A radiological study of the neural control of oesophageal vestibular function.

The oesophageal vestibule lies at the lower end of the oesophagus immediately above the stomach. Pressure recordings in normal adults indicate that after pharyngeal deglutition the vestibule relaxes. They show that this relaxation occurs shortly after deglutition and that it persists until the oeso-phageal stripping wave reaches the vestibule (Fyke, Code, and Schlegel, 1956). Carrd and Astley (1958), studying pressure recordings in normal infants and in infants with hiatal hernia, thought their findings could be interpreted as indicating an 'intrinsic closing mechanism in the region of the cardia operating independently of the diaphragm'. Radiological studies in normal infants and children examined in the supine or prone position show that after deglutition a stripping wave passes down the oesophagus, emptying the oesophageal content through the vestibule into the stomach. The vestibule opens as contrast medium passes through it, and it closes as the stripping wave empties the oesophagus. The problem about the oesophagus in the normal infant and child is that the vestibule cannot be studied independently of this stripping wave, and it is difficult to be sure if an intrinsic sphincteric action in the vestibule is present or not. The radiological demonstration of a sphincter depends on showing that no contrast medium flows through a sphincteric zone when the sphincter is closed, but contrast medium must be present proximal to the sphincter for such an observation to be made. An efficient oeso-phageal stripping wave precludes such studies in normal infants and children. In this paper an analysis of flow through the oesophageal vestibule in 14 children is presented. These patients have been divided into five groups. A feature common to 10 patients (groups 1 to 3) was the absence of an oesophageal stripping wave, and this made it possible to study the vestibule without flow through it being influenced by the propulsive effect of a normal oesophageal stripping wave. From the findings it has been deduced that flow through the vestibule is influenced by a neural factor. PATIENTS STUDIED GROUP 1 (Fig. 1) This group comprised two patients with a congenital tracheo-oesophageal fistula without atresia in whom an oesophageal stripping wave was absent. No thoracotomy had been undertaken before the study. t n.c.o. GROUP 2 (Fig. 2) In this group were four patients who had previously had a technically successful repair of an oesophageal atresia with closure of a tracheo-oesophageal fistula and in whom the oeso-phagus was non-contractile above the …