232 THE LARYNX, BRONCHI AND OESOPHAGUS
defect, however, is an irregular one from which the stream of barium issues
eccentrically. This contrasts with the smooth tapering concentric appearance
of cardiospasm. Cancer may also show as an irregular oesophagitis at the
lower end with some ulceration.
4. Oesophagoscopy. This is indicated in the following circumstances:
(a) Where the radiograph suggests the presence of cancer, (b) Where there are
no radiographic findings to explain the patient's condition, and (c) Where a
Fig. 119. Carcinoma of upper oesophagus.
benign condition has been diagnosed, but has failed to respond to the
requisite treatment. At oesophagoscopy the site and extent of the lesion are
noted, and a biopsy is taken.
Lower Third. If the tumour is a squamous-cell carcinoma, the initial
treatment is by irradiation, and if a recurrence is found early enough an
oesophagogastrectomy can be done. If the tumour is an adenocarcinoma the
treatment should be primarily surgical.
Middle Third. These tumours are all squamous-cell carcinomas and thus the
treatment is primary radiotherapy. In the event of a recurrence an oesophageal
resection and gastric replacement can be attempted, but the chances of this
being possible are remote.
Cervical Oesophagus. The treatment of these tumours is similar to that of
postcricoid tumours. Radiotherapy is the primary method of treatment and
will cure about 15 per cent. In recurrences the larynx, pharynx and at least
part of the oesophagus must be removed. With regard to this it is wise to
follow the example of the thoracic surgeons and to remove a hand's breadth
of normal oesophagus distal to the lesion. This makes sound sense when one
considers the extent of the submucosal lymphatic system and the presence of
'skip* lesions. If a hand's breadth is removed from below a cervical oesophageal
tumour BO type of skin repair is possible, and one is left with a choice of the
various visceral transplants, among which are colon9 jejunum and stomach.