A)
Zenker's Diverticulectomy
Three procedures have been described
to treat a Zenker's diverticulum: diverticulectomy, diverticulopexy, and peroral
endoscopic division of the party wall between the diverticulum and the esophagus.
Diverticulectomy is usually selected for treating large diverticula in otherwise
healthy patients (1). It involves an open-neck operation where the(Zenker's) hernia
sac is identified and isolated. The sac is then resected its neck, taking care
not to compromise the esophageal lumen by resecting too much mucosa, and closing
the pharyngotomy with a watertight closure. A cricopharyngeal myotomy is performed
as close to the posterior midline as is possible to minimize risk to the recurrent
laryngeal nerves; the myotomy consists of dividing the entire circular cricopharyngeus
muscle.
Diverticuloplexy, combined with cricopharyngeal myotomy, is preferred
by some surgeons for dealing with small diverticula or large diverticula in high-risk
patients. The sac is isolated and tacked with permanent suture to the prevertebral
fascia, such that the mouth of the sac is in a dependent position (1). Diverticulopexy
avoids a pharyngotomy, reducing the risk of a pharyngocutaneous fistula or injury
to the recurrent laryngeal nerves.
Endoscopic peroral division of the
party wall between the sac and the esophagus was first described by Dohlman in
1960 (2) . He used a special double-lipped esophagoscope, inserting one lip into
the sac and one lip into the esophagus. Electrocautery was used to divide the
party wall, including the cricopharyngeus muscle. Dohlman's procedure fell into
disfavor because of an unacceptably high complication rate and mortality from
mediastinitis. More recently, with some modifications to Dohlman's original technique
such as utilization of an operating microscope and a laser, the endoscopic approach
has gained acceptance, especially for very ill patients in whom an open procedure
might pose greater risks (3).
B) Cricopharyngeal Myotomy
Dysphagia as a result of abnormalities with the cricopharyngeus muscle may
be ameliorated by selective use of cricopharyngeal myotomy. Cricopharyngeal myotomy
may be either surgical or pharmacologic (botulinum toxin). In general, cricopharyngeal
myotomy is primarily useful for true cricopharyngeal achalasia such as after vagus
nerve injury at the base of the skull where pharyngeal motor function remains
otherwise intact (4, 5). Cricopharyngeal myotomy is contraindicated in conditions
when there is impaired pharyngeal peristalsis or when significant reflux disease
exists. Many disease entities where cricopharyngeal myotomy was thought to be
useful in improving dysphagia, such as myopathy and brainstem stroke, may actually
be of no benefit (6, 7 , 8).
C) Salivary Diversion Procedures
Dysphagia severe enough to result in the threat or actual circumstance of
food and saliva constantly soiling the airway typically requires aggressive management.
Surgical procedures that divert or diminish the flow of food and saliva from the
airway include vocal fold medialization (9), tracheostomy, laryngeal stents (10),
reversible laryngeal closure procedures (11, 12), laryngotracheal separation (13)
and total laryngectomy (14) . The application of any one of these treatment modalities
depends on several patient factors such as underlying disease process and overall
health status of the patient.
Patients who are aspirating regularly
frequently become malnourished, which only exacerbates their underlying condition.
Therefore, as measures are considered to prevent aspiration, alimentation through
non-oral means should be implemented as well. Feeding gastrostomy or jejunostomy
tubes, placed endoscopically (percutaneous endoscopic gastrostomy (PEG) or percutaneous
endoscopic jejunostomy (PEJ)), are excellent ways to aliment patients who are
at high risk for aspiration as a result of severe dysphagia.
References
1. Laccourreye O et al. Esophageal diverticulum: diverticulopexy
versus diverticulectomy. Laryngoscope 1994; 104: 889-892.
2. Dohlman G, Mattsson
O. The endoscopic operation for hypopharyngeal diverticulum. A roentgen cinematographic
study. Arch Oto Head Neck Surg 1960; 71: 744-752.
3. Van Overbeek JJM. Meditation
on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of
endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994; 103: 178-185.
4. Wisdom G, Blitzer A. Surgical therapy for swallowing disorders. Oto Clin NA
1998; 31: 537-560.
5. 133. Pou AM. Surgical treatment of swallowing disorders:
Cricopharyngeal myotomy in Carrau RL, Murray T (eds.). Comprehensive Management
of Swallowing Disorders. Singular Publishing Group, Inc. San Diego, CA 1999, pp.
6. Stevens KM, Newell RC. Cricopharyngeal myotomy in dysphagia. Laryngoscope
1971; 81: 1616-1620.
7. Lebo CP, Sang K, Norris FH. . Cricopharyngeal myotomy
in amyotrophic lateral sclerosis. Laryngoscope 1976; 86: 862-868.
8. Calcaterra
TC, Kadell BM, Ward PH. Dysphagia secondary to Cricopharyngeal muscle dysfunction:
surgical management. Arch Otolaryngol Head Neck Surg 1975; 101: 726-729.
9.
Netterville JL, Stone RE, Luken ES, Civantos FJ, Ossoff RH. Silastic medialization
and arytenoid adduction, a review of 116 procedures: the Vanderbilt experience.
Ann Otol Rhinol Laryngol 1993; 102: 413-424.
10.
Eliachar I, Nguyen D. Laryngotracheal stent for internal support and control of
aspiration without loss of phonation. Otolaryngol Head Neck Surg 1990; 103: 837-840.
11. Castellanos PF. Method and clinical results of a new transthyrotomy closure
of the supraglottic larynx for the treatment of intractable aspiration. Ann Otol
Rhinol Laryngol 1997; 106: 451-460.
12. Biller HF, Lawson W. Total glossectomy.
Arch Otolaryngol Head Neck Surg 1983; 109: 69-73.
13. Lindeman RC, Yarington
CT, Sutter D. Clinical experience with the tracheoesophageal anastomosis for intractable
aspiration. Ann Otol Rhinol Laryngol 1976; 85: 609-613.
14. Cannon CR, McClean
WC. Laryngectomy for chronic aspiration. Am J Otolaryngol 1982; 3:145-149. |
Surgery
