Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1015_Библиотеки_им_академика_М_И_Перельмана

A smoothly curving defect in the barium-filled esophagus indicates an extraluminal mass that may be intrinsic to the esophageal wall or extrinsic to the esophagus. The esophagus is the second-most common siteforduplication,aftertheileum(Berrocaletal.1999). Itcanformacystlinedwithsecretorymucosathatcauses increasing symptoms as it grows. The mucosa can also be gastric in differentiation; its presentation will be due to ulceration. The location is usually in the intrathoracic esophagus. The same type of embryologic error in the respiratory tree forms bronchogenic cysts (Nobuhara et al. 1997). In their usually central location,close to the carina, they can cause respiratory symptoms that may mask feeding problems and delay diagnosis. If compli­cated by infection, their presence may be detected by a mediastinal air–fluid level on a plain radiograph (Hedlund et al. 1998). Leiomyomas are rare, smooth muscle tumors, and the esophagus is an unusual place for them, but they can occur. In children, they are more likely to be multiple or infiltrative than in adults. Leiomyomatosis is a very rare condition seen in about 5% of patients with Alport syndrome where widespread

cleft remnants, whereas the third and fourth clefts can fistulize to the piriform sinuses. Cysts of the thyroid, thyroglossal duct, thymic remnants, or larynx can also occur. Duplication is a rare finding in this region (Wootton-Gorges et al. 2002).

had other VATER/VACTERL elements excludedas an infant should not be dismissed as having behavioral problems if it presents later with feeding difficulties. Rather, a search for a neuroenteric cyst or aduplication cyst should be considered, both of which can also coexist with spina bifida, hemivertebra, and fusion defects (Berrocal et al. 1999). Finding one abnormality should not stop the search for others. Case reports abound inthe literature illustrating odd and unexpected assortments of allied anomalies: EA–TEF with esoph­ageal stenosis (Newman and Bender 1997), TEF with web and duplication (Snyder et al. 1996), and anomalous origin of a bronchus from the esophagus (Lallemand et al. 1996).

arteries that cross and impinge on mediastinal struc­tures (Strife et al. 1998). Two entities that form ana­tomically complete rings that encircle the trachea and esophagus and are fairly common are the double aortic arch (Fig. 4) and the right arch with aberrant left subclavian artery and intact ductus or ligamentum (Fig. 5). These patients will present with respiratory and feeding difficulties, although when the former is thought to cause the latter, diagnosis can be delayed. Surgical treatment is usually mandated. Patients with an arch with contralateral subclavian aberrancy, such as the very common left arch with aberrant right subclavian artery, will not have respiratory symptoms if the ligamentum is broken or elongated. Although a posterior defect may be seen in the barium-filled esophagus from the aberrant vessel, surgery is not usually necessary unless the symptoms interfere with growth. Likewise, a pulmonary sling, where the left pulmonary artery passes between the trachea and esophagus on its way to the left side from its anom­alous origin on the right, may distort the esophagus without compression (Fig. 6); its compressive effect on the tracheobronchial tree, however, may be pro­found and this can secondarily interfere with feeding (Siripornpitak et al. 1997). Where a vascular anomaly is suspected, either primarily or uncovered on a bar­ium esophagram, MRI can definitively delineate it and show its effect on mediastinal structures; angi­ography is contraindicated. A contrast-enhanced CT