.

At roentgenoscopies Items study a pharyngeal segment (a guttural part of a throat) and segments actually of a gullet: tracheal, aortal, mezhaortobronkhialny, bronchial, subbronchial, retropericardiac, epiphrenic, intra phrenic and belly.

In a pharyngeal segment (see. Throat ) the small epiglottidean deepenings symmetrized between a root of language and a back surface of an epiglottis, divided among themselves median, lingual nadgortannikovoy by a fold, and considerably big sizes the pear-shaped pockets located below on front side surfaces of a cavity of a guttural part of a throat both as if the cartilages which are symmetrically bordering arytenoid and cricoid forming the general for a throat and a guttural part of a throat a wall come to light. Pear-shaped pockets, connecting below, below a plate of a cricoid pass into an entrance to P. (fig. 8, b). By consideration in front the column of barium has the form of a spindle with absolutely equal contours, most the venter of which corresponds to pear-shaped pockets. Sometimes in the center of this expansion the enlightenment caused by pressure of the throat raised up appears. By consideration sideways the column has the form of a funnel with the smooth, but wavy contour of a back wall repeating a form of deepenings of bodies of vertebrae and ledges of intervertebral disks. In some cases to specify localization of an entrance to P. can be difficult. On a front contour of a column of barium at the level of Cv small semi-oval impression of a cricoid often is found.

In a phase of the subsequent emptying a guttural part of a throat falls and filled with air (thus, the double contrast study — on walls of a throat a thin coat of the accumulated barium, in a gleam of a throat — air is created). By consideration are in front visible: the poles of an epiglottis, pear-shaped pockets, folds of a mucous membrane going obliquely from pear-shaped sine and connecting at an entrance to the Item. Side contours at the level of poles of an epiglottis often have impression from adjacent big horns of a hypoglossal bone. The upper edge of an epiglottis in the form of the umbrella hanging over an epiglottis is sometimes visible. By consideration are sideways visible: the root of language, poles of an epiglottis squeezed in front by a body of a hypoglossal bone and covered behind with an epiglottis pear-shaped pockets and at the C6 level an entrance in P. Posledny is determined by the impression of a back wall caused by a pharyngoesophageal sphincter.

The tracheal segment P. having length apprx. 8 cm begins at the level of a cricoid and comes to an end at the upper edge of an aortic arch.

Length of an aortal segment P. apprx. 2,5 cm according to diameter of an aortic arch. Its left wall, and also pe re day the left and left contours have impressions (aortal impression) as a result of a prileganiye of an aortic arch.

The Mezhaortobronkhialny segment P. is located between bottom edge of an aortic arch and verkhnenaruzhny edge of the left bronchial tube.

The bronchial segment P. is located at the level of bifurcation of a trachea. On its front and perednelevy walls there is an impression caused by a prileganiye of the basis of the left bronchial tube.

The subbronchial segment P. is located length apprx. 5 cm between the level of bifurcation of a trachea and the upper edge of an auricle.

The retropericardiac segment P. in front adjoins to heart, above — to a back surface of the left auricle, below — to a back surface of a left ventricle. The back wall of a segment adjoins and crosses a front surface of the descending part of an aorta.

The epiphrenic segment P. is rejected by length apprx. 3 — 4 cm kpered and to the left. During the passing of a contrast suspension in a phase of a deep breath or at Valsalva's test the segment often extends, getting a form of a pear and forming a so-called ampoule of the Item.

The intra phrenic segment P. passes obliquely in a fibrous ring of a diaphragm where it is quite well displaced. It comes to light in a phase of reduction of a diaphragm, at the same time there are visible thin parallel folds of a mucous membrane.

The belly segment P. has length on average of 3 cm. It is inclined forward and to the left and falls slightly closer than a kpereda into the right wall of an upper pole of a stomach. Thus, the segment includes also a cardial part (cardia) of a stomach. The left wall of a segment forms an angular excess whereas right smoothly passes into the area of small curvature of a stomach with a bottom (arch) of a stomach. Radiodiagnosis of diseases of P. is based on identification of changes of its situation, form, the sizes, fillings, character of folds of a mucous membrane, detection on contours of roughnesses, retractions, protrusions, niches, defect of filling, changes of a tone, a rhythm and depth of peristaltic reductions, and also on assessment of a condition of bodies and fabrics, adjacent to P. The task rentgenol, researches includes identification of signs patol, P.'s conditions on the basis of studying of anatomic and its functional features.

Age changes Items are characterized by some of its lengthening which was more expressed by pressure of adjacent bodies of a thorax, repetition of the curvatures of a kifosko-liotichesky backbone, emergence connected with these factors of shift and crimpiness P. and, at last, decrease in elasticity and a tone of its walls.

In P. at elderly and old people of a fold of a mucous membrane or do not come to light at all, or they are thickened and are visible only on certain sites. Sometimes as a result of spiral turn P. of a fold of front and back walls as if cross.

Fig. 10. Roentgenograms of a gullet at cancer: and — the narrowed neperistal-tiruyushchy site with uneven contours is visible; — contours of a gullet uneven with multiple regional defects and nishepodobny ledges (ulceration).

Rentgenol, a picture at P.'s cancer is various and depends on situation, a form, the sizes, the nature of growth of a tumor, a stage of development of process and other factors. More or less constant symptoms of cancer of P. are lack of a vermicular movement of a wall of P. on site arrangements of a tumor, defect of filling or roughness of a contour, destruction of a normal relief of a mucous membrane, a shadow of the tumor. In the expressed cases it is always possible to find at least three of the listed symptoms of a malignant tumor of P. and among them the site of loss of a vermicular movement (fig. 10, a).

Fig. 11. The roentgenogram of a cervical part of a gullet at endophytic cancer: the defect of filling formed by a tumor (it is specified by shooters).

Sometimes blastomatous infiltration of a wall is shown only by straightening and loss of elasticity of a contour in the place of tumoral growth that is well noticeable during the passing of a big lump of a dense baric suspension. Sometimes cancer infiltration causes only a nek-ry illegibility or a roughness of a contour. With an endoluminal growth of a tumor defect of filling (fig. 11) appears. The Intuition the small defect of filling which is located on one of walls of P. is possible only at a multiaxial research with hard filling of the Item. At the tumors acting in a gleam as P. massive much and at the corresponding technique of a research defect of filling can be visible also on an opposite wall. Polyrecurrence of a contour is characteristic of the cancer tumor growing at several nodes.

At considerable damage of a mucous membrane rentgenol, the picture is characterized by shapeless accumulations of a baric suspension of various size in ulcerated sites and zones of an enlightenment on site of protrusion of a tumor in P.'s gleam (fig. 10, b). When P.'s tumor extends under a mucous membrane and does not break its inner surface but only smoothes folds, the early diagnosis of cancer can be made only at the account funkts, changes, i.e. on lack of a vermicular movement.

At perforation of a tumor in a trachea or a bronchial tube the contrast suspension is late in the field of a tumor, and then gets into underlying department of P. Odnovremenno from one of walls of P. the baric strip separates. If fistula is rather wide, then a lot of baric suspension gets into a trachea or bronchial tubes. At perforation in a mediastinum near a gullet shapeless accumulations of barium are found.

Rentgenol. the research has special value after operation on P. Tolko with his help it is possible to establish existence of new anatomic relationship and functional features, to reveal complications, and also to objectively estimate efficiency of surgical intervention. Not less important rentgenol, a research P. for assessment of results of beam and drug treatment of malignant tumors of this body.

Fig. 12. Roentgenograms of a gullet: and — with an intraparietal tumor (leiomyoma); accurately outlined semi-oval defect of filling (it is specified by an arrow) is formed by a tumor; — with a cicatricial esophageal stenosis on a big extent; above narrowing the gullet is expanded.

Benign tumors, intraparietal (a leiomyoma, fibroma, etc.), form sharply outlined defect of filling; at the level of a tumor P.'s gleam sometimes is as if displaced aside, sometimes in certain projections is expanded (fig. 12, a). The corner between the lower regional site of a tumor and the next normal wall of P. can come nearer to acute (a symptom of «visor»). Folds of a mucous membrane can come to light only on P.'s wall, a protivoleyachashchy tumor. Against the background of a mediastinum the semi-oval shadow forming together with defect as if a flattened sphere often is found. In cases when the tumor of a dolchat and its nodes are located at the different levels, the contrast suspension filling a depression in the ground between separate protrusions in P.'s gleam creates a picture of decussation of contours. Seldom Suprastenotichesky expansion is found. Very important sign is the configuration of a wall of P. changing at peristaltic reductions in the field of an arrangement of a tumor. The picture identical to a benign intraparietal solitary tumor, the intraparietal cyst creates.

The endoluminal benign tumor (polyp) forms single (tsvetn. fig. 13), is more rare the multiple defects of filling of different size with accurate smooth contours which as if are flowed round by a contrast suspension and displaced together with a wall of the Item. At an ulceration of a tumor against the background of defect the resistant depot of barium appears. Sometimes the polyp has a long leg and is thrown in a throat or gets through the cardia into a stomach. In this case during the research the iyepeme-shcheniye of defect of filling is visible. The peristaltics of a wall of P. in the location of the basis of a polyp is kept.

The cicatricial stenosis of P. after burns differs in symmetric narrowing of its gleam and rather equal or wavy contours of the narrowed site with moderate suprastenotichesky expansion (fig. 12, b).

Fig. 13. The roentgenogram of a gullet at dysfunction: the deep not peristaltic reductions giving to a gullet a shtoporoobrazny look.

Neurogenic frustration of P. are characterized by the alternating narrowings of a gleam usually at the certain level (a regional spasm, a cardiospasm, etc.) or the diffusion narrowings giving P. a type of a saw, beads or a corkscrew (fig. 13). Along with this picture can be observed Skhmeshchayushchiyeey but to P.'s longitudinal axis of narrowing, combined with expansion of its gleam (dystonia, achalasias, etc.). Neurogenic frustration can accompany quite often many organic processes (tumors, diverticulums, cicatricial changes, an ulcer etc.).

Inflammatory processes in P.'s wall have various rentgenol. picture. At an esophagitis the usual folded structure of P. is broken, changes longitudinal napr an avlennost of folds. Folds can be refined or thickened, quite often completely disappear. The mucosal surface of a cover acquires the «shagreen» drawing. At localization inflame telny process in a submucosa of P. the surface layer of a mucous membrane is displaced, simulating intraparietal education. The peristaltics is usually kept.

Fig. 14. Roentgenograms of a gullet: and — the diverticulum with a wide neck is visible at the left; — the multiple oblong defects formed by varicose veins.

P.'s diverticulums on the roentgenogram represent local protrusions of its wall (fig. 14, a). They can have various form and the sizes. Small diverticulums are capable to be emptied during the passing of a peristaltic wave. Diverticulums of the considerable sizes independently are not emptied (their walls do not peristaltirut). The inflammation of a diverticulum is followed by a long delay in it a contrast agent, emergence of roughness of a contour.

At a round ulcer of P. on its contour or a relief the niche, sometimes an inflammatory shaft and seldom radiarny convergence of folds of a mucous membrane is visible (see. Peptic ulcer ). Detection of an ulcer requires detailed multiaxial studying of all walls of P. at all levels.

Varicose veins of P. are shown in the form of speakers in a gleam of the multiple accurately outlined roundish and oval enlightenments of 1 in size — 2 cm (fig. 14, b). Sometimes the same changes are found also in a cardial segment of a stomach.

Rentgenol, a picture of syphilis of P. has no idiosyncrasies and is shown by defect of filling in the location of a gumma with formation of depot of barium at its ulceration or rigid circular narrowing at the stenosing form.

At an ulcer form of tuberculosis of P. on a relief of a mucous membrane accumulations of a contrast agent of irregular shape appear. The stenosing form leads to P.'s narrowing various degree.

Fungal infections of P. (most often Candidiasis) in the expressed stage lead to its narrowing on a big extent, usually in distal department, with loss of elasticity of a wall.

In time ezofagoskopiya (see) according to indications (generally at suspicion of a malignant tumor) carry out aim biopsy (see) from the suspicious site of a mucous membrane of P. by means of special nippers. Usually for a research take several pieces of fabric from different sites, to-rye then subject gistol, to a research.

Cytologic research (see) often apply to diagnosis of tumoral and inflammatory diseases P. Material for this research can be received in various ways: by method of washout (exfoliative cytodetection), scraping (abrasive method, etc.). In the first case conduct a research of a deposit or tsentrifugat of rinsing waters P., to-rye easier to receive in the presence of P.'s narrowing or preliminary obturation of its distal piece the inflated rubber barrel. At an abrasive method use a rubber bulb with a rough surface which after introduction to P. is filled with air and way of rotary motions do scraping of slime. Materials for tsitol, researches it is also possible to receive, wiping with a cotton plug a mucous membrane during an ezofagoskopiya. At tsitol, a research, in addition to leukocytes, bacteria, cells of an epithelium it is possible to find cancer (atypical) cells. However tsitol, diagnosis of cancer of P. is possible only in the presence in several drugs of a complex of atypical cells. Gistol. and tsitol, researches, mutually supplementing each other, allow to make the diagnosis of organic lesion of a mucous membrane of the Item with the maximum accuracy. For differential diagnosis of malignant and high-quality (cicatricial and inflammatory) narrowings of P. conduct a radio isotope research using 32P which is entered intravenously at the rate of 1 mkkyur on 1 kg of weight of the patient and the subsequent determination of level of radioactivity into P. by means of the flexible intracavitary probe («counter») connected to the data-acquisition equipment (see. Radio isotope diagnosis ). In the presence of malignant process percent of accumulation 32 P in a zone of defeat in comparison with healthy sites reaches 140 — 400% and considerably does not decrease in the 24 and 48 hour. At inflammatory processes accumulation of radioactive phosphorus in a zone of defeat happens quickly, but further its contents sharply falls.

The important place in diagnosis of functional and some organic diseases of P. occupies a method of graphic record of reductions and a tone of its walls and sphincters — ezofagotonografiya (see).

P.'s rn-Metriya is applied for definition of intensity of a gastrofood reflux. It will be out by means of the ordinary pH-metric probe or a radiopill (see. Stomach, methods of a research ; Endoradiozondirovaniye ). It is reasonable to use the probe not less than with two rn-metric sensors: distal have in a body of a stomach, proximal — in P., directly over the cardia; in the presence of the probe with additional sensors register pH in P. at several levels. The research is conducted on an empty stomach, in the beginning in position of the patient lying on spin, and then in a sitting position. At healthy people in P. the neutral or alkalescent environment is defined. At a gastroesophagal reflux there is a falloff of pH that on a rn-metric curve decides in the form of so-called waves of acidulation on gradual recovery in P. of the initial pH level. Use of the probe with 3 — 4 sensors allows, in addition to frequency and amplitude of waves, to define on what distance there is a pelting of a gastric juice in P., i.e. intensity of a reflux.

At a research of patients with P.'s diseases use also pharmakodiagnostichesky methods. Most often carry out test with nitroglycerine for differential diagnosis of organic and functional narrowings of P. V the first - a case after reception of 1 — 2 Tabulettaes Nitroglycerini the effect is absent, in the second case spastic esophageal pains disappear, passing of the contents which accumulated in P. over the place of narrowing to a stomach is facilitated; on an ezofagotonoki-mogramma register decrease in a tone of a sphincter of the cardia. Apply also other pharmakodiagnostichesky tests (about acetyl sincaline, karbokho-liny, introduction to P. divorced «salt to - you and so forth).

PATHOLOGICAL ANATOMY

the Dystrophic changes which are found in P. it is extremely rare, can be shown by the amyloidosis of walls of vessels isolated by a melanosis and focal calcification of a mucous membrane.

Necrotic changes in P. are connected with exogenous, more rare endogenous action of chemical agents (see. Necrosis ), arising at vomitings, in the agonal period or after death as a result of influence salt to - you a gastric juice. The necrosis of an endogenous origin is more often localized in belly part P. At postmortem changes of a wall of P. gain dirty-brown color. At distribution of a necrosis on muscular layers perforation of a wall of the Item is possible. At penetration of gastric contents into cellulose of a mediastinum it gets a brownish shade that is observed usually posthumously. About прижизненное™ process the infiltration by neutrophilic leukocytes defined in several hours after influence speaks.

Fig. 15. Makroprenarata of a gullet: and — with an acute ulcer esophagitis after a burn hydrochloric acid; superficial acute ulcers (1) and hemorrhages (2); — the changed chest part resected cicatricial; over a stricture the foreign body (1) below which the opening (2) formed as a result of perforation of a wall of a gullet by fragment of the tool for bougieurage (string) in attempt to take a foreign body is visible is located; in — with the rupture of a wall which arose on third day after extraction of a bone; in a cervical part of a gullet — grazes of a mucous membrane and perforation of a wall (1); in a chest part — the intraparietal false course (2) formed during the carrying out the tool; in the bottom of a gullet, in a zone of an arrangement of the probe, decubituses with an ulceration of a mucous membrane (); — with a chronic ulcer esophagitis in the cicatricial changed gullet in 2,5 years after a burn; hems (1) and ulcers (2) of a mucous membrane, a surface of a stricture it is ulcerated (3).
Fig. 16. Microdrug of a wall of a gullet in a day after a burn sulphuric acid: a necrosis of a cover epithelium in the form of a scab (1) and a sharp plethora of vessels of a submucosal layer (2); coloring hematoxylin-eosine; h140.

Character and depth of a necrosis of the exogenous nature depend on the acting agent. Acids lead to dehydration of fabrics, alkali — to their saponification and hypostasis facilitating penetration of poison deep into. The burn acetic essence gives to a necrosis a white shade, a burn salt to - that leads to an escharosis of grayish-brown color (fig. 15, a), a chamois to - that is to an escharosis of yellow coloring. Alkali burns give to fabrics a dirty-brown shade. In an acute stage of a necrosis contours of an epithelial cover microscopically remain, blood clots and a plethora in vessels of a submucosal layer (fig. 16) are found.

The arterial hyperemia observed often at an acute esophagitis comes to light overflow by blood and thrombosis of vessels. The venous hyperemia of P. meets at hron, a pulmonary heart. The mucous membrane gets a cyanotic shade, appear through the veins filled with blood it.

At portal hypertensia the varicosity of a belly part and lower half of the Item develops. Protrusion of expanded veins in P.'s gleam leads to formation of an erosion of a mucous membrane and defects of a wall of a vein which consequence bleedings are.

Hemorrhages on a mucous membrane of P. arise at an acute esophagitis, hemorrhagic diathesis, a violent pemfingoid, medicinal defeats, but are more often observed at defeats of a wall by the tool or a foreign body (fig. 15, and 15, c) and less often at the closed injury of a breast.

The inflammation in P. can be acute and chronic, have focal or diffusion character (see. Esophagitis ). The specific inflammation in P. meets seldom. At an acute inflammation, a cut maybe manifestation of allergic reaction to medicines, observes a hyperemia of a mucous membrane, excess amount of slime on its surfaces and hypostasis of a wall. At allergic defeats the vasculitis and a fibrinoid necrosis of walls of arteries can be found.

Fig. 19. Macrodrug of a gullet with a varicosity at cirrhosis (the gleam of a gullet is opened): arrosions of expanded veins (are specified by shooters) a mucous membrane in the field of the lower third of a gullet. Fig. 20. Microdrug of a wall of the cicatricial changed gullet in a zone of the false course formed owing to damage by the tool: along the false course (1) extensive hemorrhages (2); coloring hematoxylin-eosine; X 108.
Fig. 17. Microdrug of a wall of a gullet for the third day after perforation by a foreign body: ulceration of a mucous membrane (1) and diffusion treatment of a wall purulent exudate (2); coloring hematoxylin-eosine; X 56.
Fig. 18. Microdrugs of a gullet: and — with a chronic esophagitis; diffusion infiltration of a mucous membrane and submucosa limfoplazmotsitarny cells; coloring hematoxylin-eosine; x 108; — with a kandidamikozny esophagitis; a mycelium (are specified by shooters) among the necrotic masses located on a surface of ulcers of a mucous membrane; CHIC reaction; x 120.

Microscopically the catarrh comes to light. In an epithelium of a mucous membrane activity of an alkaline phosphatase increases, in glands there are the raised products of slime, in a submucosal layer moderate leukocytic infiltration is defined. P.'s injuries usually come to an end phlegmon (see), the wall which is followed by hypostasis, formation of ulcers and the false courses of different length. Microscopically in 6 hours after an injury comes to light diffusion (fig. 17) or a focal purulent inflammation (tsvetn. fig. 20) and formation abscesses (see). Hron, an inflammation in P. is shown various size by ulcers or hems on site of their healing, a thickening of a wall at the expense of hems (fig. 15, d). Microscopically the expressed limfoplazmokletochny infiltration in day of ulcers and a submucosa with formation of lymphoma, reorganization of walls of vessels and their scarring is found (fig. 18, a). Obturation of a gleam of output channels of glands leads to formation of cysts. At the long course of process there comes reorganization of an epithelium of a mucous membrane as a leukoplakia (tsvetn. fig. 12).

The candidiasis occurs at the weakened patients and children of early age in P. (see. Candidiasis ). On a mucous membrane there are small or merging whitish spots eminating over a surface. The ulceration of a mucous membrane comes early, and in a zone of deep necroses dog-vdodifteritichesky plaques among which the mycelium giving PAZ-positive reaction is found are located (fig. 18, b). At the South American zymonematosis there are pustuloobrazny rashes on a mucous membrane and small abscesses in P. Mikroskopicheski's wall meet the centers of a caseous necrosis surrounded with shaft of polymorphonuclear leukocytes and colossal cells of foreign bodys. Differential value is gained by positive CHIC reaction (see).

P.'s actinomycosis meets extremely seldom, process usually extends from an oral cavity. Macroscopically among the hems extending to surrounding cellulose of a neck and a mediastinum abscesses and the fistular courses in the next bodies are located. Microscopically the actinomycosis is confirmed by detection of druses.

P.'s tuberculosis is rare, is observed at generalization of process. Develops in an upper half of P. in the form of ulcers, sclerous forms or tuberculomas. Ulcers meet more often, happen flat to uneven raised edges. At a sclerous form P.'s wall is thickened, condensed that can lead to a stenosis of a gleam. P.'s tuberculomas are located in surface layers of a wall, have a dryish cut surface and yellowish color. The microscopic picture of tuberculosis is typical.

In P. the syphilomas which are located more often in the area fiziol, narrowings and passing to P.'s wall from other bodies meet. Retractions in the center of gummas lead to formation of ulcers of different depth and formation of esophageal and tracheal fistulas. Gistol, changes are specific for syphilis (see).

At hron, disease of Shagas, a trypanosomiasis sharp expansion of a gleam of P. owing to a productive miositis with a necrotic vasculitis and death of nerve knots of a wall can develop, the hypertrophy of muscle fibers develops less often. Trypanosomes in muscles are found with great difficulty. At the general trichinosis in P.'s wall trichinellas can be found. To an inner surface of an upper half of P. suction of bloodsuckers is possible. Carry herpetic pustular rashes on his mucous membrane to rare defeats of P., to-rye can become gate of consecutive infection.

Fig. 19. Macrodrug of a gullet at atonic expansion: a hypertrophy of a wall (it is specified by an arrow).
Fig. 20. Microdrug of a gullet at an atony: a hypertrophy (1) and an atrophy (2) muscle fibers of a wall, hypostasis and inflammatory infiltrates in it; coloring hematoxylin-eosine; X 108.

The atony of walls of P. usually has the neurogenic nature, but can develop also at prolonged use of massive doses of cholinolytic drugs. At the same time sharp increase in the sizes P. without signs of a stenosis of a gleam and acquisition of a funneled form (fig. 19) by it is characteristic. Most often expansion of a gleam is found in a chest part. Microscopically the hypertrophy of muscle fibers with the subsequent their atrophy (fig. 20) and dystrophic changes in ganglionic cells of neuroplexes comes to light. At long stagnation in traction and pulsion diverticulums (see) there is a diverticulitis which sometimes is coming to an end with perforation of a wall of the Item. Wall thickness of diverticulums is various and is defined by availability of muscle fibers in it. On an inner surface of a diverticulum it is long ulcerations and a papillomatosis remain. Pharyngoesophageal diverticulums of a back wall call tsenkerovsky. They are located in a zone of poorly developed layer of muscles of a throat and P. and can reach the big sizes, squeezing P.'s gleam outside.

Fig. 21. Macrodrug of a belly part of a gullet: moderate narrowing of a gleam (it is specified by shooters) with an ulceration of a mucous membrane in the outcome a reflux esophagitis.

Round ulcers of P. meet usually in belly part P. (fig. 21), in overlying parts they are found seldom. Round ulcers (see) happen superficial, have smooth edges and an equal bottom, but can lead to a stenosis of a gleam, perforation of a wall or development of a tumor. Histologically find an ulceration of a mucous membrane in their zone, and sometimes a heterotopic arrangement of gastric glands. At the scanning microscopy find microvillis and yamkopodobny structures of gastric glands in a zone of a heterotopy.

PATHOLOGY

functional diseases Most often meet (an atony, an esophagism inflammatory defeats (see. Esophagitis ), round ulcers, cancer of a gullet, cardiospasm (see), etc.

Among numerous malformations of P. at children the greatest value inborn impassability (atresia), esophageal and tracheal fistulas and various stenoses have Malformations.

The atresia of a gullet occurs at one newborn from 3000 been born (G. A. Bairov, 1968).

Fig. 22. Diagrammatic representation of some types of an atresia of a gullet: and — total absence of a gullet (connective tissue tyazh it is specified by an arrow); — the gullet forms two isolated cul-de-sacs (are specified by figures 1 and 2), in — the upper segment of a gullet (1) terminates blindly, the lower segment (2) is connected to a trachea (higher than bifurcation) the fistular course; — the upper segment of a gullet (1) terminates blindly, lower (2) is connected by the fistular course to bifurcation of a trachea; d — the upper segment of a gullet (1) is connected to a trachea the fistular course, the lower segment (2) terminates blindly; e — top and bottom segments of a gullet (1, 2) are connected to a trachea the fistular courses.

Formation of 6 main types of inborn impassability of this body (fig. 22) is possible.

The first earliest and constant symptom of an atresia of P. is a large number of foamy allocations from a mouth and a nose. After suction of slime the last continues to collect quickly. By the end of the first days of life disturbance of breath is noted.

Fig. 23. Roentgenograms of the contrasted gullet in perednezadny and side (6) projections: a contrast agent fills an expanded upper blind segment of a gullet (it is specified by shooters).

At the first feeding P.'s impassability is confirmed by the fact that all drunk liquid pours out back at once, there is a fit of coughing with sharp disturbance of breath. Rentgenol, contrast inspection of children with suspicion on P.'s atresia with exhaustive reliability confirms the diagnosis (fig. 23, and, b). Pictures make in vertical position of the child then a contrast agent is carefully sucked away. In the analysis kliniko-rentgenol, given to estimate important attentively a condition of lungs. Treatment of atresias of P. operational.

Preoperative preparation is carried out from the moment of establishment of the diagnosis in a maternity home. Intensity and duration of preoperative preparation at P.'s atresia depend on terms of receipt in a hospital, time which passed from the moment of the birth, and expressiveness of the aspiration pneumonia which is the most frequent complication of an atresia of the Item. At early receipt preoperative preparation consists in careful aspiration of slime from P., an oral cavity and a nose; at later receipt along with the above-stated actions symptomatic therapy and the intensive treatment of aspiration pneumonia including bronchoscopic sanitation of a tracheobronchial tree is carried out.

An operative measure is carried out under an inhalation anesthesia (see. the Anaesthesia, in children's surgery ). For operation use an extra-pleura of l ny access which considerably facilitates a current of the postoperative period. Operation of the choice at P.'s atresia should be considered creation of a direct anastomosis. However the last is possible only when diastases between segments P. does not exceed 2 — 2,5 cm. If during thoracotomies it is found considerable diastases between segments or a narrow lower segment (less than 0,5 cm), then make the first part of two-stage correction.

Fig. 24. Technique of creation of an anasyumoz end sideways: and — the lower segment of a gullet a back surface is hemmed by a continuous silk suture (through muscular layers) to an upper segment, the first row of a lip of an anastomosis is formed; — both segments are opened parallel to the line of seams, formation of the second row of regional silk seams of a back lip of an anastomosis is begun; in — from an upper segment in lower the thin polyethylene tube (it is shown by a dotted line) is carried out, formation of the first row of seams of a front lip of an anastomosis is begun; — strengthening of an anastomosis the second row of a continuous suture.
Fig. 25. Formation of an anastomosis of a gullet stapler: and — a habit view of the device (1 — a persistent head, 2 — the case, 3 — the fixer, 4 — a core, 5 — a safety lock); — introduction of the device to an upper segment of a gullet; in — the persistent head of the device screwed on a core is shipped in the lower segment, around it will tighten a blanket seam, thread is dissected away (it is specified by an arrow); — segments of a gullet are tightened before contact; d, e — the gullet is sewed, created a gleam of an anastomosis, the device is taken.

After mobilization of pieces of P. they are brought up to each other for threads handles. If their ends freely approach (that is possible at being available to a diastase to 2 — 2,5 cm), then start a neostomy. Due to the variety of anatomic options at an atresia apply a slanting anastomosis on type the end in the end or use the simplest anastomosis the end sideways (fig. 24), or apply a mechanical seam of pieces of P. (fig. 25) the special device.

Two-stage operation at P.'s atresia is made at impossibility of a neostomy.

Fig. 26. The diagrammatic representation of operation of removal of an upper segment of a gullet on a neck: and — the blind end of a gullet (it is specified by an arrow) is removed in a wound; the dotted line designated the line of cutting off of a gullet; at the upper left the black line showed the place of a section of soft tissues of a neck; — the type of an educated ezofagostoma, a gullet is partially hemmed to edges of a wound.

At double esophagostomy across Bairov allocate an upper segment on perhaps bigger extent, tie up the lower segment at a trachea, cross between two ligatures and carefully allocate to a diaphragm. Expand with a stupid way an esophageal opening and cut a leaf of a peritoneum around cardial department. Make a verkhnesredinny laparotomy and a distal segment reduce in an abdominal cavity. To the left of the centerline make cross section (1 cm) through all layers of an abdominal wall where remove mobilized to P. Stenk it from within fix several seams to a peritoneum, outside hem to skin. Through the removed P. insert a spaghetti into a stomach, to-ruyu fix the silk thread tied around the acting part P. Wounds sew up tightly. Then make upper esophagostomy (fig. 26).

Postoperative maintaining patients shall be directed to the prevention and treatment of possible atelectases and aspiration pneumonia. Feeding of the child is carried out through the tubule which is carried out during operation to a stomach. Deficit of liquid and food ingredients compensate parenterally.

The heaviest complication of the postoperative period should be considered insolvency of seams of an anastomosis and a rekanalization of tracheosesophageal fistula. Treatment is carried out by creation of a gastrostomy (see. Gastrostomy ). At increase of the phenomena mediastinitis (see) drainage of a mediastinum is shown (see. Aspiration drainage ). Postoperative maintaining the child, to Krom the first part of two-stage plastics of P. is made, has differences due to the need of food through ezofagosty. From the 10th day after operation the stomach increases so that through ezofagosty it is possible to enter slowly breast milk in dosages, normal on volume. Write out children from a hospital after the resistant increase of body weight is established. The second stage of operation — artificial P.'s creation (see. the Gullet artificial, at children ) — make at the age of 1 — 2 years.

Inborn esophageal and tracheal fistula. Existence of an inborn anastomosis between P. and a trachea without other anomalies of these bodies meets rather seldom. At the same time the fistular course can be narrow and long, short and wide; the gullet and a trachea have the general wall.

Fig. 27. The diagrammatic representation of esophageal and tracheal fistulas (across Bairov and Trofimova): and — the fistular course narrow and long; — the fistular course short and wide; in — the gullet and a trachea have one general wall.

The wedge, symptoms are shown after the first feedings, but their intensity depends on option of a malformation. The narrow and long fistular course (fig. 27, a) can not come to light in the period of a neonatality because such children during the feeding occasionally have weak fits of coughing. In cases of wide and short fistula (fig. 27, 6) feeding of the newborn is followed by a fit of coughing, cyanosis, foamy allocations from a mouth, development of aspiration pneumonia. The big anastomosis (fig. 28, c) is shown at the first feeding. Each drink of liquid causes a fit of coughing. Disturbance of breath happens long, is followed by sharp cyanosis.

Rentgenol, a research is not of great importance for diagnosis. Existence of esophageal and tracheal fistula can be revealed at ezofagoskopiya (see). More clearly the fistular course is defined at a trakheobronkhoskopiya (see. Bronkhoskopiya ).

Treatment only operational. Preoperative preparation begin right after identification a wedge, symptoms of esophageal and tracheal fistula. Its duration is defined by signs of elimination or noticeable reduction of the phenomena of pneumonia.

Access extrapleural on the fourth intercostal at an interval on the right. Items will mobilize throughout 1 — 1,5 cm up and from top to bottom from the place of its message with a trachea. In the presence of the long fistular course it is allocated, tied up and crossed. At a wide and short fistula of P. cut scissors og tracheas, and formed in these bodies of an opening close a two-row continuous suture. It is the most difficult to liquidate esophageal and tracheal fistula, at Krom both bodies on nek-rum an extent have the general wall. In such cases of P. cross in two places at the level of connection with a trachea. The opening formed in a trachea is taken in, then recover P.'s continuity by a neostomy the end in the end.

In the postoperative period continue treatment of pneumonia. The first 10 — 12 hours carry out parenteral food, then carry out feeding through the stylet left during operation. The patient is written out home after elimination of the phenomena of pneumonia and at establishment of a resistant increase: weight.

Fig. 28. Diagrammatic representation of an inborn esophageal stenosis; and — the circular form which developed due to inclusion in a wall of a gullet of a fibrous or cartilaginous ring; — a hypertrophy of the muscular coat closing a gleam of a gullet; in — a webby (hymenoid) stenosis; — a hypertrophy of atypically located mucous membrane of gastric type.

Inborn esophageal stenoses meet seldom. They can be a circular form, have character of a webby (hymenoid) stenosis, etc. (fig. 28).

The wedge, a picture depends on degree and option of narrowing. Circular and webby stenoses cause difficulties of swallowing of food, vomiting. Vomiting does not happen. Symptoms dysphagies (see) come to light soon after the birth or aged apprx. 1 year more often. In some cases during food the swallowed dense piece closes the place of narrowing, and there comes impassability of the Item. The erased signs which are observed for many years are often regarded incorrectly. Inborn narrowings of belly part P. are shown usually aged apprx. 6 months by a dysphagy. Vomiting becomes persistent, plentiful, accepts the nature of vomiting which arises either during meal, or several hours later. Children badly put on weight, pale, are a little mobile. Small children often greedy eat, despite vomiting and vomiting, but, becoming is more senior, are afraid to eat food, especially dense since its stagnation in P. is followed by unpleasant feelings.

In diagnosis of inborn narrowing of P. plays an important role contrast rentgenol, a research, a cut make in horizontal position of the child with the raised basin. Pictures do in two projections at hard filling of P. and after its emptying. Esophagoscopic inspection is shown to each child with an inborn stenosis of P. for clarification of extent of narrowing and a condition of a mucous membrane.

Treatment, as a rule, operational. More rare, at insignificant narrowing, apply conservative actions (bougieurage, expansion of narrowing by the dilator).

Fig. 29. The diagrammatic representation of operation at an inborn esophageal stenosis with formation of an anastomosis the end in the end: and — the mediastinal pleura longwise is cut also an otsloyena (1), above and below the place of narrowing seams handles for which the gullet is tightened in a wound are imposed (the dotted line showed the place of a resection); in, d — stages of imposing of an anastomosis the end in the end; e — a mediastinal pleura (1) is taken in over a gullet, the tampon (2) through an additional section in the fifth mezhreberye is brought to an anastomosis.
Fig. 30. The diagrammatic representation of plastic surgery on the narrowed department of a gullet movement of a triangular rag (across Bairov): and — a section of a gullet (1 — a catheter, 2 — a section); — the top of an educated rag is hemmed to the place of the termination of a slit; in — edges of a rag and a wall of a gullet are sewed by a two-row seam.

Operational treatment of narrowings of P. is made right after establishment of the diagnosis irrespective of age. Circular narrowings liquidate by a resection and an anastomosis the end in the end (fig. 29). In the presence of considerable predstenotiche-sky expansion apply simpler operation — movement, a triangular rag to plastics of the waist of P. (fig. 30). The webby form of narrowing is liquidated by a resection of a membrane. Operational treatment of narrowings of belly part P. is carried more often out by a technique of Petrovsky (1957) (see. Cardiospasm ). As inborn stenoses are in most cases localized in belly or nizhnegrudny parts P., it is reasonable to supplement all operations directed to elimination of a stenosis with an ezofagofundoplikation across Nissen (see. Stomach, operations ). It prevents a gastroesophagal reflux and increases reliability of seams on P. Tselesoobrazno also to make pyloroplasty (see) for improvement of evacuation from a stomach in the postoperative period.

At the inborn stenoses caused by an allotopia of a hyaline cartilage in P.'s wall, operation consists cartilaginous inclusions whenever possible without injury of a mucous membrane at a distance. At wound of a mucous membrane it is taken in in transverse direction and covered with a number of muscular and muscular seams.

Fig. 31. The diagrammatic representation of operation of valve gastroplication on Kanshin in Isakov's modification: and — the gullet (1) is taken on a handle, the stomach (2) is mobilized; — lengthening of a gullet (1) at the expense of the site of a stomach (2); in — the beginning of creation of a fundoplikatsionny cuff (2) from a greater cul-de-sac; — a final type of valve gastroplication with three lines of seams.

The inborn short gullet — a malformation of P., at Krom distal department of P. on a bigger or smaller extent is covered by a mucous membrane of a stomach. The disease often is followed by a gastroesophagal reflux. At malformations ezofagokardial-ache areas, followed by a gastroesophagal reflux (most often at inborn short P.), at children apply valve gastroplication across Kanshin. One of its modifications is the way offered by Yu. F. Isakov et al. After a verkhnesredinny laparotomy will mobilize a stomach in a cardial part and on big curvature (fig. 31, a). Then a cardial part of a stomach is created in the tube extending a gullet by imposing of serous and muscular seams in transverse direction (fig. 31, b). This tube is shrouded in the mobilized part of a stomach, creating a fundoplikatsionny cuff. Edges of a cuff hem to a gastric tube. This operation reliably eliminates a reflux, keeping a possibility of vomiting at excessive build-up of pressure in a stomach. In all cases at anti-reflux operation the pyloroplasty for acceleration of evacuation from a stomach and prevention is shown pylorospasm (see).

Damages

P.'s Damages arise at different types of injuries — mechanical, chemical, beam, etc. They more often are closed, is more rare open.

Damages at a proglatyvaniye of foreign bodys or their extraction happen generally at the level fiziol, narrowings (apprx. 30 — 50% — in cervical department of P., apprx. 50 — 60% — in chest, more rare there are multiple damages). Their weight is defined by physical properties of a foreign body (a form, the sizes), behavior of the victim (whether he tried to take or push a foreign body). Damage can come at once or as a result decubitus (see. Foreign bodys, drinks and gullet). P.'s damage is in some cases possible during diagnostic or to lay down. actions, in particular at an ezofagoskopiya (see). P.'s damages by flexible endoscopes happen to fiber glass optics considerably less than rigid (respectively 0,2% and 2%). Damage happens: 1; at the forced carrying out a tube of the rigid esophagoscope not on an axis P.; 2) at excessive hyperextension of a backbone when P.'s wall nestles a tube of the endoscope on cervical vertebrae; 3) at a research under anesthetic when the hyperinflate cuff of an endotracheal tube squeezes P. from the outside and complicates carrying out the endoscope.

Fig. 32. The roentgenogram of a gullet at perforation of a cicatricial stricture: flowed a contrast agent through a perforation opening (it is specified by an arrow).

Frequency of damages at bougieurage depends on a technique and terms of bougieurage after a chemical burn of P. Osobenno danger of damage is big at early bougieurage at a complication of a burn esophagitis peptic a reflux-ezofa-gitom owing to secondary cicatricial shortening of P. and an incompetence of cardia, at suprastenotichesky extension and an eccentric arrangement of an entrance to the channel of the stricture (fig. 32) having diverticulums, ulcers or the false courses in a mediastinum. Bougieurage «blindly» or even under esophagoscopic control is dangerous if the channel of a stricture gyrose. At the safest method of bougieurage on a string under rentgenol, control P.'s damage as a gap can happen if diameter of a buzh considerably exceeds a gleam of a stricture.

Ruptures of a nizhnegrudny part ^наддиафрагмального a segment) P. at cardiodilatation concerning a cardiospasm occur more often during the use of the mechanical dilator of Stark, at far come disease, at elderly patients, at non-compliance with the principle of gradual increase in diameter and pressure in the hydrostatic or pneumatic dilator.

Decubituses of a wall of P. are possible it is long the probes which are in it, a cuff of an endotracheal or tracheostomy tube at long artificial ventilation of the lungs.

Damages at vomiting (spontaneous gaps), stupid injuries of a neck, breast, stomach, compressed air, at road and train accidents are caused by the sharp pressure difference, P.'s prelum and tracheas between a breast and bodies of vertebrae, stratification of a wall of P., disturbance of its food and the subsequent necrosis. They are often combined with damages of other bodies therefore proceed especially hard.

Damage at radiation happens owing to the arising disintegration of a malignant tumor.

Disturbance of an integrity of a wall of P. at operations, especially on lungs, is caused by a direct injury, disturbance of its blood supply, destruction by purulent process. Owing to what in P.'s mediastinum is located to the right of a midline damages to its thicket happen at right-hand thoracic interventions. P.'s removal to the right, the divertikulopodobny protrusions developing at inflammatory processes in the right lung and a mediastinum promote emergence of damages.

The course of damages, their weight and speed of development a wedge, manifestations depend on many factors: from an etiology of a basic disease, anatomic features, the combined damage of other bodies, associated diseases, the general condition of the patient, timeliness of diagnosis and correctness of carrying out to lay down. actions.

At superficial wounds the wedge, symptomatology scanty, at through (depending on localization) damages develop symptoms of an inflammation of cellulose of a neck (see), mediastinitis (see), empyemas of a pleura (see. Pleurisy ), peritonitis (see), at the combined damage of a respiratory organs — aspiration pneumonia (see).

Fig. 33. The survey side roentgenogram of a neck in the presence of a foreign body (needle) in a gullet (it is specified by an arrow): the shadow of soft tissues is expanded.
Fig. 34. The survey roentgenogram of bodies of a thorax at injury of a gullet: expansion of a shadow of a mediastinum.
Fig. 35. The roentgenogram of the contrasted gullet at damage of its nizhnegrudny department: flowed a contrast agent through a perforation opening (it is specified by an arrow).

Rentgenol, a research is the main diagnostic method of damages. It should be begun with a non-contrast research, at Krom it is possible to reveal a X-ray contrast foreign body (fig. 33), a hydropneumothorax, emphysema of a mediastinum and expansion of its shadow (fig. 34), emphysema of cellulose of a neck. Complete radiodiagnosis by the contrast research specifying the nature of damage (fig. 35). It must be kept in mind that the effluence of a contrast agent out of limits of a gleam of P. at narrow through damages can be absent because of hypostasis of the wound channel.

Ezofagoskopiya is applied usually to removal of foreign bodys, is more rare for diagnosis of damages.

Conservative treatment (an exception of food through a mouth, parenteral administration of solutions of proteins, electrolytes of blood, antibiotics etc.) can be carried out: 1) before establishment of the final diagnosis and at a delay of delivery of the patient in a surgical hospital; 2) at superficial damages and wounds of cervical department of P.; 3) as addition to surgical.

Operational treatment (palliative and radical) is shown at more extensive damages when P. is widely reported with a mediastinum, a pleural cavity, a tracheobronchial tree. A complex of palliative operations — esophagostomy (see. Esophagotomy ), gastrostomy (see), a jejunostomy (see. Enterostomy ) and drainage of kletchatochny spaces of a neck and a pleural cavity (see. Drainage ), chressheyny and transphrenic Mediastinotomy (see) — it is shown at through wounds of P. when time for radical operation is missed or it is contraindicated.

The nature of radical operation (sewing up of defect, P.'s extirpation) is defined by extensiveness of damages and P.

Defekt' condition sew up with two rows of seams in the direction of longitudinal axis P. In seams of an internal row take all layers of a wall, then impose the second row of seams on a muscular coat.

Fig. 36. Diagrammatic representation of stages of the shelter of a gullet rag of a parietal pleura: and — stitches on defect of a wall of a gullet are put; in — the rag of a parietal pleura is consistently hemmed to a gullet to the left of the line of seams, in the area of seams and to the right of the line of seams.
Fig. 37. The diagrammatic representation of stages of the shelter of seams of a gullet a wall of a greater cul-de-sac at fundoplication (across Nissen): and — the beginning of fundoplication (1) after suture (2) on a gullet; — fundoplication (1) is finished, the line of seams on a gullet (it is specified by a dotted line) is covered by a wall of a stomach.

Around seams for the purpose of their sealing and isolation from the infected pleural cavity and a mediastinum it is necessary to hem (depending on an arrangement of defect) muscles of a neck, a muscular and pleural rag, a rag of a parietal pleura (fig. 36), a pericardium, a diaphragm on Petrovsky, a wall of a greater cul-de-sac (fig. 37) as operation of an ezofagofundorafiya or fundoplication on Nissen (see. Diaphragm ).

The main reason for failures is caused by insufficiency of seams, the frequency of such outcomes increases at the delayed radical operation from 12 up to 67%, according to Yungs, Nikolov (J. Youngs, D. Nikoloff, 1971), and even up to 80%, according to G. Heberer et al. (1971).

After operation make according to indications aspiration purulent separated from a mediastinum and a pleural cavity, washing by their antiseptic agents and antibiotics, proteolytic enzymes;

Burns ===

according to E take measures for prevention of hit of saliva and gastric contents in P. ===. H. Vantslpa and R. A. Toshchakov (1971), 72 — 75% of burns of P. occurs at children aged up to 10 years at accidental reception of the pyretics applied in life and incorrectly stored (the caustic soda, sulfuric, salt, acetic to - you and so forth). Apprx. 20 — 25% of victims adults with P.'s burns owing to a home accident make.

It is accepted to allocate three degrees of a burn of the Item. At a burn of the I degree only the surface layer of a mucous membrane is surprised. At a burn of the II degree the submucosa and the inner layer of a muscular coat are involved in process. At a burn of the III degree of a complication, life-threatening the patient, are caused by the shock, intoxication and heavy local damages extending to all layers of a wall of P. (up to its perforation), paraezo-fagealny cellulose and surrounding bodies.

Early perforation at P.'s burns are connected with direct effect of chemical substances on its wall.

The mediastinitis at chemical burns develops as a result of perforation of a wall of P., hematogenous and lymphogenous infection.

At heavy burns the area of a reactive inflammation has no clear borders. Accession of an infection causes development of the prolonged necrotic process which can lead to late perforation, a mediastinitis, esophageal bronchial or esophageal tracheal to fistula and other complications. Wedge, and rentgenol. signs of perforation of P. in similar conditions appear not at once, and after rejection of a necrotic scab, i.e. on 1 — 2nd week after a burn. The burn of the I degree comes to the end usually with epithelization, heavier burns in late terms lead to scarring, formation of ulcers, P.'s shortening, development of the sliding hernia of an esophageal opening of a diaphragm, an incompetence of cardia, a reflux esophagitis.

Wedge, a picture is defined by weight of a burn and is shown by the moderate pain during the swallowing strengthened by a sialosis, vomiting with impurity of blood, and in hard cases — symptoms of a mediastinitis, a collapse, shock.

Acute medical aid at P.'s burns comes down to removal and neutralization of the swallowed pyretics, prevention or лечению^ shock, disintoxication therapy. The gastric lavage via the probe, is justified by neutralized solutions in the nearest future (to 6 hours) after poisoning. The procedure is carried out after introduction of narcotic analgetics, local anesthesia of an oral cavity and a throat of 5 — 10% solution of novocaine, by 2% solution of Dicainum. Parenterally enter solutions of proteins, electrolytes, vitamins. At slight burns patients with 2 — 3 days can give cream, milk, sour cream, crude eggs. Further gradually the diet is expanded.

At heavy burns, considering! it is better to delay a possibility of late perforation, meal through a mouth to 5 — the 10th day; allow reception of vegetable oil. After subsiding of the acute inflammatory phenomena (7 — the 15th day) apply early (preventive) bougieurage, a cut then proceeds at a stage of development of cicatricial strictures (see. Bougieurage ).

At the correct and timely treatment of a burn in an acute stage the favorable result is observed more than at 90% of patients. According to B. V. Petrovsky et al. (1967), in the absence of treatment at 70% of patients after a burn cicatricial narrowing of the Item develops.

Cicatricial stenoses differ on localization, extent, depth of cicatricial changes and are shown by a dysphagy.

Esophagoscopic pictures are normal (fig. 1 — 2) and at some diseases of a gullet (fig. 3 — 9). Fig. 1. Cardial department of a gullet: an entrance to a stomach (it is specified by an arrow). Fig. 2. Average third of a gullet. Fig. 3. An acute esophagitis at a corrosive burn: hyperemia and hypostasis of a mucous membrane, stratification of fibrin. Fig. 4. A cicatricial esophageal stenosis after a corrosive burn. Fig. 5. A pressure diverticulum in the form of sacculate deepening (it is specified by an arrow) a posterolateral wall of an average third of a gullet. Fig. 6. The Traktsponny diverticulum in the form of triangular deepening (it is specified by an arrow). Fig. 7. A varicosity of a gullet, shooters specified expanded veins in the form of gyrose by tyazhy. Fig. 8. Hernia of an esophageal opening of a diaphragm, is visible a mucous membrane of a stomach in epiphrenic area in the form of brightly painted circle. Fig. 9. A peptic esophagitis at hernia of an esophageal opening of a diaphragm with the expressed hyperemia (it is specified by an arrow) a mucous membrane of a gullet.

The diagnosis of cicatricial narrowing shall be based on data of the anamnesis, a X-ray and endoscopic inspection (tsvetn. fig. 4).

Treatment of cicatricial strictures is performed bougieurage. The safest method is bougieurage by hollow X-ray contrast buzha on a metal string conductor under X-ray television control.

In case of unsuccessfulness of bougieurage apply operational treatment — creation artificial II.

Diseases

Atony and paralysis of a gullet, as a rule, happen secondary. They are caused or disturbance of its innervation and are observed at defeats as central (at injuries of the head, hematencephalons, tumors of a brain, poliomyelitis etc.), and a peripheral nervous system (defeat of a vagus nerve, neuroplexes of P.), or arise at defeat of its muscular coat (at a myasthenia, a scleroderma, etc.).

The main symptom is dysphagy (see), especially shown at food lying. At an atony and insufficiency upper (pharyngoesophageal) and lower (esophageal and gastric) fiziol, sphincters the eructation and vomiting owing to regurgitation of esophageal or gastric contents at an inclination of a trunk are observed.

The current is defined by a basic disease, but usually gradually progressing. At an atony lower fiziol, a sphincter and preservation of activity of gastric secretion usually there is a reflux esophagitis. With the help ezofagotopografiya (see) it is possible to define decrease in force of its peristaltic reductions, decrease in a tone of an esophageal and gastric sphincter.

Fig. 38. The roentgenogram of a gullet at a double contrast study air and barium: a sharp esophagectasia owing to hypotonia

The diagnosis is confirmed rentgenol. the research allowing to reveal an atony hypo - and an akineziya of esophageal walls (fig. 38), expansion of a gleam of P., and at a research in horizontal position — a long delay of the swallowed baric suspension in P. and gastroesophagal reflux (see). Special methods rentgenol. researches — rentgenokimografiya (see) and the programmed large picture frame serial fluorography (see) — allow to catch initial disturbances of a tone and P.'s vermicular movement, to determine the speed of passing by it contrast weight.

Treatment first of all shall be directed to elimination of a basic disease. Appoint mechanically sparing diet, recommend to eat slowly, carefully chewing food. Patients with an incompetence of cardia are recommended not to lay down right after food and to sleep with highly raised headboard of a bed. From pharmaceuticals at an atony of P. which is followed by a heavy dysphagy Carbacholinum, aceclidine and antikholi-nesteraziy drugs raising a tone of smooth muscles, Metoclopramidum (cerucal, a raglan) contributing to normalization of a tone of P. and the lower esophageal and gastric sphincter at these states are recommended.

Esophagism — spastic dyskinesia of P. — is characterized by periodically arising spastic reduction of P. Razlichayut primary esophagism which, apparently, is a consequence of cortical disturbances of regulation of function P., and secondary (reflex and symptomatic) the esophagism arising at such diseases as an esophagitis, ulcer and cholelithiasis, P.'s cancer and a stomach, etc., or at the diseases which are followed by the general convulsive syndrome (epilepsy and so forth). At a pathoanatomical research quite often find moderately expressed, and in some cases — a sharp hypertrophy of a muscular coat of a wall of P. (a so-called huge or diffusion muscular hypertrophy of P.), destructive changes of generally afferent nerve fibrils in branches of a vagus nerve and intramural neuroplexes of the Item.

At an esophagism the non-constant dysphagy which is perceived sick as feeling of a delay of food in P., retrosternal «lump», a prelum, etc. is observed. The dysphagy in one cases appears 1 — 2 time a month, in others is observed almost at each meal, is followed by a retrosternal pain and happens very painful. The long and persistent dysphagy can seriously break food of the patient. At some patients the dysphagy can have paradoxical character: arises at drink of the liquid, especially cold more often, and is absent at a proglatyvaniye of dense and kashitseobrazny food. During strong spastic reductions of a wall of P. regurgitation of the swallowed food masses in a mouth can be observed. Sometimes attacks of an esophagism arise out of communication with meal: in operating time, walks. If the attack is followed by pain behind a breast, it is difficult to otdifferentsirovat it from an attack of stenocardia especially as nitroglycerine, possessing the weakening action on smooth muscles, kills a spasm and pains in both cases. At some patients the dysphagy is expressed poorly, and pain behind a breast is the dominating symptom; it can irradiate in a back, a neck, jaws.

Sometimes the esophagism arises in the form of short-term episodes and then independently passes, the chronic or recurrent current is more often observed. A complication of an esophagism is emergence of pressure diverticulums (see) and the sliding hernia of an esophageal opening of a diaphragm (see. Diaphragm, hernias of an esophageal opening ).

Major importance in diagnosis has rentgenol, a research. At an esophagism at the time of a proglatyvaniye of a baric suspension various spastic deformations of P. are found: in the form of a corkscrew, beads, false diverticulums, spastic banners etc. This pathology comes to light not always at the first rentgenol. a research, in these cases are necessary a repeated research in the period of an aggravation of symptoms or provocation of an esophagism by use during the research of the acidified or cooled dense suspension of fixed white. Big help in diagnosis of an esophagism is given by use of a method ezofagotonografiya (see): the waves reflecting spastic reductions of P. have the unequal form, amplitude, quite often consist of several repeated teeth.

Differential diagnosis is carried out with early stages cardiospasm (see), organic strictures and prelums that is quite often considered the basis for carrying out ezofagoskopiya (see).

At a secondary esophagism crucial importance has treatment of a basic disease (ulcer, cholelithiasis and» other). In all cases sedative drugs, tranquilizers are shown. In the period of an aggravation of an esophagism appoint cholinolytic and Myotropic spasmolytic drugs: atropine, Platyphyllinum, papaverine, Nospanum, etc.; at some patients use of Metoclopramidum (a raglan, cerucal) appointed inside in 20 — 30 min. prior to meal or parenterally is especially effective. At especially hard proceeding esophagism just before meal appoint anaesthesin (0,25 — 0,3 g to reception in powders or in mucous mixture).

From physiotherapeutic methods appoint an electrophoresis with novocaine or solution of magnesium sulfate to area of cervical nodes of a sympathetic trunk.

Diverticulums. On an arrangement distinguish the following types of diverticulums: in a cervical part (a pharyngeal segment) — tsenkerovsky, in chest (a bronchial segment) — bifurcation, in an epiphrenic segment — epifrenalny diverticulums. They are single and multiple. On a pathogeny allocate pulsion, traction and pulsion and traction. Diverticulums happen full when all layers of a wall of a gullet participate in their education, and incomplete — if their wall consists only of a mucous membrane, prolabirovan-ache in defect between fibers of a muscular coat. The pulsion mechanism is the main thing in a pathogeny of tsenkerovsky diverticulums: the diskoordination of the act of swallowing and function upper physiological, or pharyngoesophageal, a sphincter leads to substantial increase of endoluminal pressure and gradual stretching of a wall of P. in the specified department.

In an etiology of bifurcation diverticulums major importance is attached to an inborn factor, heredity, an inflammation limf, nodes and cellulose of a mediastinum with the subsequent cicatricial traction of a wall of a gullet. Nissen (R. Nissen, 1958) ranks bifurcation diverticulums to pulyeionny, and B. V. Petrovsky and E. N. Wangqiang (1968) — to bullets-sionno-traction. V. I. Chissov (1967) showed that in a pathogeny of bifurcation and epifrenal-ny diverticulums in the beginning the leading role is played by increase in vnut-ripishchevodny pressure owing to disturbance of motility of P. as an esophagism, and then the sliding hernia of an esophageal opening of a diaphragm, an incompetence of cardia, a gastroesophagal reflux develops.

In a pathogeny of epifrenalny diverticulums the pulsion mechanism is dominating.

Specific a wedge, symptoms of diverticulums of P., especially at an early stage, no. Complaints to unpleasant feelings to areas P., pressure sense, «jamming» of food, a dysphagy, neck pain, behind a breast, in spin, hypersalivation, an eructation, vomiting are characteristic.

Diagnosis is based preferential on data rentgenol, researches. Ezofagoskopiya (tsvetn. fig. 5, 6) carry out generally for differential diagnosis with high-quality and malignant new growths.

The heaviest complications of a current of diverticulums are: the perforation (proceeding usually as microperforation and leading to the erased forms of a mediastinitis, esophageal and tracheal and esophageal and bronchial fistulas); formation of polyps, cancer; bleeding.

Fig. 39. Diagrammatic representation of operation of a diverticulectomy: and — cutting off of a diverticulum between clips; — underrunning of a neck of a diverticulum under a clip a continuous suture; in — imposing of the second row of seams.

The main method of treatment of diverticulums — operational, consisting in their excision (fig. 39, and, c).

Fig. 40. The diagrammatic representation of operation of invagination of a diverticulum (1) by imposing of the invaginating seams (2).

At small diverticulums use of invagination (fig. 40) is possible. This operation often leads to a recurrence, and the diverticulum invaginated in a gleam by P. can create difficulties during the swallowing and a passage of food.

According to aggregated data, the lethality at operational treatment of diverticulums of chest part P. averages apprx. 6%.

See also Barshonya — Teshendorfa a syndrome , Diverticulum .

Diverticulitis — inflammation of a diverticulum. It can be observed at large diverticulums, their narrow neck and in cases when there are conditions for a long delay in it food masses, saliva, and sometimes and foreign bodys. Bacterial decomposition of the remains of food which accumulated in a diverticulum promotes emergence and maintenance of inflammatory process.

It is in most cases observed hron, the catarral or erosive diverticulitis, is much more rare — purulent or gangrenous (often their emergence is promoted by a delay in a diverticulum of a foreign body).

At P.'s diverticulitis pains, feeling of a sadneniye and prelum are watched a breast. At a purulent and gangrenous diverticulitis severe pains, body temperature increases, the general condition of patients sharply worsens; in blood are noted: considerable neutrophylic leukocytosis, acceleration of ROE.

A current of catarral and erosive forms of a diverticulitis — acute, subacute or chronic; purulent and especially gangrenous forms — acute.

— periezofagit complications, an acute mediastinitis, esophageal bleeding.

Treatment is antiinflammatory, generally conservative. At a purulent and gangrenous diverticulitis appoint massive doses of antibiotics of a broad spectrum of activity. After subsiding of the phenomena of an inflammation in some cases surgical treatment is shown.

Prevention of a diverticulitis is timely operational treatment of large diverticulums in which the food remains constantly accumulate. At impossibility of operation it is recommended to wash out a diverticulum after food, drinking V2 of a glass of warm mineral or soda water (small drinks), to adopt (for 5 — 8 min.) the provision promoting emptying of a diverticulum. It is necessary to warn patients about need to slowly eat, avoid the distracting moments during food, to carefully chew food. Food shall not cause P.'s, mucous about lochka, irritation, contain hot spices.

Allergic and medicinal damages of a gullet. Many drugs (streptocides, antibiotics, drugs of iodine, etc.), various foodstuff (nek-ry fruit, berries, mushrooms, rare sea and fish products etc.) can cause allergic damages to P.

Damage of a gullet at inhalation receipt in an organism of allergen is possible (pollen of flowers, vapors and dust of some chemical substances, etc.); products of microbic disintegration (e.g., at a diverticulitis, a cardiospasm, etc.) can be allergens also. Allergic reactions can be provoked by a mental condition of the patient (nervousness, stressful situations and so forth), meteorological and other factors. Medicinal defeats of P. can not have bonds with an allergy.

The main symptoms of allergic defeat of P. are the dysphagy and a painful sadneniye or pain during the swallowing. More often into the forefront symptoms of defeat of other bodies act went. - kish. path. At a blood analysis reveal eosinophilias). At an ezofagoskopiya the diffusion or focal hyperemia of a mucous membrane of P. is noted, more or less expressed hypostases and the hemorrhagic phenomena quite often come to light. Find a large number of eosinophils in a smear of the slime taken over sites of an inflammation.

The current can be acute, subacute, chronic or recurrent.

Diagnosis of allergic defeats of P. is difficult. Concerning the allergic nature of defeat emergence of a dysphagy and retrosternal pains soon after taking the medicine or certain products to which often there are allergic reactions, and the termination of these phenomena after their cancellation is suspicious. In certain cases carry out treatment of ex juvantibus by antiallergenic drugs.

For the purpose of treatment of the patient it is necessary to isolate from action of alleged agents (e.g., drugs, production factors). If allergen is definitely not established, appoint hunger or a diet with the minimum set of products (a bezallergenovy diet) to a certain term. From pharmaceuticals appoint antihistaminic (Dimedrol, Suprastinum, etc.) and corticosteroid drugs. If allergen is known and defeat often recurs, further it is possible to try to carry out desensitization (see. Desensitization ).

See also Allergy , Medicinal allergy .

Fungal infections. The actinomycosis of a gullet meets seldom. The disease can be both primary, and secondary — with struck bifurcation (tracheobronchial, T.) limf, nodes, bronchial tubes, backbone.

Pains during the swallowing are observed, a dysphagy. At an ezofagoskopiya define the surface and deeper infiltrates covered with a crimson and cyanotic mucous membrane, abscesses and ulcers from which surface slivkoobrazny pus, sometimes with impurity of the yellowish grains containing textures of a mycelium flows down. The diagnosis is confirmed by data of a biopsy, bacteriological and serological researches.

A current — progressing. Complications: formation of the fistular courses with a trachea, bronchial tubes, a mediastinum, a pleura, a purulent mediastinitis.

Treatment is specific, in some cases (at formation of fistulas, stenoses and other complications) — operational.

See also Actinomycosis .

The candidiasis meets more often other mycoses of P., it develops at the weakened patients at prolonged use of antibiotics of a broad spectrum of activity. Simultaneous use of corticosteroid drugs contributes to emergence of a candidiasis of P. Usually P. is surprised for the second time, at distribution of a fungus from an oral cavity and a throat; at very weakened patients the candidiasis can proceed as sepsis.

The dysphagy, pains during the swallowing are observed. Have major importance in diagnosis: an ezofagoskopiya with a biopsy at which reveal the whitish-yellow plaques alternating with sites of not affected mucous membrane and its ulcerations; gistol, the research, at Krom is found accumulation a dispute and filamentous interlacings of a fungus; mycologic research.

Treatment is carried out by high doses of nystatin, levorinum and other antifungal drugs.

See also Candidiasis .

Zymonematoses of a gullet meet seldom. Defeat begins with skin and lungs, then in the hematogenous way other bodies, including and G1 are surprised. Sometimes blastomi-kozny abscesses from a backbone extend to P. In P. single or multiple papules are formed, to-rye abscess and turn into abscesses and ulcers.

The main symptom of a disease is the dysphagy. The diagnosis is confirmed by means of an ezofagoskopiya, histologic and mycologic researches. Nek-ry help is given by serological tests with antigens from culture of a fungus.

A current — progressing. Complications — a purulent mediastinitis, esophageal and tracheal and bronchial fistulas are possible.

Treatment — drugs of iodine, an isoniazid, nystatin, V.'s Amphotericinum

See also Zymonematoses .

Esophagitis. The acute esophagitis develops at thermal or corrosive burns of P. (tsvetn. fig. 3). Hron, esophagitis (tsvetn. fig. 9) is a consequence of acute esophagitis (see); it is observed at a specific inflammation, the incompetence of cardia complicated by a gastroesophagal reflux develops after the operative measures breaking locking function of the cardia and leading to free regurgitation in P. of gastric or intestinal contents and in some other cases.

The varicosity of a gullet most often arises at portal hypertensia (see) at patients with cirrhoses or tumors of a liver, at thrombophlebitis of hepatic veins, prelums of a portal vein etc. (tsvetn. fig. 7; 19).

At a pathoanatomical research find expanded gyrose veins of P. and a cardial part of a stomach. The mucous membrane over veins is often thinned, can be inflamed, an erozirovana. After severe bleedings of a vein are fallen down. owing to what the opening from which there was bleeding often happens imperceptible.

The disease usually before developing of bleeding proceeds asymptomatically or with insignificant symptoms (unsharply expressed dysphagy, heartburn etc.), to-rye fade into the background before manifestations of the main suffering (cirrhosis or cancer of a liver, a cordial decompensation and so forth).

Varicosity it is possible to find at rentgenol, a research: scalloped gear contours of P., rough gyrose folds of a mucous membrane, small roundish or longitudinal serpantinopodobny defects of filling are characteristic. More reliable data can be obtained at an ezofagoskopiya (see), to-ruyu it is necessary to carry out carefully because of danger of bleeding.

The current is defined by a basic disease. The most frequent and terrible complication — acute esophageal bleeding.

Fig. 10. Cardial department of a gullet at Mallori's syndrome — Weiss: bleeding from a longitudinal rupture of a mucous membrane of a gullet. Fig. 11. Cardial department of a gullet at Mallori's syndrome — Weiss: a longitudinal rupture of a mucous membrane of a gullet in a stage of epithelization (it is specified by an arrow). Fig. 12. A leukoplakia of cardial department of a gullet (it is specified by an arrow). Rhee of page 13. A polyp of cardial department of a gullet (it is specified by an arrow). Fig. 14. A lipoma of a gullet (it is specified by an arrow). Fig. 15. A leiomyoma of a gullet (it is specified by an arrow). Fig. 16. Nodal cancer of a gullet (it is specified by an arrow). Fig. 17. Skirrozny cancer of a gullet: a stenosis owing to growth of a tumor. Fig. 18. Cancer of a gullet (the arrow specified the site of an ulceration of a tumor). V. A. Romanov's slides.

Differential diagnosis should be carried out with an esophagitis, a tumor of a gullet. Esophageal bleeding can be also caused by a round ulcer of a gullet, the breaking-up tumor, Mallori's syndrome — Weiss (see. Mallori — Weiss a syndrome ) (tsvetn. fig. 10, 11), etc.

Treatment aims to eliminate threat of esophageal bleeding. In rare instances it is reached by effective treatment of a basic disease, in the same cases when it is possible, recommend operational treatment — imposing of a porto-caval or splenorenalny anastomosis (see. Porto-caval anastomosis , Splenorenalny anastomosis ), providing an additional outflow tract of blood from a portal vein in the lower hollow. However more often the patient of a sparing diet should be limited to appointment, restriction of exercise stresses and periodic purpose of the knitting and antiacid drugs.

Fight against esophageal bleeding is carried out by means of the special probe of Sengstaken — Bleykmora with two cylinders, to-rye in the inflated state well are fixed in the cardia and squeeze esophageal veins. At the same time carry out haemo static therapy (transfusion is fresher than blood small doses, enter calcium chloride, solutions aminocaproic or pas-ra-aminobenzoic to - you with the subsequent administration of fibrinogen, Vikasolum). Kapelno is intravenously entered by 15 — 20 PIECES of Pituitrinum into 200 ml of 5% of the solution of glucose causing temporary decrease in portal pressure. Further, for prevention of repeated bleedings, imposing of a porto-caval or splenorenalny anastomosis is recommended.

Round ulcer gullet meets approximately by 25 — 30 times less than round ulcers of a stomach and duodenum.

The etiology and a pathogeny of this disease are studied insufficiently. Often at patients the incompetence of cardia caused by the sliding hernia of an esophageal opening of a diaphragm comes to light (tsvetn. fig. 8); the frequent combination of a round ulcer of P. to a peptic ulcer of a stomach and duodenum, cholelithiasis is noted. In all cases high secretion salt to - you a gastric juice is characteristic.

Round ulcers of P. in most cases of an odinochna, but can be and multiple. They are located in distal segments P., by outward round ulcers of a stomach, a form their roundish or extended in lengthwise direction remind; diameter of an ulcer seldom exceeds 1 cm.

The main symptom of a round ulcer of P. — pain behind a breast or in epigastric area, arising or amplifying during food or right after it, during the swallowing, sometimes in a prone position (owing to a reflux of an active gastric juice in P.). Frequent symptoms are the dysphagy arising owing to the accompanying esophagism, inflammatory hypostasis or cicatricial narrowing of P., persistent heartburn, an eructation, vomiting by acid gastric contents. Heartburn and vomiting usually amplify at an inclination of a trunk or in a prone position.

Fig. 41. Roentgenograms of a gullet: and — big: a round ulcer (it is specified by an arrow); — esophageal and pleural fistula (it is specified by shooters).

At rentgenol, a research the round ulcer is found in the form of a niche on a contour or a relief of a mucous membrane of P. (fig. 41, a).

The most reliable method of identification of a round ulcer of P. is the ezofagoskopiya with a biopsy.

The ulcer in most cases is represented roundish or oblong, is frequent with a yellow-gray or bloody plaque under which the purple-red uneven bottom is found.

The current is long, progressing, however the periods of an aggravation and remission are possible.

Esophageal bleedings, perforation, development of a stricture of P. during the scarring of an ulcer can be a complication of round ulcers. It is long the existing round ulcers of P. also lead to its cicatricial shortening that is the reason of education or gradual increase in already existing sliding hernia of an esophageal opening diaphragms (see).

The differential diagnosis is carried out with P.'s ulcers of other nature: cancer, tubercular, syphilitic, dekubitalny. The ezofagoskopiya with an aim biopsy from edges of an ulcer facilitates differential diagnosis.

For the purpose of treatment appoint an antiulcerous diet, rest. For prevention of a gastroesophagal reflux situation in a bed with the raised upper half of a trunk is recommended. From drugs antiacid means have major importance knitting (bismuth nitrate or solution of silver nitrate) (magnesium oxide, the calcium carbonate besieged hydrosodium carbonate); Almagelum, etc.). The good effect is rendered by the complex domestic drugs «Vicairum» and «Vicalinum», to-rye at an ulcer of IT. appoint in the form of suspension in a small amount of warm water. Spasmolytic and cholinolytic drugs are appointed only in the presence of the accompanying esophagism since they reduce a tone of a cardial sphincter and can be strengthened - an esophageal reflux. For the purpose of strengthening of processes of regeneration by the patient administer parenterally vitamin drugs (Vkh, B6, etc.), extract of an aloe, inside Peloidinum, methandrostenolone and other drugs of metabolic action. Treatment shall be long since round ulcers of P. rather slowly and difficult begin to live (usually it is required apprx. 1,5 — 2 months of treatment in a hospital with the subsequent treatment in out-patient conditions). Further patients shall be on the dispensary account for the purpose of periodic inspection and about-tivoretsidivnogo treatments.

Surgical treatment is shown only in the absence of effect of conservative treatment and in the presence of complications of a disease since the applied methods of operational treatment of this disease (a resection of a zone of an ulceration and the narrowed site P. with creation of an ezofagogastroanastomoz, etc.) are insufficiently effective in respect of prevention of a gastroesophagal reflux and a possible recurrence of a disease.

See also Round ulcer .

Fistulas. The acquired P.'s fistulas can be internal and outside, reported with a mediastinum, a pleural cavity, respiratory tracts. As a rule, the acquired fistulas are a consequence of disturbance of an integrity of a wall of a gullet as a result of a mechanical, chemical, thermal, beam injury, decubituses, perforation, diverticulums, progressing of tumoral and inflammatory processes, round ulcers of a gullet.

Fistulas begin to form right after perforation; in their development it is possible to allocate two stages: acute — a stage of an acute inflammation directly after perforation of a wall of a gullet and a chronic stage — a stage of development of cicatricial fabric and formation of the fistular channel.

Allocation of the swallowed food masses or saliva through the fistular course is characteristic of fistulas. Wedge, picture of fistulas is defined by their etiology, a pathogeny, anatomy, complications accompanying and preceding fistula diseases, etc. Pishchevodno-medi-astinalnye the fistulas developing usually from diverticulums form slowly, in process of emergence of repeated microperforations and are shown by «unmotivated» rises in temperature, an oznobama, pain in epigastric area and spin. Brighter symptoms characterize fistulas, through to-rye P. is reported with respiratory tracts (see. Bronchial fistula ). Are inherent to them pristupoobrazny cough at meal, a poperkhivaniye, a pneumorrhagia, abdominal distention. Sometimes these symptoms appear after food during a gastroesophagal reflux. These fistulas quite often are complicated by the abscessing pneumonia.

The main diagnostic method of fistulas — Polyposition rentgenol, a research (fig. 41, b). In an initial phase of filling with a suspension of barium the fistula brought at roentgenoscopy out of a shadow of a gullet is defined in the form of a short mustache, a niche, a linear zatek and so forth.

Difficulties of contrasting can be caused by narrowness of fistula, its valve structure, filling of its gleam with food or decomposition products. Because of cough and the high speed of passing a contrast agent can not always come to the pishchevodnorespiratorny fistulas especially proksimalno located.

The X-ray cinematography is important. Ezofagoskopiya is applied as an auxiliary diagnostic method of fistulas. The combined methods have advantage: rentgenoezofagoskopiya, ezofagobronkhoskopiya.

Treatment of the created fistulas, as a rule, surgical. Conservative treatment and palliative operations do not lead usually to treatment, but allow to prepare the patient for radical operation.

Palliative operations (gastrostomies, jejunostomy, esophagostomy, etc.) carry out generally in the acute period, at premature closing of outflow tracts and in combination with radical operation. At the expressed incompetence of cardia of a gastrostomy) it is not necessary to carry out in the isolated look, it is better to supplement it with operations, corrective locking function of the cardia (an ezofagofundorafiya, fundoplication, valve gastroplication).

Radical operations (dissociation of fistula or P.'s extirpation) at fistulas differ in complexity of performance and weight of a postoperative current. They are contraindicated at serious condition of the patient. Therefore all patients before operation need to carry out thorough training, especially if intervention on a lung is supposed. The resection or removal of a lung are shown at an irreversible hron, the purulent abscessing process which is not giving in to conservative therapy. At not started forms hron, pneumonia, hron. the deforming bronchitis it is possible to be limited to dissociation of fistula. Some patients can carry out step-by-step treatment — at first dissociation of fistula, and then lung operation. Fistulas operations, complicated by the abscessing pneumonia, an empyema of a pleura, a mediastinitis are more traumatic, at postoperative fistulas, especially after a pneumonectomy.

At operation it is necessary to allocate carefully the fistular channel and to dissect away it from P. at the level of not changed wall. Further defect in P. is sewn up. If fistula was reported with respiratory tracts, then its channel after allocation is cut from a wall of a trachea or a bronchial tube. The defect formed in their wall is sewn up and at indications carry out lung operation in necessary volume.

P.'s extirpation at fistulas — rare operation. It is shown when P.'s preservation is inexpedient that meets at fistulas against the background of tumoral or cicatricial changes.

The most frequent postoperative complication is pneumonia, insufficiency of seams, bleeding. The lethality at radical operations for the acquired fistulas averages apprx. 20%.

Parasitic diseases. Trypanosomiasis. The Chagas disease is widespread in South America (see. Shagasa disease ), the caused Schizotrypanum cruzi. At a part of the persons who transferred an acute stage of a disease in addition to signs of damages of other internals, the disease, on a wedge, to signs and patol, to changes reminding develops further cardiospasm (see) and megacolon (see). At gistol, a research in P. find dystrophic changes of ganglionic cells and nerve fibrils of intramural textures of P., the cardia, a large intestine.

Therapeutic actions at P.'s defeat in an acute stage are directed to a basic disease, in hron, to a stage — to treatment of a cardiospasm and megacolon.

Miaza. Cases of diseases of P. caused by implementation in its wall of the larvae of some species of flies which are accidentally swallowed with food are described (see. Miaza ). The diverticulums and stenoses leading to a long delay in P. of food masses contribute to esophageal localization of process. In the place of implementation of a larva there is an infiltrate which resolves after an exit of a larva outside. It is clinically shown by unpleasant feelings in P., a dysphagy. Danger of consecutive infection and formation of purulent complications is big.

Ascaridosis. In P. ascarids can migrate. In rare instances (especially in the presence of a diverticulum or P.'s narrowing) they can be late for a long time in it and be the reason of an esophagitis.

The diagnosis can be established at a X-ray and endoscopic inspection (at the last the ascarid can be removed).

For treatment use antivermicular drugs (see. Ascaridosis ).

Tuberculosis. Tubercular defeat of P. represents one of rare localizations of this disease and is in most cases observed at persons with far come forms of pulmonary tuberculosis (see. Tuberculosis , Tuberculosis of a respiratory organs ). Most often P.'s tuberculosis arises during the swallowing the infected phlegm by patients with open forms of tuberculosis or as a result of direct transition of tubercular process from surrounding bodies: bifurcation limf, nodes, backbone, thyroid gland, throat, epiglottis and throat.

Tubercular process is in most cases localized in P. at the level of bifurcation of a trachea, is more rare in its proximal piece. The ulcer form meets more often. The ulcer results from caseous disintegration of tubercular hillocks. The sizes of tubercular ulcers are variable — from dot to several centimeters in the diameter. Also the stenosing forms meet also miliary.

P.'s tuberculosis can proceed asymptomatically, however more often the available symptoms are shaded by the expressed manifestations of tubercular defeat of other bodies (first of all lungs and a throat) and a serious general condition of the patient.

The brightest symptom of tuberculosis of P. is the dysphagy arising owing to narrowing of a gleam of P. infiltrative process or scarring of tubercular ulcers. The dysphagy can be followed by sharp pain at a proglatyvaniye.

Diagnosis of tuberculosis of P. is difficult. Emergence of a dysphagy or pains during the swallowing at the patient with a pulmonary tuberculosis gives the chance to suspect tubercular damage of a gullet. Rentgenol, a research allows to reveal tubercular ulcers and cicatricial narrowing of its gleam. The Ezofagogastroskopi-chesky picture of tubercular ulcers is characteristic: ulcers with caseous disintegration in the center or covered with a gryaznosery plaque, surrounded with tubercular hillocks. The diagnosis is facilitated by a biopsy and bacterial, a research of the material received from an ulcer. In cases when changes in lungs are absent and the diagnosis is complicated, carry out tuberkulinovy reactions (see. Tuberculinodiagnosis ).

The forecast is defined by expressiveness of tubercular changes in easy and other bodies. Among complications developing of fistulas of P. with a trachea, bronchial tubes, a pleural cavity, accession of consecutive infection with development of a purulent mediastinitis is noted. The break of a tubercular ulcer in a large vessel threatens with profuse bleeding. During the healing of tubercular ulcers P.'s strictures breaking its passability as a result of commissural process between bifurcation limf are formed, nodes and an esophageal wall form traction diverticulums.

Treatment would be carried out in specialized antitubercular by the general rules of antitubercular therapy (see. Tuberculosis, general principles of treatment ). At tubercular ulcers of P. in addition hold the same events, as at a round ulcer of the Item. In the presence of cicatricial narrowing of P. carry carefully out bougieurage or impose a gastrostomy.

Syphilis. Syphilitic defeat of P. meets seldom, as a rule, in the tertiary period of a disease, is more rare at inborn syphilis (see).

Syphilitic defeat is, as a rule, localized in upper, is more rare in an average third of P. and is shown in the form of gummous and ulcer process. Scarring of an ulcer is followed the stenozirovaniy Item. The esophagitis is in certain cases observed diffusion hron.

The most constant symptom is the dysphagy sometimes accompanied with pains behind a breast. At rentgenol, a research circular infiltration of a wall of P. 5 — 10 cm long, a smoothness and rigidity of folds of his mucous membrane, a moderate stenozirovaniye of a gleam comes to light. Ezofagofibro-skopiya and an aim biopsy allow not only to specify the nature of inflammatory process, but also to reveal syphilomas (in the form of uneven limited protrusions of a mucous membrane), ulcers (round, limited, covered with a dirty-gray or yellow plaque), the characteristic hems of a star-shaped form which are formed during the healing of ulcers. Serological researches in some cases can yield at tertiary syphilis negative takes therefore special value has comprehensive examination of the patient and identification of the defeat of other bodies (an aorta, heart, a liver, a nervous system, etc.) which is found considerably more often than P.

Techeniye's defeat chronic. Such complications as perforation of an ulcer in a trachea and bronchial tubes (with formation of esophageal and tracheal and esophageal and bronchial fistulas), development of a periezofagit are possible.

The differential diagnosis is carried out with malignant tumors and tuberculosis of a gullet. In rare instances there can be a thought of a round ulcer, .no the last is usually localized in distal department of the Item. P.'s mycoses which are found seldom, in some cases on a wedge can remind manifestations syphilitic defeat of the Item.

Rather reliable data for the correct diagnosis the ezofagoskopiya with an aim biopsy gives, bacterial, a research.

Treatment — specific.

The forecast, generally is defined by character and extent of defeat of other bodies.

Tumors

P.'s Tumours are subdivided on high-quality and malignant. Both those, and others can be an epithelial and not epithelial origin. According to the International classification of tumors of P. (WHO, 1977) the following types of new growths distinguish:

I. Epithelial tumors.

A. Dobrokachestvennye: planocellular papilloma.

B. Zlokachestvennye: 1) planocellular cancer; 2) adenocarcinoma; 3) ferruterous kistoznyyrak; 4) mukoepidermoidnyyrak; 5) ferruterous and planocellular cancer; 6) undifferentiated cancer.

II. Not epithelial tumors.

A. Dobrokachestvennye: 1) leiomyoma; 2) others.

B. Zlokachestvennye: 1) leiomyosarcoma; 2) others.

III. Enclavomas.

A. Carcinosarcoma.

B. Malignant melanoma *

B. Others.

IV. Secondary tumors.

V. Not classified tumors. VI. Opukholepodobny processes.

A. Geterotopiya.

B. Inborn cysts.

V. Fibrovaskulyarny polyp (fibrous polyp).

Benign tumors of a gullet are rare, meet at men of middle age more often and make 1 — 6% of new growths of this localization. Develop in any department of the Item.

Benign epithelial tumors (planocellular papillomas) meet seldom. Can be single and multiple. Multiple papillomas of P. are observed at patients with acanthosis nigricans (see) and as extremely rare hereditary disease in combination with giperke-ratozokhm palms and soles.

Benign not epithelial tumors (leiomyomas, fibromas, neurinoma, lipomas, hemangiomas, lymphangiomas, etc.) develop from different elements of a wall of the Item.

Leiomyomas (see) make up to 70% of all benign tumors (tsvetn. fig. 15). Proceed from a muscular coat of a wall of P. or from a muscular plate of a mucous membrane. On a structure are similar to similar tumors of other localizations. At development in leiomyomas of connecting fabric of a tumor are regarded as fibromyomas. Leiomyomas develop vnutristenochno, is more often in the form of the single node covered with mucous and muscular covers. Sometimes they otdavlivat an adjacent mucous membrane and press in a gleam in the form of polipovidny education (fig. 42, a), can surround P., being located preferential extra-ezofagalno. Unlike leiomyomas of other departments went. - kish. a path at localization in P. the mucous membrane over a tumor can be not changed. Leiomyomas need to be distinguished from the diffusion leiomyomatosis which is found seldom, hl. obr. at youthful and young age as an uneven thickening of a wall of P., sometimes with narrowing of a gleam. Treat rare benign not epithelial tumors of P. also fibroma (see. Fibroma, fibromatosis ), neurinoma (see), lipoma (see), hemangioma (see), lymphangioma (see), etc. (tsvetn. fig. 14).

Wedge, displays of benign tumors of P. depend on their sizes, localization and a growth form. Quite often small tumors prove nothing during lifetime and are an accidental section find. Such leiomyomas meet in 5% of openings. Sometimes even new growths, considerable by the sizes, clinically of a bessimptomna are also found only at rentgenol. research. The general condition of patients with a benign tumor of P., as a rule, does not suffer. At tumors with an endoluminal growth form the most frequent symptom is the dysphagy which can be observed within several months and even years. Degree of a dysphagy can not correspond to the sizes of a new growth since at the small volume of a tumor the spastic component quite often takes place; the periods of improvement of passing of food are connected with its reduction. The benign tumor seldom leads to full obturation of a gleam of the Item. Along with a dysphagy patients sometimes complain of feeling of a foreign body, nausea, pains at food. At preferential ekstraezofagalny development of process into the forefront symptoms of defeat of bodies of a mediastinum — pain behind a breast act, short wind, cough, disturbances of a cordial rhythm, etc.

Klin, symptoms of benign tumors, not tumoral diseases and P.'s cancer are identical. In this regard diagnosis of benign tumors of P. is difficult and is based on a complex research.

The research P. allowing to assume existence of a benign tumor is important rentgenol. It is possible to confirm this assumption on the basis of data of an ezofagoskopiya (see). At epithelial tumors, coming from a mucous membrane of P. (papilloma), it is possible to make a biopsy. At intraparietal benign tumors the biopsy is contraindicated because of frequent impossibility of receiving material for a research and a possibility of infection of the broken mucous membrane that it in the subsequent can complicate an operative measure. The radio isotope research allows to obtain Nek-ry ancillary data (see).

Treatment of benign tumors of P. — surgical. Long observation can be allowed only in cases of extra risk of an operative measure. Tumors on a leg can be removed via the esophagoscope with an electroknife of a pla a laser beam.

At intraparietal not epithelial tumors make thoracotomy (see) and enucleating of a new growth; at the same time it is necessary to be careful of wound of a mucous membrane of the Item. In certain cases during removal of big tumors major defects of a muscular coat of P. cover with a phrenic rag on the feeding leg. P.'s resection is made in exceptional cases at the big sizes of a tumor and impossibility to exclude m an alignization of process.

The forecast at benign tumors of P. favorable. Long-term results of treatment good. Recurrent tumors are observed extremely seldom.

Nek-ry opukholepodobny processes (a heterotopy of elements of a mucous membrane of a stomach, inborn cysts of P., fibrovaskulyarny polyps) are clinically shown as benign tumors of P. and cause suspicion on existence of a malignant new growth. At heterogonies and inborn cysts often there are signs of intraparietal growth, at polyps — endoluminal growth.

Diagnosis and treatment of the called processes are similar stated above.

Malignant tumors

Cancer of a gullet makes 2 — 5% of all malignant new growths. In the USSR he takes the 7th place among malignant tumors. Most often meets in Yakutia and the republics of Central Asia. In other countries the highest incidence is noted in Switzerland, France, Finland, China, Japan, Puerto Rico, South Africa. P.'s cancer arises at men at the age of 50 — 60 years more often.

Frequency of developing of cancer of P. depends on features of a way of life and food of the population of the country or area.

The use hot, acute, badly processed (fish, meat) food contributes to development of cancer of gullet. Carry to the contributing factors also a high mineralization and salinity of drinking water, smoking, the use of alcoholic beverages, hron, went. - kish. infections, anatomic and functional disturbances (hernias, diverticulums, ectopia of a cylindrical epithelium, gastric glands, achalasias, etc.).

Carry a leukoplakia to precancerous diseases of P., hron, an esophagitis, ulcers, hems after a burn, polyps.

A specific place is held by a dysplasia. Slight dysplastic changes can accrue up to emergence carcinoma in situ (see).

Invasive cancer of a gullet can develop as through a stage of cancer of in situ, and directly from the centers of a dysplasia.

P.'s cancer is most often observed in an average third of P. (according to All-Union oncological scientific center of the USSR Academy of Medical Sciences, in 66.2% of cases), is more rare in the lower third (24,3%), is even more rare in an upper third (9,5%). It proceeds from epithelial formations of a mucous membrane and a submucosal layer of P.: a multilayer flat epithelium, output and secretory departments of mucous glands, seldom islands of a cylindrical epithelium or glands of a stomach, malrelated in a mucous membrane of a gullet.

On the structure in most cases P.'s cancer is planocellular (90%), other forms of cancer meet seldom. Planocellular crayfish can be various degree of a differentiation. The Verrukozny (warty) carcinoma is option of well differentiated planocellular cancer. Carry the planocellular cancer from the extended cells which sometimes is mistakenly taken for sarcoma to the low-differentiated planocellular cancer.

Adenoakantoma is estimated as a kind of an adenocarcinoma. Adeno-kistozny and mucoepidermoid cancer (see. Mucoepidermoid tumors ) are analogs of similar tumors of sialadens. In the presence of accurately expressed components in the form of planocellular cancer and an adenocarcinoma zhelezistoploskokletochny cancer which should be distinguished from an adenoakantoma (adenocarcinoma) is allocated.

Fig. 42. Macrodrugs of a gullet (shooters specified tumors): and — the leiomyoma covered with an intact mucous membrane; — exophytic (endoluminal; a form of cancer with an ulceration; in — an endophytic form of cancer: — a polipovidny form of a carcinosarcoma.

As growth P.'s cancer can be exophytic (fig. 42,6), growing in a gleam, and endophytic, extending preferential on a submucosa, a muscular coat and in surrounding fabrics (fig. 42, c). The mixed growth forms are often observed. At a certain stage of development the surface of both exophytic, and endophytic new growths can ulcerate. At endophytic forms the tumor sometimes is tsirkulyarno covered by P. Vozmozhen and the multitsentrichny growth of cancer P.

Harakter limfarkhitektonik and P.'s limfodinamik determines ways of possible distribution of tumor cells by a submucosa and a muscular coat on considerable distance from the main node that can make a false impression of a multitsentrichnost and does necessary a research of borders of operational cuts. Going beyond P., the tumor can extend to a trachea, bronchial tubes, vessels of a root of a lung, an aorta, pulmonary fabric, a pericardium, nervous trunks, a chest channel, bodies of vertebrae. Germinations of a tumor result esophageal and tracheal and gsh-shchevodno-bronchial fistulas, pleurisy, a mediastinitis, a pericardis develop, fatal bleedings are possible.

For P.'s cancer the lymphogenous way of innidiation is usual (see), however it can metastasize also in the hematogenous way. Distinguish the following stages of innidiation: metastasises in the next regional limf, nodes, metastasises in regional limf, nodes of more remote zones and the remote metastasises on circulatory system.

Owing to features limf, systems P. there is a possibility of retrograde innidiation. At cancer of upper and midthoracic departments of P. retrograde metastasises in paracardiac and retroperitoneal limf are observed. nodes. Quite often it is possible to find tumoral defeat in patients limf, nodes in the left supraclavicular area (so-called metastasises of Virkhov).

At P.'s cancer widespread hematogenous metastasises meet less than at cancer of other localizations. Usually the liver, lungs, adrenal glands are surprised. Frequency of innidiation of cancer of P. decreases the patient with age.

It is accepted to distinguish four stages of cancer of the Item I a stage — accurately delimited small tumor or an ulcer localized in a mucous membrane and a submucosa; P.'s passability is broken in insignificant degree; metastasises in limf, nodes are absent. The II stage — the tumor or an ulcer which is not going beyond P.'s wall considerably narrows its gleam; metastasises in limf, nodes single. III stage: a) the tumor or an ulcer occupies the most part of a circle of P. and narrows or carries out its gleam almost before total loss of passability; b) the tumor of any sizes sprouted P.'s wall and was soldered to the next bodies and fabrics; there are metastasises in regional limf, nodes. The IV stage — a tumor left far beyond body and caused burrowing; there are motionless metastasises in regional limf, nodes and the remote bodies.

Classification by the TNM system (see. The international system of clinical classification of cancer) during the definition of prevalence of process considers data clinical (radiological) and tool methods of a research. According to the level of cancer of P. struck regional limf, nodes are cervical, intrathoracic and intraperitoneal.

Primary tumor (T): T1 — is limited to one area and does not cause disturbance of a vermicular movement or mobility of body: T2 — a tumor is limited to one area, causes disturbance of a vermicular movement or P.'s mobility; The T3 — a tumor extends more than to one area; T4 — a tumor extends to the next structures. Regional limf, nodes (N): N0 — limf, nodes are not defined; Nx — are defined displaced limf, nodes on one party; N2 — are palpated displaced limf, nodes on both sides; N3 — are probed constant limf. nodes. As to estimate a condition intrathoracic and intra belly limf, nodes are impossible, it is necessary to use category Nx. Remote metastasises: (M i: There is no M0 — signs of the remote metastasises; Mkh — there are remote metastasises.

The wedge, symptoms of cancer of P. can be divided into three basic groups: local symptoms — a dysphagy (see), various unpleasant feelings in P. connected and not connected with passing of a food lump vomiting, vomiting, hypersalivation; the remote symptoms — symptoms from outside as a number of the lying bodies, and remote, caused by involvement in process of the guttural, wandering nerves, nerves of a sympathetic trunk and their terminations, i.e. signs of damage of a trachea, lungs, heart, a stomach, intestines, and also nevrol, symptoms — neck, backbone pains, etc.; the general symptoms — morfol, changes of blood, temperature increase, bystry fatigue, etc.

Cancer detection of P. in initial phases of a disease presents considerable difficulties. It is connected first of all with the fact that quite often first symptoms are not local signs (disturbances of passing of food according to P.), and the remote, general symptoms and their combination which are the cornerstone of so-called clinical masks. Among such symptoms is more often than others synalgias in a neck, a breast, a backbone, heart, a stomach and the dispeptic phenomena — an eructation, heartburn, nausea, vomiting, vomiting etc. are observed.

Knowledge of features a wedge, symptoms of cancer of P. allows to reveal a disease timely. In early stages when patients look healthy people, even the minimum unpleasant feelings in the area P. or connected with swallowing shall draw attention of the doctor. Use in such cases of antispasmodics without rather full purposeful studying of the patient should be considered an appreciable error.

P.'s cancer can arise against the background of the previous diseases of this body (cicatricial changes in P. after a corrosive or thermal burn, esophagites, diverticulums, benign tumors, etc.). In these cases the diagnosis of cancer of P. presents considerable difficulties. Increase of already available symptoms, emergence of new signs, deterioration in the general condition of the patient shall induce the doctor to careful repeated inspection.

Special difficulties are presented by cases of the hidden current — so-called mute cancer of the Item. The diagnosis in this case is usually made already in the presence of metastasises or germination in the next bodies.

During a disease it is possible to allocate the following a wedge, forms of cancer of P., to-rye meet approximately the following frequency: esophageal (49%), gastritichesky (14%), neuralgic (10%), cordial (9%), laryngotracheal (8%), plevropulmonalny (5%), mixed (5%).

The typical esophageal form is characterized by group of symptoms, anyway testimonial of existence patol, process in P. (a dysphagy, a dysphagia, pains during the passing of food according to P.). At a gastritichesky form symptoms of damage of a stomach — an eructation, heartburn, nausea, vomiting, vomiting etc. prevail. At a neuralgic form into the forefront synalgias in a neck, a shoulder, a hand, a backbone act. The cordial form is followed by pains in heart. The laryngotracheal form is characterized by hoarseness, an aphonia, the barking cough. At a plevropulmonalny form patients complain of cough, short wind, attacks of suffocation.

The wedge, a picture of cancer of P., including radiological and esophagoscopic signs, depends on the nature of growth of a tumor, level of defeat and surrounding P.' syntopy of bodies and fabrics.

Considering dynamics of growth of new growths of P., allocate the following options of their development.

The first option — the tumor is sharply delimited, and in its growth the intraezofagealny direction prevails (the tumor usually is located on one of walls of P.).

The second option — the tumor is not delimited and its growth is made both along P.'s wall, and in its gleam.

The third option — in the tumor developing by the second option is observed also circular growth.

The fourth option — growth of a tumor is made along one wall of P. and preferential knaruzh.

The fifth option — in the tumor developing by the fourth option is observed also circular growth; usually at the same time the muftoobrazny enveloping of the Item is noted as if.

The sixth option — the tumor is not delimited, and its growth is made both along P.'s wall, and in its gleam (the tumor is usually localized on one of walls).

The seventh option — in the tumor developing by the sixth option is observed also circular growth (such tumors affect usually all walls of P.).

Each of options of spread of a tumor can meet as independently, and in combination with others. The provided scheme explains presence of this or that a wedge, forms or \to U-00AB\of a mask» P.'s cancer and is the cornerstone of the choice of a method of treatment. So, with an exophytic growth of a new growth by the first and conducting a wedge, a sign is the dysphagy caused by both mechanical, and reflex factors. Existence of a pharyngeal dysphagy at localization of a tumor in the lower segments P is explained by the last. In some cases disturbance of a sialosis, sometimes pains during the passing of a food lump happens the main symptom. At rapid growth of a tumor of pain dysphagies can precede.

With an endophytic growth of a new growth the clear wedge, symptoms can long not come to light. The dysphagy a long time is absent. Pains develop at defeat of sensitive fibers of nervous trunks and nerve terminations, can have the reflected character, being projected on that body which nervous formations are involved in process.

With an intraparietal growth the tumor probably coming from elements of mucous glands, grows at hl. obr. in a submucosa, removing both a mucous membrane, and muscular (creeping distribution). The wedge, symptomatology at this type of growth in many respects depends on extent of involvement in process internal and periblasts of a wall of the Item.

Widespread tumors of upper segments P. are followed by signs of damage of a trachea with development of aspiration pneumonia. At defeat of nervous trunks the aphonia is observed.

Symptoms of germination of a tumor in the next bodies come to light at defeat of midthoracic segments P more often. At germination in cellulose pains in interscapular space develop. Germination of nervous trunks brings to nevrol, to frustration (feeling of heat, shoulder and hand pain, the increased perspiration, paresthesias, intercostal pains). At germination of a tumor in a wall of a bronchial tube cough develops, during the formation of esophageal and bronchial fistula — pristupoobrazny cough, symptoms of aspiration pneumonia. Perforation of a tumor in a mediastinum conducts to a mediastinitis (see). At germination of large vessels bleedings are observed.

At localization of cancer of P. in nizhnegrudny department germination by a tumor of a pericardium is followed by signs of a pericardis (see).

Expressed a wedge, the picture of a disease can not always correspond to the amount of defeat. It should be considered at the choice of a method of treatment.

Early and reliable diagnosis of cancer of P. requires use of a complex of diagnostic actions. Is important correctly and carefully collected anamnesis. Pay attention to any manifestations of so-called esophageal discomfort in the form of a scratching, burnings at a proglatyvaniye of hot and spicy food, unpleasant feelings at reception of rough food, a poperkhivaniye during the swallowing, etc. It is necessary to remember not only the symptoms connected with disturbance of passing of food but also the so-called remote symptoms, a wedge, forms and «masks» of cancer of the Item. Experience of All-Union oncological scientific center of AMD USSR showed that the most rational need to recognize the following order of diagnostic actions: profound studying of the anamnesis and a condition of the patient, rentgenol, a research, tsitol, a research of washouts from a mucous membrane, an ezofagoskopiya with a biopsy, indication by radioactive phosphorus.

Rentgenol, a research is the leading method of detection of cancer P.

Material for tsitol, researches can serve wash liquids, aspirirovanny contents of P. Ispolzuyut aim aspiration. Detection of tumor cells is the convincing proof of malignant process, but the negative take does not exclude existence of cancer P.

Ezofagoskopiya (see) carry out after rentgenol, researches (tsvetn. fig. 16, 17, 18). During the carrying out a research it is necessary to make a biopsy of the sites which caused suspicion of a tumor and also of not changed mucous membrane and the tumor located on border. In cases, difficult for diagnosis, the ezofagoskopiya should be repeated. The negative take of a biopsy is also not the basis to reject the diagnosis of cancer of the Item. During an ezofagoskopiya it is possible to receive material and for tsitol, researches.

For differential diagnosis the radio isotope research based on ability of malignant tumors to accumulate and detain the phosphorus entered into an organism is applied. About existence of a malignant new growth judge by relative accumulation of a radiotracer. The radio isotope research after operation or radiation therapy in some cases allows to judge radicalism of the carried-out treatment and emergence of a recurrence.

P.'s cancer is differentiated with a cardiospasm (see), cicatricial narrowing of P., P.'s ulcer, an esophagitis, benign tumors of P., a varicosity of P., P.'s diverticulums, P.'s prelum from the outside the tumors of a mediastinum, hems after the postponed mediastinitis which are abnormally located vessels in a mediastinum, etc.

Surgical and beam methods are the main at cancer therapy P. Himioterapiya of cancer P. is a little effective.

50 — 60% of patients can be subjected to surgical treatment. At the same time radical operation manages to be performed only at 27 — 45% of the operated patients. The quantity of postoperative complications is high, postoperative mortality is rather high. Nevertheless, the surgical method at early stages of cancer of P. does probable radical treatment.

At assessment of indications to operation localization, prevalence of a tumor and the general condition of the patient are considered. Surgical tactics is various depending on the level of defeat of the Item. At cancer of a belly and nizhnegrudny part the single-step transpleural resection of P. and the cardia with imposing intrathoracic esophageal - ludochnogo an anastomosis under an aortic arch is shown. Beam cancer therapy of nizhnegrudny part P. is less acceptable because of difficulty of impact on pericardiac limf, nodes, to-rye are regional at these localizations of cancer.

At cancer of midthoracic department of P., except surgical intervention, the beam treatment which is especially shown at advanced age can be carried out. From surgical methods give preference to two-stage operation of Dobromyslov — Toreka.

At cancer of cervical part P. an operative measure is extremely risky. Perhaps beam treatment.

At sharply expressed dysphagy in cases of nonresectable tumors palliative operations can be made — the gastrostomy or P. Poslednyaya's rekanalization consists in introduction of a plastic prosthesis to a gleam stenosed a tumor of the Item.

Beam cancer therapy of P. is an effective method. In the selected group of patients five-year survival reaches 20%. At use of radiation therapy function P. remains, at many patients working capacity is not lost.

The correct selection of patients is important for radical or palliative beam treatment. It is necessary to consider a form, the sizes of a tumor, localization in a segment P., a stage patol, process, the nature of growth — spread of a tumor, a condition of surrounding fabrics, the general condition of the patient, etc.

Contraindications to radiation therapy (see), except the general, are: P.'s perforation, remote metastasises.

Radiation therapy is carried usually out by conventional radiations, however increase in its efficiency is connected with use of heavy nuclear particles. Different options of remote mobile or static radiation are applied. The combination of outside and intracavitary radiation is reasonable. For intracavitary radiation artificial radioactive nuclides are used.

In all cases for radiation of a tumor, and also regional limf, nodes it is reasonable to create in a mediastinum the field of radiation of approximately cylindrical form to dia. 5 — 6 cm blocking the borders of a new growth seen on roentgenograms by P. higher and are 3 — 6 cm lower. Full destruction of a tumor of P. can take place at a total focal dose 6000 — 7000 is glad (60 — 70 Gr). Usual fractionation of a dose is applied — 200 I am glad (2 Gr) daily 5 days a week. At beam to lay downeniya with the palliative purpose single and total doses can be lowered.

Expressiveness of the general and local beam reactions (see. Beam damages) is defined by a type of ionizing radiation, a rhythm of treatment and specific features of the patient.

For prevention of possible beam reactions and damages radiation therapy needs to be combined using the means which are sharply lifting resistance of an organism (see. Beam damages). Special attention shall be paid to stimulation of immunoprotective and gemato-poetic functions of an organism.

Radiation therapy at the first stage of the combined treatment aims at creation of conditions for more successful performing surgery. Usually total absorbed dose in a tumor happens to 3000 — 5000 is glad (30 — 50 Gr). It is reasonable to carry out surgical treatment in 2 weeks after the end of radiation. Preirradiation with the subsequent operation within 1 — 2 days is offered also accelerated (in 2 — 3 days). In these cases the total absorbed dose happens till 2000 is glad (20 Gr).

The forecast at P.'s cancer without treatment is adverse. Average life expectancy from the moment of emergence of the first symptoms of a disease from 5 to 10 months. Sometimes patients live and 2 — 3 years. At operational treatment 5-year survival makes 8 — 10%, at beam treatment of the patients who are not subject to an operative measure, 5%. The combined method of treatment allows to improve the long-term results.

Malignant not epithelial opukho-l and (leiomyosarcomas, fibrosarcomas, rhabdomyosarcomas, etc.) meet seldom and make 1 — 1,5% of all malignant tumors of the Item.

Leiomyosarcomas (see) — the most often arising malignant not epithelial tumors of the Item. Their most part is observed in average and lower thirds of the Item. They have but the lipovidny form.

P.'s carcinosarcomas (fig. 42, d) meet extremely seldom. At microscopic examination it is difficult to differentiate them with a so-called pseudosarcoma — option of planocellular cancer. The last is usually presented by nests of the epithelial cells surrounded with the stromal cells of the extended form giving looking alike a carcinosarcoma (see).

The principles of treatment and the forecast of a leiomyosarcoma and carcinosarcoma same, as well as at P.

Melanom P. cancer (as primary tumor) it is observed extremely seldom, more often at advanced age. Differential diagnosis between primary melanoma of P. and a metastasis of a melanoma is difficult and is based on existence in primary tumor of the centers of so-called boundary activity in basal layers of a multilayer flat epithelium (see. Melanoma ). The forecast both at primary tumors, and at metastatic defeat is adverse.

As rare options of primary tumors of P. are described carcinoids (see) and horionepitelioma (see. Trophoblastic disease ).

Secondary epithelial tumors of P. are rare. Are observed at contact germination of tumors of a thyroid gland, throat, trachea, bronchial tubes, a stomach and generalization of blastomatous process (metastatic defeat of P. at primary tumors of a mammary gland, testicles, prostatic and pancreatic glands).

OPERATIONS

the Vast majority of patients with P.'s diseases suffers from the dysphagy leading to disturbance of food, decrease in blood proteins, dehydration therefore special preoperative preparation is necessary. The last shall include good parenteral nutrition (intravenous administration of amino acids, fats, carbohydrates, blood and its components, water-salt solutions, vitamins, etc.). At full impassability of P. when parenteral food does not give due effect, the gastrostomy is shown (see).

Anesthesia — an endotracheal anesthesia (see. Inhalation anesthesia ). At an anesthesia it is necessary to consider need of duration of anesthesia, exhaustion of patients, their advanced age.

For the purpose of reduction of operational risk at the elderly and weakened patients hyperbaric oxygenation (see) which is of great importance for prevention of a hypoxia of vitals at surgical interventions with the increased operational risk is applied.

Quick accesses to P. depend on localization patol, process.

Fig. 43. The diagrammatic representation of a section of skin (it is specified by a dotted line) at access to cervical department of a gullet.

At diseases of cervical part P. of the best access the section on a first line left grudino - a clavicular and mastoidal muscle (fig. 43) is. Position of the patient on spin with the roller enclosed under shoulders, the head is turned to the right. Cut skin with hypodermic cellulose, a hypodermic muscle of a neck. Allocate grudino - a clavicular and mastoidal muscle and remove its knaruzh. Allocate the left share of a thyroid gland and take it to the medial party. During approach to P. it is necessary to delay carefully the general carotid artery and an internal jugular vein in the lateral direction that during manipulations on P. not to damage them. P.'s allocation during operation is facilitated if to enter the thick rubber probe into its gleam. In need of mobilization of all circle of P., getting in the stupid way through a tracheosesophageal furrow, allocate P. and bring under it a gauze or rubber handle. Upon termination of the main intervention on P. the wound is sewn up, leaving a drainage in the area of seams.

Access to verkhnegrudny part P. can be provided by a partial median sternotomy or right-hand thoracotomies. The partial median sternotomy is carried out by means of a special circular saw, a chisel or an ultrasonic wave guide. Position of the patient on spin with longwise the located roller. The breast is cut from jugular cutting to the II—III level of edges and crossed in transverse direction at the level of II or III mezhreberye. Such access is less traumatic in comparison with a full median sternotomy.

The transpleural access to verkhnegrudny part P. provided in the way perednebokovy a thoracotomy in the fifth — the sixth mezhreberye, is most convenient on the right as the chest department of P. deviates to the right and directly prilezhit to a mediastinal pleura.

Quick access to midthoracic part P. is provided also in the way right-hand perednebokovy thoracotomies in VI or the VII mezhreberye.

Access to nizhnegrudny department of P. is carried out by left-side thoracotomies in the seventh mezhreberye with crossing of a costal arch. The pleural cavity is opened in the seventh mezhreberye, cross a costal arch then widely part with a special ranorasshiritel edges. Cut a pulmonary sheaf, cut a mediastinal pleura to an esophageal opening of a diaphragm from top to bottom and allocate P. from cellulose of a mediastinum. When there is a need for access to a stomach, the diaphragm is cut between two styptic clips. If during an operative measure of P. did not resect, then after suture on a diaphragm, a mediastinal pleura sew rare noose sutures. The chest cavity is sewn up with leaving of a drainage tube at the level of VIII mezhreberye on the back axillary line.

Access to belly part P. is provided by a median laparotomy (see) from a xiphoidal shoot to the middle of distance between a navel and a pubis or way of a slanting section in left hypochondrium. Position of the patient on the operating table on spin with the roller enclosed under lumbar area. Good access to belly part P. and a cardial part of a stomach is promoted by use of ranorasshi-ritel. The left triangular ligament of a liver is crossed at a diaphragm then the liver is taken away to the right. Cross legs of a lumbar part of a diaphragm that allows to bare P. in a mediastinum on 5 — 6 cm.

At cancer of midthoracic part P. most often apply Dobromyslov's operation — Toreka. It was developed by V. D. Dobromyslov (1900 — 1902) in an experiment, and at the person the first successful operation was executed by Torek (F. J. A. Torek, 1913). In the USSR this operation was manufactured for the first time by V. I. Kazansky, and P.'s extirpation with imposing of an intrapleural esophageal and gastric anastomosis — B. V. Petrovsky. Operation consists in an extirpation of chest part P. with imposing of an ezofagostoma on a neck and gastrostomies.

Fig. 44. The diagrammatic representation of operation of Dobromyelov — Toreka: and allocation of a gullet (1) from a mediastinum; — underrunning of a gullet (1) is higher than a tumor (2) a stapler (3); in — allocation of a gullet (1) on a neck with the subsequent extraction of a stump (2) from a mediastinum via the tunnel (3) in hypodermic cellulose; formation of a cervical ezofagostoma — sewing together of edges of skin (1) with a wall of a stump of a gullet (2)

For performance of this operation use a right-hand thoracotomy in the sixth mezhreberye. The mediastinal pleura is cut from a diaphragm to a dome of a pleura. Ligirut and cross an unpaired vein. All chest part P. is allocated from a mediastinum (fig. 44, a). A belly part is stitched a stapler or tied up a ligature. P.'s stump at a cardial part of a stomach is immersed in a purse-string seam over which put noose sutures.

Above, near a dome of a pleura, P. also stitch the device (or tie up) and delete a piece together with a tumor (fig. 44, b).

Put on a rubber cap a stump of oral department of P. not to infect a pleural cavity, and sew up the last with leaving of a drainage. The patient is stacked on a back in situation for access to cervical part P. and with a section in the left half of a neck allocated and remove an oral stump of the Item from a mediastinum. An additional small section at the level of a clavicle or slightly below in hypodermic cellulose form a tunnel to which carry out P.'s stump (fig. 44, c). Cut the end of the stump stitched by paper clips and hem P. to skin noose sutures (fig. 44, d). Neck wound is sewn up with leaving of the rubber graduate. Impose a gastrostomy (see. Gastrostomy ).

After P.'s extirpation on the Kind myslovu — to Torek at a number of patients carry out oesophagoplasty (see the Gullet artificial).

The resection of chest department of P. is shown to hl. obr. at cancer of nizhnegrudny part P. After left-side thoracotomies and a diaphragmotomy will mobilize nizhnegrudny part P. with a tumor and a cardial part of a stomach. Items cross above a tumor and at the cardia. The stomach in the field of the cardia is sewn up with a two-row seam, in a pleural cavity impose an anastomosis between P. and a greater cul-de-sac. At higher localization of a tumor P.'s resection often results in insufficiency of seams of an esophageal and gastric anastomosis owing to what the direct postoperative lethality reaches 40-50%.

The resection of cervical part P. is possible at I and II stages of cancer of the Item. By data A. V. Melnikova, a resection of cervical part P. is shown at malignant new growths with a diameter no more than 4 cm which lower bound is clearly probed over jugular cutting at a zaprokidyvaniye of the head of a kzada and during the swallowing. Quick access — on a neck at the left. If approach to P. is insufficient, then the section is continued from top to bottom, turning over a clavicle on the opposite side. Items allocate for 3 cm above and lower than a tumor. Underlying part P. will be mobilized and extend approximately on distance 5 cm, P. resect. If length of the rezertsirovanny site no more than 4 cm, then impose an esophageal and esophageal anastomosis the end in the end. During imposing of an anastomosis the head of the patient is bent down by kpered to reduce a tension of seams. With the same purpose the lower piece of P. below seams of an anastomosis is hemmed to long muscles of a neck.

FEATURES of DAMAGES, BURNS AND DISEASES of the GULLET AT CHILDREN

Injuries of a gullet at children can be connected with jamming of accidentally swallowed foreign bodys, various diagnostic and lay down. manipulations on P. (an ezofagoskopiya, bougieurage, removal of foreign bodys, sounding of a stomach). Outside damages occur at children very seldom and are connected with the accidental getting wounds or damages of body at operative measures. Spontaneous ruptures of P. meet extremely seldom.

Foreign bodys meet at children from 2 to 5 years as a result of an accidental proglatyvaniye of various objects during the game or food more often. Among foreign bodys coins, small parts of toys, badges, fish and meat stones prevail. Usually foreign bodys get stuck in cervical part P. — is slightly lower than the first fiziol, narrowings, are more rare in a chest part at the level of bifurcation of a trachea. The item is damaged by acute foreign bodys right after their jamming or in attempts of extraction or owing to decubitus at their long stay.

P.'s damages occur even at newborns at rough performance of such manipulations as suction of slime from a throat rigid catheters, mistakes at an intubation of a trachea, sounding of a stomach. In these cases of damage most often occur in a transition range of a throat in P.; the contributing factor is the subtlety of a wall of P. U of children the risk of damage of P. at an ezofagoskopiya is high rigid endoscopes if this research is carried out without anesthesia.

Incorrectly executed P.'s bougieurage at children can also lead to its damage. The cicatricial narrowed P. is most often damaged in attempts of bougieurage blindly through a mouth or via the esophagoscope. Damages at bougieurage for thread through a gastrostomy arise extremely seldom.

Wedge, a picture at damages from P.'s gleam is defined first of all by the sizes and level of perforation. Most hard damages of chest department of P. U of children quickly proceed symptoms of shock and intoxication develop: owing to involvement in inflammatory process of cellulose of a mediastinum, and it is frequent also pleurae. In diagnosis the research is emergency rentgenol, decisive. At survey roentgenoscopy and a X-ray analysis a reliable sign of perforation is availability of air in a mediastinum, the shadow of a mediastinum is usually expanded. Specification of nature of perforation requires a research P. with a contrast agent. The research is made in position of the patient lying using water-soluble contrast mediums or Iodolipolum. To children of younger age they are entered by means of a catheter. Flowing of a contrast agent for P.'s contours demonstrates macroperforation, lack of this symptom does not exclude a mikroiyerforation.

Damages of cervical part P. at children are followed less expressed a wedge, a picture. In diagnosis such symptoms as difficulty of swallowing, hypersalivation matter. Emergence of air in hypodermic cellulose of a neck is an important objective sign.

In treatment one of the first actions is the termination of meal and liquid through a mouth, at once begin infusional therapy with inclusion of antibiotics. At microperforations feeding is carried out via the probe. At macroperforation impose a gastrostomy (see the Gastrostomy, at children). Sewing up perforative openings is shown at recognition of perforation in the first 12 — 24 hours. At damage of chest part P. at children operation is made by a dorsal intercostal extra pleural mediastinotomy without resection of edges. If the cicatricial narrowed P. is damaged, suture on the changed fabrics is inexpedient, the resection of the Item is shown. Days later and more after P.'s damage at makroperforation tactics is defined already by existence and character of a mediastinitis (see the Mediastinitis, features at children).

Burns of a gullet at children but frequency win first place among all diseases of the Item. The largest specific weight among victims is made by children aged from 1 year up to 3 years. Accidental intake of caustic chemical substances at their negligent storage or wrong giving them instead of drugs or drink is the reason. Unlike adults, at children in connection with reception of small amounts of pyretics of display of a burn prevail over poisoning.

At children, as well as at adults, distinguish three degrees of burns P. Klien, the picture in the first 3 — 4 days is caused by acute inflammatory process: at patients temperature increases, the concern, hypersalivation, a dysphagy are noted. Meal, and sometimes and waters, is limited or impossible. At reception of pyretics, owing to their inhalation or aspiration, edematization of a throat is possible. In these cases an inspiratory asthma, concern, respiratory insufficiency is noted. The course of burns of P. with 5 — is characterized the 6th day by gradual improvement of the general state, decrease in temperature, hypersalivation and a dysphagy disappear, there is possible food through a mouth. The specified improvement at burns of I and II degrees is resistant, and children recover. At deep burns (in the absence of adequate treatment) the period of wellbeing is temporary, «imaginary». With 4 — 6th week there are difficulties at reception of firm, and then and liquid food owing to the beginning cicatricial process in

P. V the acute period, on the basis a wedge, symptoms it is impossible to assume or deny existence of a burn of P. and furthermore to determine its depth and prevalence. At the isolated burn of an oral cavity and at P.'s burn symptoms can be identical. Lack of plaques in an oral cavity also does not exclude a burn of the Item. Proceeding from these features, diagnosis of burns of P. at children shall be based first of all on data of an objective research — an ezofagoskopiya. The research is made under anesthetic, more preferable the flexible fibroendoskopa allowing to examine not only P., but also a stomach and to reveal the combined defeats.

The first ezofagoskopiya is made on 5 — the 6th day, and during the use of fiberscopes — on 2 — the 3rd day. On the basis of this research it is possible to exclude P.'s burn or to establish its easy degree which is not demanding treatment. At burns of the II—III degree fibrinous imposings on sites of bigger or smaller extent are defined. However the first diagnostic ezofagoskopiya does not allow to differentiate burns of II and III degrees. It is possible only at a repeated ezofagoskopiya, to-ruyu make in 3 weeks after the first. At burns of the II degree there comes full epithelization of burn surfaces by this time, and at deep burns of the III degree ulcerated surfaces with sites of fibrinous imposings are noted.

Treatment needs to be begun right after reception of chemical substance. As first aid the child is given a large amount of water or milk and cause vomiting. In the ambulance car or the accident ward wash out a stomach via the probe a plentiful amount of water. Depending on weight of a state determine the volume of infusional therapy, considering at the same time existence of symptoms of poisoning. Appoint antibacterial therapy with constant sanitation of an oral cavity weak antiseptic solutions, through a mouth give fish oil and butter. After recovery of swallowing begin feeding with kashitseobrazny food, passing gradually to the food corresponding to age. Only at extremely heavy total burns of P. there can be indications to a gastrostomy.

Represents certain features to lay down. tactics at the burns which are followed by hypostasis of a throat. In these cases during the first hours make intranasal novocainic blockade, enter a hydrocortisone, potassium chloride, appoint dehydrational and sedative therapy, revulsives. At inefficiency of the specified actions the prolonged nazotrakhealny intubation allowing to avoid a tracheostomy at most of patients is reasonable. The main objective in treatment of heavy burns (the III degree) is the prevention of development of a cicatricial stenosis. The most reliable is early preventive bougieurage of a buzhama, P. corresponding to age diameter (see Bougieurage). At the correct use of a method development of cicatricial narrowing is noted in exclusively exceptional cases at very deep and widespread burns.

Diseases. Secondary stenoses owing to chemical burns or a peptic esophagitis, a varicosity of II occur at children among acquired diseases of P. a peptic esophagitis because of a gastroesophagal reflux., pi-shchevodno-tracheal and pishchevodnobronkhialny fistulas, diverticulums.

The peptic esophagitis at children is caused by cadioesophagal relaxation at malformations of ezo-fagokardialny area (inborn short P., ezofagealny hernias), a halaziya (a gaping of the cardia) owing to insufficiency of its neuro and muscular regulation. Aggressive impact of a gastric juice on mucous P. leads to various forms of an esophagitis: to catarral,

fibrinous, ulcer fibrinously, stenosing. Wedge, manifestations are quite often noted already in the period of a neonatality and consist in persistent vomiting and vomiting to gastric contents, a weight loss.

Also hemorrhagic syndrome is characteristic (impurity of blood in emetic masses or a coffee-ground vomit, anemia, the occult blood in Calais). At development of a stenozirovaniye owing to scarring of ulcers symptoms of disturbance of passability of P. join (a dysphagy, vomiting undigested food, the senior children have a pain syndrome). It is necessary for establishment of a gastroesophagal reflux rentgenol, a research P. and a stomach with a contrast agent in vertical position of the patient and in the provision of Trendelenburga (see. Trendelenburga situation ) at hard filling of a stomach and a moderate compression of epigastric area. The second necessary research is the ezofagoskopiya, it is more preferable by means of a fibroendoskop. An additional method in diagnosis of a gastroesophagal reflux is intra esophageal rn-met-riya. Depending on degree of manifestation of an esophagitis and its reason is defined to lay down. tactics. At a catarral and fibrinous esophagitis because of a functional incompetence of cardia (halaziya) conservative treatment is shown, a cut consists in giving of constant situation to the patient (the head end of a bed is raised), fractional feeding by dense mixes in the small portions, purpose of the antiacid, enveloping and sedative drugs. Efficiency of therapy is controlled clinically and endoscopic. In the absence of effect, the proceeding vomiting and emaciation, and also during the progressing of an esophagitis anti-reflux operations are shown. Operational treatment is necessary also at an ulcer esophagitis, as a rule, accompanying malformations ezofagokardial-ache areas. At a stenozirovaniye anti-reflux operations are supplemented with a gastrostomy for the purpose of the subsequent elimination of a stenosis by bougieurage for thread.

Fig. 45. The roentgenogram of a gullet of the child with cicatricial narrowing in an average third.
Fig. 46. A double ezofagoskopiya proximal and distal (through a gastrostomy) departments of a gullet at cicatricial impassability.

Cicatricial esophageal stenoses because of chemical burns occur among acquired diseases of P. most often. They, as a rule, develop at uncured or incorrectly treated burns or very deep and extensive defeats by caustic chemical substances. A wedge, manifestations of a stenozirovaniye begin with 4 — 6th week after a burn and consist in the progressing symptoms of disturbance of passability of P. (a dysphagy, vomiting food and water, emaciation). Periodically at children episodes of full impassability in connection with jamming of firm food are noted. The establishment of gastric fistula is shown to patients with cicatricial stenoses of P. for good nutrition. For specification of level and extent of a stenosis, assessment of a condition of a mucous membrane of proximal and distal departments of P. carry out rentgenol, a research with a contrast agent (fig. 45) and an ezofagoskopiya. For contrasting of distal department of P. the baric suspension is entered on a catheter which is tightened through a gastrostomy to level of the lower bound of a stenosis by means of the thread drawn through the Item. Inspection of distal department of P. is performed by an ezofagoskopiya through a gastrostomy (fig. 46).

The main method of treatment of cicatricial narrowings of P. at children which gained the greatest distribution is bougieurage for thread (see. Bougieurage, a gullet at children ). At the stenoses which are not giving in to expansion by bougieurage or at their recurrence after the carried-out treatment there are indications to artificial P.'s creation (see. Gullet artificial ). In assessment of prospects of treatment by bougieurage

depth of cicatricial process is important.

In this regard Yu. F. Isakov with sotr. (1978) offer intraoperative audit of the cicatricial narrowed P. at children extra pleural access without resection of edges. At the cicatricial process taking only a mucous membrane and a submucosa single-step elimination of a stenosis by the forced intraoperative bougieurage is carried out. In cases of involvement in cicatricial process of a muscular coat at short stenoses it is shown ezofagoezofagoanastomoz, during the narrowings of considerable extent — a resection of chest part P. with the subsequent creation of an artificial gullet.

At full impassability of P. at children caused by chemical burns in all cases the establishment of gastric fistula is shown. In diagnosis along with X-ray and esophagoscopic inspections color test (existence or lack of a vykhozhdeniye of the tinted liquid entered through a mouth) is applied. Full cicatricial impassability is the absolute indication for creation of the artificial Item.

The varicosity of a gullet at children is a consequence of portal hypertensia (see) and quite often leads to bleeding. The principles of diagnosis and treatment are similar applied at adults.

The acquired fistulas between P. and a trachea or bronchial tubes occur at children seldom. Can be the reasons perforation and wound during bougieurage and surgeries, and also owing to nonspecific and specific inflammatory processes in a mediastinum. A wedge, manifestations depend on level, diameter of fistula and secondary is purulent - destructive changes in lungs. The cough amplifying at reception of liquid food and in a prone position, frequent aspiration pneumonia up to development of abscessing is characteristic. In diagnosis these trakheobronkhoskopiya, and also rentgenol, researches matter (esophago-grafiya, a bronchography). Treatment consists in operational division of fistula.

The acquired P.'s diverticulums at children are extremely rare and connected with cicatricial changes in a pas-raezofagealnoy to cellulose because of chemical burns, P.'s injury and the postponed mediastinitis (traction diverticulums). Tactics is defined by a basic disease.



Bibliography:

Anatomy, physiology — Zolotko Yu. L. Atlas of topographical anthropotomy, p. 2, page 129, M., 1964; F. P. Marquises. Venous system of a digestive tract of the person, Kuibyshev, 1959, bibliogr.; M e l-man E. P. Functional morphology of an innervation of digestive organs, M., 1970, bibliogr.; Petten B. M. Embryology of the person, the lane with English, page 128, etc., M., 1959; Sinelnikov R. D. Atlas of anthropotomy, t. 2, page 49, M., 1979; With t and N of e to I. Embriologiya of the person, the lane soslovatsk., page 222, Bratislava, 1977; Physiology of digestion, under the editorship of A. V. Solovyov, JI., 1974; In e of of t about 1 i n i K. and. Leutert G. Atlas der Anatomie des Menschen, Bd 2, S. 69 u. a., Lpz., 1979; Gray H. Gray’s anatomy, Z., 1973; L e r-c h e W. The esophagus and pharynnx in action, study of structure in relation to function, Springfield, 1950, bibliogr.; Rho-din J. A. Histology, N. Y., 1974.

Pathology — Topical issues of gastroenterology, under the editorship of V. of X. Vasilenko, century 4, page 23, M., 1971; Alexandrov N. M., Kolychev N. I. and And d and l and r e e in and Page X. About morphological and some cytophotometric features of displaziya and cancer of in situ of a gullet, Vopr, onkol., t. 26, No. 1, page 41, 1980; Arablinsky V. M. and Salma M. M. Fiziologiya's N and pathology of motive function of a gullet, M., 1978; B and and r about in D. M., Wangqiang E. N. and P erelman M. I. The acquired fistulas between a gullet and airways, Baku, 1972; Baran JI. And. and d river. The combined and complex treatment of malignant tumors, page 41, Kiev 1979; Belousov A. S. Differential diagnosis of diseases of digestive organs, page 4, M., 1978; B of e r e-zo in Yu. E. Rak of a gullet, M., 1979, bibliogr.; Berezov Yu. E. and Grigoriev of M. S. Hirurgiya of a gullet, M., 1965; Diseases of digestive organs, under the editorship of C. G. Masevich and S. M. Ryss, page 5, L., 1975, bibliogr.; In and of N of e r E. A. The getting wounds of a breast, M., 1975; Wangqiang E. N. and With to about e of l to and N of O.K. A plastic surgery of a gullet with use of a stomach, Tashkent, 1975, bibliogr.; Wangqiang E. N. Is also lean - to about in R. A. Treatment of burns and cicatricial esophageal stenoses, M., 1971, bibliogr.; Vasilenko V. of X. and r e e of N of e in And. JI. Hernias of an esophageal opening of a diaphragm, M., 1978, bibliogr.; Vasilenko V. of X., Grebenev A. JI. and With and l m and M. M N. Diseases of a gullet, M., 1971, bibliogr.; Grebenev A. JI. and d river. Diagnosis of a round ulcer of a gullet, Klin, medical, t. 50, No. 10, page 56, 1972, bibliogr.; Kagan E. M. Radiodiagnosis of diseases of a gullet, M., 1968; Kazan V. I. Hirurgiya of cancer of a gullet, M., 1973, bibliogr.; Clinical oncology, under the editorship of H. N. Blochina and B. E. Peterson, t. 1 — 2, M., 1979; B. D. mosquitoes, To and N sh and N of H. N and Abakumov M. M. Injuries of a gullet, M., 1981; To at with and to and N and G. K., Kolychev N. I. and Adilgi-reeva of Page X. To morphology of reserve cells of output channels of mucous glands of a gullet at a chronic esophagitis, Arkh. patol., t. 40, 10, page 40, 1978; The Multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 4, book 1, page 236, 1956, t. 9, page 713, M., 1964, bibliogr.; Odina K. M., Kauffman O. Ya. and Kapuller JI. JI. Changes of veins of a gullet at a portal hypertension, Arkh. patol., t. 34, No. 10, page 69, 1972; Patsiora M. D., Tsatsa N and d both K. N. and Eramishantsev A. K. Bleedings from varicose veins of a gullet and a stomach, M., 1971, bibliogr.; Peterson B. E., JI e of t I am and V. P. and Vasilyev I. D. N. Results of cancer therapy of a gullet, Surgery, No. 4, page 8, 1976, bibliogr.; Petrov-with to y B. V. Surgical cancer therapy of a gullet and cardia, M., 1950; Petrovsky B. V. and In and N of c I am E. N N. Diverticulums of a gullet, M., 1968, bibliogr.; Petrovsky B. V., etc. Treatment of damages and fistulas of a gullet, Surgery, No. 7, page 7, 1976; Podgorbun-with to and y M. A. and III r and e r T. I. The getting damages and perforation of chest department of a gullet, Kemerovo, 1970, bibliogr.; Rose trees B. S. Foreign bodys and injuries of a gullet and related complications, M., 1961, bibliogr.; Ruderman A. I. Complex diagnosis of cancer of gullet, M., 1970; P at d e r-man A. I., Weinberg M. Sh. and Zholkiver K. I. Remote gamma therapy of malignant tumors, M., 1977; Rusanov A. A. Cancer of a gullet, JI., 1974, bibliogr.; Owl's A. G. Removal and recovery of chest department of a gullet, Surgery, No. 10, page 74, 1944; Sapozhnikovam. And. To morphology of reparative processes in the early period of corrosive burns of a gullet, Arkh. patol., t. 37, No. 8, page 25, 1975, bibliogr.; it, Ruptures of a gullet, in the same place, t. 39, No. 9, page 22, 1977; Modern methods of researches in gastroenterology, under the editorship of B. X. Vasilenko, M., 1971; Shalimov A. A., Saenko B. F. and Sh and - m about in S. A. Hirurgiya of a gullet, M., 1975; Yudin S. S. A plastic surgery at impassability of a gullet, M., 1954, bibliogr.; Alimentary tract roentgenology, ed. by A. R. Margulis a. H. J. Bur-henne, v. 1, St Louis, 1973; B o m b e with k C. T., Boyd D. R. a. N y h u s L. M. Esophageal trauma, Surg. Clin. N. Amer., y. 52, p. 219, 1972; Brombart M. Clinical radiology of the oesophagus, Bristol, 1961; D o d d s W. J., H o g a n W. J. a. Miller W. N. Reflux esophagitis, Amer. J. dig. Dis., v. 21, p. 49, 1976; The esophagus, ed. by L. Van der Reis, Basel, 1978; Fitzpatrick P. J. a. Rider W. D. Half body radiotherapy, Int. J. Radiat. Oncol. Biol. Phys., v. 1, p. 197, 1976; Fletcher G. H. Textbook of radiotherapy, Philadelphia, 1973; Foster J. H. Esophageal perforation, Mod. Treatm., v. 7, p. 1284, 1970; Heberer G., L an u s e like H. u. Hau T. Pathogenese, Klinik und Therapie der Oesophagusrupturen, Chi-rurg, S. 433, 1966, Bibliogr.; Histological typing of gastric and oesophageal tumors, Geneva, 1977; H o p w o o d D. o. Changes in enzyme activity in normal and histologically inflamed oesophageal epithelium, Gut., v. 20, p. 769, 1979; Lehrbuch der Rontgendiagnostik, hrsg. v. H. Schinz, Bd 5, Stuttgart, 1965; M o r s o n B. C. a. Dawson I. M. P. Gastrointestinal pathology, p. 3, Oxford, 1974; Palmer E. D. a. W i r t s C. W. Survey of gast-roscopic and esophagoscopic accidents, J. Amer. med. Ass. v. 164, p. 2012, 1957; Pearson J. G. The present status and future potential of radiotherapy in the management of esophageal cancer, Cancer, v. 39, suppl. 2, p. 882, 1977; Postlethwait R. W. Surgery of the esophagus, N. Y., 1979; Sleisenger M. H. a. Fordtran J. S. Gastrointestinal disease, Philadelphia a. o., 1973; S piro H. M. Clinical gastroenterology, p. 1185, N. Y., 1977; Strahlenthe-rapie, Radiologische Onkologie, hrsg. v. E. Scherer, S. 438, B. — N. Y., 1976.

Gullet at children — Bairov G. A. Urgent surgery of children, JI., 1973; Biyezin A. P. Corrosive burns of a gullet at children, M. — Berlin, 1966, bibliogr.; Isakov Yu. F., Stepanov E. A. igeraskin V. I. The guide to thoracic surgery at children, page 264, M., 1978; Ternovsky S. D., etc. Treatment of corrosive burns and cicatricial esophageal stenoses at children, M., 1963, bibliogr.; Surgery of malformations at children, under the editorship of G. A. Bairova, page 230, L., 1968; G e 1 e at L. Oesophagusperforation im Kindesalter, Z. Kinderchir., Bd 17, S. 138, 1975; Hollwarth M. u. Sauer H. Speiserobrenveratzungen im Kindesalter, ibid., Bd 16, S. 1, 1975, Bibliogr.; Jewett T. C. a. W a t e r s t o n D. J. Surgical management of hiatal hernia in children, J. pediat. Surg., v. 10, p. 757, 1975; Livaditis A. Eklof O. Esophageal atresia with tracheoesophageal fistula, results of primary anastomosis in premature infants, Z. Kinderchir., Bd 12, S. 32, 1973; Rickham P. P., Lister J. Irving I. M. Neonatal surgery, L. — Boston, 1978; Vos A. Boerema I. Surgical treatment of gastroesophageal reflux in infants and children, J. pediat. Surg., V. 6, p. 101, 1971; W a t e r s t o n D. J. Atresia of the oesophagus, Bull. Soc. int. Chir., t. 26, p. 345, 1967.


A. L. Grebenev, V. I. Chissov; G. A. Bairov, E. A. Stepanov, V. I. Geraskin (it is put. hir.), E. N. Wangqiang (hir.), V. V. Kupriyanov (annate.), R. S. Orlov (fiziol.), A. I. Ruderman (PMC., I am glad., rents.) and T. A. Belous (PMC.), M. A. Sapozhnikova (stalemate. An.).

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