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. TREATMENT. 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.