The Surgery of the Alimentary Tract

960 Pages·1940·38.394 MB·English

by  Hugh Devine (Auth.)

THE SURGERY OF THE
ALIMENTARY TRACT
BY
SIR HUGH DEVINE
M.S., F.R.A.C.S., F.A.C.S., HON. F.R.C.S (ENG.)
Formerly Senior Surgeon, St, Vincent's Hospital Clinical School, Melbourne, and other Stewart
Lecturer in Surgery, Melbourne University ; President, Royal Australasian College of
Surgeons ; Hon. Fellow of the Association of Surgeons of Great Britain and
Ireland; Chairman, Editorial Committee of the Australasian and
New Zealand Journal of Surgery
WITH 690 ILLUSTRATIONS, SOME IN COLOUR
BRISTOL: JOHN WRIGHT & SONS LTD.
LONDON: SIMPKIN MARSHALL LTD.
1940
PRINTED IN GREAT BRITAIN BY
JOHN WRIGHT AND SONS LTD.
STONEBRIDGE HOUSE, BRISTOL, I
PREFACE
THIS book deals with important aspects of the surgery of the
alimentary canal and its adnexal organs. It is the fruit of many
years' experience of clinical teaching and surgical practice. No
attempt has been made to make it a complete and comprehensive
treatise on the surgery of the abdomen ; such an attempt would
destroy its individuality and defeat the author's purpose.
In the first place the work represents a clinical research into
the pathology of living tissue as seen at the operation table, with a
view to adding to the standard diagnosis of text-books those refine-
ments in clinical, radiological, and other forms of surgical diagnosis
which help early and accurate recognition of disease and therefore
successful surgical treatment.
In the second place it represents the distillate of surgical experi-
ence in regard to selection of operative methods, improvements in
the operative technique of the commoner operations, and advantageous
pre-operative and post-operative treatment—all with the object of
trying to lessen the morbidity of surgical treatment and make it as
safe as possible for the patient.
Assuming as it does a certain amount of text-book knowledge,
this work is intended mainly for the post-graduate. It will, I feel,
be of use to the student as a reference work. But I hope it will be of
special value to those who intend to practise, or who are practising,
abdominal surgery.
Part I is devoted to the diagnosis of dyspepsia. The reason
for this is that the weakness in my own abdominal surgery has been
incompetence in clinical diagnosis in contrast to increasing competence
in radiological diagnosis and surgical treatment : cases did not reach
the radiologist, and therefore the surgeon, as early as they might
have done ; the organic significance of non-text-book-like syndromes
of dyspepsia was not recognized.
With this knowledge in mind, I have tried to add on to the
clear-cut text-book pictures of dyspeptic syndromes (usually based
on well-established disease) those dyspeptic ' patterns ' which are
the manifestations of early disease, and which can only be learnt
from observation on the pathology of living tissue at the operation
VI PREFACE
table and the post-operative review of the case-history in the light
of the operation findings.
With a view of helping in the early recognition of these early
dyspeptic ' patterns ', I have attempted to show the mechanism of
causation of dyspepsia : how it is that certain diseases produce certain
' patterns ' of dyspepsia ; how the same disease—for example, gastric
carcinoma—may produce many varieties of dyspeptic ' patterns ' ;
and how disease in one case may produce a dyspepsia and in another
may be * silent '. Further, with the object of encouraging early
discrimination between the forms of onset of diseases, and therefore
early X-ray examination, I have tried to show that in many obscure
dyspeptic manifestations a significance attaches to whether the inci-
dence of a dyspepsia is on the filling or emptying of the stomach. I
am quite conscious that some of the conceptions I have put forward
will not afford a complete explanation in all circumstances, but they
will serve, I hope, as directional thought in the search for clinical
* clues ' to use in the solution of dyspeptic problems.
With the idea, too, of further improving diagnosis and helping
the surgeon to say ' no ' when an operation of doubtful value is
recommended, I have added chapters on consultative radio-surgical
diagnosis. In these I have attempted to overcome the tendency to
divorce clinical from radiological diagnosis, and to correlate these by
dealing with them as a hypothetical consultation into which I have
also woven those equivocal radiological observations which I have
been able to check at the operation table.
In this part, Dr. John Horan had very kindly contributed a
chapter on Gastroscopy.
Part II deals with the surgical treatment of the diseases which
give rise to dyspeptic syndromes. It also has to do with the treatment
of diseases of those organs in the upper part of the abdomen other
than the stomach—liver, gall-bladder, pancreas, and spleen—which
may cause some dyspeptic manifestations. Here, by describing
methods of technique in detail and introducing refinements and
improvements in everyday operation procedures, I hope to achieve
two objects : to lessen the unnecessary morbidity which I find
often follows routine abdominal procedures ; and to minimize the
dangers of operations in the upper part of the abdomen.
The chapter on Hydatid of the Liver—incorporating mostly
my own experiences—is concerned with pitfalls in diagnosis as well
as operative difficulties.
In Part III will be found chapters on the strategy of surgical
approach to a case of intestinal obstruction or of a perforated hollow
PREFACE VÜ
organ—affections which may involve the upper or the lower part of
the abdomen. In these I have attempted to reproduce the actual
circumstances that are found in practice, and to provide the surgeon
with a preconceived plan of attack.
Part IV is mostly concerned with the surgery of the appendix,
the large bowel, and the rectum.
In the management of appendicitis I have kept in mind the
facts that deaths in acute appendicitis generally result from a failure
to recognize unusual and non-text-book-like syndromes and from an
inability to deal with the unorthodox pathological conditions so
frequently and so unexpectedly found in this disease. Accordingly,
I have tried to present this subject in a way which will throw into
perspective aspects of the disease which are of practical importance, and
aspects the study of which will arm the surgeon so that he may detect
early, and deal with successfully, the abnormal in acute appendicitis.
In the chapters on the colon and fectum, I have attempted to
indicate the way to improved results in the surgery of this region.
Since the diagnosis and treatment of diverticulitis have led me along
thorny paths, I present my experiences—successful and unsuccessful—
for the value they may have to my readers. Because it is a fact that
colon carcinoma—a relatively * benign ' malignancy—comes to opera-
tion mostly in its middle or late stages, I have made the diagnosis
of malignant colon the central point of colonie diagnosis. And for
the reason that operations on the distal colon and rectum have a
high mortality-rate owing to the surgical disabilities attendant on the
peculiar function of these organs, I have described methods designed
to ensure that operation and reparative processes in these regions
shall take place in an organ temporarily deprived of its function—
methods which experience has shown give a lower mortality-rate.
In this work the pathogenesis of disease is not systemically
considered, but only so far as it will explain the ' patterns ' of disease
and the basis of surgical treatment. Many standard methods of
technique are not dealt with as these can be found in other works.
My thanks are due to the publishers, Messrs. John Wright & Sons
Ltd., for the help I have received from them, and for the manner in
which they have produced this work ; to Miss Elizabeth Sellenger
for the illustrations ; and to Professor W. A. Osborne for his help
in the correction of proofs.
HUGH DEVINE.
MELBOURNE,
March, 1940.
THE SURGERY OF THE ALIMENTARY
TRACT
Section I
THE CLINICAL DIAGNOSIS OF SURGICAL DYSPEPSIA
CHAPTER I
DYSPHAGIA IN THE UPPER PART OF
THE (ESOPHAGUS
THE oesophagus is fairly well supplied with sensory nerves—better,
at any rate, than the stomach—and for this reason a patient can
localize an eesophageal lesion. The upper part of the oesophagus
is sensitive, the lower part insensitive,
to touch ; the oesophagus throughout its
whole length is sensitive to pressure and to
temperature. A patient with obstruction
in the oesophagus can therefore generally
point to the spot where swallowing is
obstructed (Fig. i).
In 85 per cent of cases, carcinoma of
the oesophagus is the cause of the obstruc-
tion. For this reason dysphagia, to the
medical mind, generally means a malignant
oesophagus.
Sites of Obstruction in the (Esoph-
agus : the Narrow Places.—Congenitally
Fig. 1.—Shading indicates
there are three ' narrow places ' in the the area to which pain is likely
to be referred from the lower
oesophagus: (1) The level of the larynx, end of the oesophagus.
7 in. from the incisor teeth ; (2) The bifur-
cation of the trachea, 11 in. from the incisor teeth; (3) The lower
end of the oesophagus, 17 in. from the incisor teeth, about 2 cm.
above its opening into the stomach (Fig. 2).
As swallowed fluid will impinge on these narrowings, organic
strictures, which result from swallowing corrosive fluids, will naturally
occur in these three situations. Spasm of the circular muscle of
the oesophagus is also liable to occur in these positions. Furthermore,
4 THE DIAGNOSIS OF SURGICAL DYSPEPSIA
they are the favourite sites for malignant growths. Thus it will be
seen that the site of an obstruction is a very poor guide to its nature.
In the upper part of the oesophagus the diagnosis of a dysphagia
as a rule presents little difficulty, for a dysphagia in this situation
is nearly always caused
by a malignant growth.
In this respect it
differs from the lower
part of the oesophagus,
because in that region a
diagnosis of a dysphagia
presents considerable
difficulties ; for the inno-
cent condition cardio-
spasm so frequently and
unexpectedly occurs in
that situation. Clinically,
therefore, it is of advan-
tage to discuss the ques-
tion of dysphagia in
relation to site, namely,
the three ' narrow places '
of the oesophagus, the
upper part, the middle
part, and the lower part.
In this discussion unusual
conditions, such as aneu-
rysm of the aorta, medi-
astinal tumour, enlarged
mediastinal glands, and
mediastinal abscess, will
Fig. 2.—The three narrow places in the œsophagus. .
not be considered.
DYSPHAGIA IN THE UPPER END OF THE ŒSOPHAGUS
Before discussing dysphagia in the upper end of the oesophagus,
it must be pointed out that there are certain malignant conditions
which occur in the lower part of the pharynx adjoining the oesophagus
and in the pyriform fossa, which lie close to the beginning of the
oesophagus, and which give rise to discomfort on swallowing, and
these should be considered in relation to this problem of dysphagia.
Hidden Hypopharyngeal Malignancy. — A hypopharyngeal
growth may abut on the upper end of the oesophagus and give rise
DYSPHAGIA IN UPPER PART OF (ESOPHAGUS 5
to symptoms of dysphagia. Most malignant tumours of the pharynx,
however, give some symptomatic evidence of their presence and
are then easily detected when an examination is made. But there
are in the pharynx or its vicinity some forms of malignant growth
which are difficult to detect. The cases that follow will serve as
examples to illustrate this point.
Fig. 3.—A malignant fissure (A) with thickened edges, situated in
the pyriform fossa.
Epithelioma of the Pyriform Fossa.—A woman, aged 45, complained
that she had a sensation as if something was stuck in the right side of her
throat opposite the hyoid bone. She said she was continually * getting
up ' mucus, which seemed to come from this spot. A careful examination
with the laryngeal mirror revealed nothing. As the symptoms continued,
a further examination was made with a direct laryngoscope. A fissure
with infiltrated edges was found in the pyriform fossa (Fig. 3).
Epithelioma of the Vallecula.—A man, aged 57, sought advice because
he could feel a firm, hard lump in the upper part of his neck. On examina-
tion, this lump was found to have all the characteristics of a malignant
gland. The pharynx was carefully examined for a primary growth, but
nothing abnormal could be found. The gland was removed and a section
6 THE DIAGNOSIS OF SURGICAL DYSPEPSIA
showed that it had an epithelial structure and cell-nests. Repeated
pharyngeal examinations were now made, but no primary growth could be
discovered. Some eighteen months later an epithelioma was discovered
growing from the area where the base of the tongue joins the pharynx,
that is, from the vallecula.
The reason why this epithelioma could not be seen at first was
probably owing to the fact that in its early stages it was a malignant
fissure like one of those found in leucoplakia of the tongue (the
patient had a leucoplakia of the tongue), and that in the position in
which it was situated it would be very difficult to distinguish it from
the normal crease in this region.
The history of this patient also exemplifies another important
fact : it shows that a malignant gland in the upper part of the neck,
even though no primary malignant condition is obvious, is nearly
always secondary to a hidden malignancy either in the pharynx, the
pyriform fossa, the vallecula, or in some part of the larynx or the
upper part of the oesophagus.
The causes of dysphagia in the upper part of the oesophagus are :
(i) Carcinoma of the upper part of the oesophagus ; (2) Diverticula.
Carcinoma of the Upper Part of the (Esophagus.—Carcinoma
of the upper part of the oesophagus usually occurs in women. The
patient complains that the food seems to stop in the region of the
larynx ; she can point to the actual spot. She may be aphonie from
the direct extension of the growth to the vocal cords. Usually
she has salivary troubles and dribbles constantly because she cannot
swallow her saliva. Examination generally reveals a hard, painless
gland in the neck ; indeed, this may be the first sign, and may be
present for many months before the patient complains of any sym-
ptoms. A laryngeal examination easily reveals the growth.
A woman, aged 45, complained that she could not swallow and that
the food seemed to cling to a spot opposite her larynx. Two months after
the onset of the dysphagia she noticed that her voice became hoarse. She
constantly dribbled saliva, which she could not swallow. On examination
of the neck, an enlarged, hard, painless gland was discovered.
Diverticulum of the Upper Part of the (Esophagus.—Diver-
ticula occur commonly at the junction of the oesophagus and the
pharynx. However, they rarely cause a dysphagia in the upper part
of the oesophagus. They are caused by pressure from the inside of
the oesophagus and are called ' pressure diverticula ', and are con-
genital. Patients generally give a history of : (a) Long-standing
dysphagia ; (b) Régurgitations of portions of food after eating ;
(c) Discomfort and pressure in the neck ; (d) A complaint that if
DYSPHAGIA IN UPPER PART OF ŒSOPHAGUS J
pressure be made on the pouch, some of its contents can be made
to empty into the mouth. X rays will show the diverticulum.
Treatment.—The treatment of the so-called pulsion diverticulum
of the oesophagus, which actually arises in the pharynx, is removal of
the sac and closure of the opening in the pharynx thus made. This
may be carried out in a one- or two-stage operation. In the two-
stage (Moersch and Judd1) the sac is first freed and sutured to the
neck muscles. Eight days later it is exposed and removed and the
neck sutured over. Shallow2 employs a one-stage operation. He
recommends that after the usual exposure the eesophagoscope should
be passed into the sac, which should be emptied by aspiration and
pushed into the wound. The sac should then be grasped and the
eesophagoscope passed into the oesophagus and kept there while
the sac is dissected free, excised, the defect closed, and the wound
in the neck closed.
Dysphagia due to traction diverticula is not common, and,
furthermore, traction diverticula occur less frequently than pressure
diverticula ; they also occur farther down in the oesophagus. They
are, as a rule, small, and do not give rise to trouble.
DYSPHAGIA IN THE MIDDLE PART OF THE ŒSOPHAGUS
This is generally caused by—
Carcinoma of the Œsophagus at the Level of the Bifurcation
of the Trachea.—In this condition the manifestations are as follows :
(a) Symptoms of oesophageal obstruction referred to the level of the
bifurcation of the trachea ; (b) Aphonia caused by paralysis of the
recurrent laryngeal nerve ; (c) Symptoms of mediastinitis and of
pleuritic effusion ; (d) Indications of pressure on either bronchus,
such as evidence of deficient entry of air into either lung ; and
(e) It is not uncommon for a carcinoma in this situation to perforate
into the bronchus. The following is an example :—
A man, aged 60, complained of a sensation under the upper part of
the sternum, as if the food lodged there. He could not, he said, swallow
solids, but could get down liquids. His voice had become husky. He
regurgitated a small quantity of food after each meal. This had a nasty
smell and taste, and was often mixed with blood. He had lost a lot of
weight, and looked very pale and ill.
REFERENCES
1 MOERSCH and JUDD, Surg. Gynecol. and Obst., 1934, 58, April, 781.
2 SHALLOW, Ibid., 1936, 62, March, 624.