New endoscope for (laser) endoscopic diverticulotomy

Endoscopic cricopharyngeal myotomy: indications and technique

PURPOSE OF REVIEW

Cricopharyngeal muscle myotomy to treat swallowing disorders has a definite role in the management of cervical dysphagia. Several reports emphasize the benefits of the endoscopic approach compared with the transcervical technique. This review examines recent surgical management of cricopharyngeus dysmotility.

RECENT FINDINGS

Several investigations have provided pertinent information on selecting patients for cricopharyngeal myotomy. Manofluorography appears to be more accurate in detecting intrabolus pressure anomalies during swallowing. Isolated cricopharyngeus dyscoordination, however, is not easily identified using this method. Electromyographic activity of the inferior pharyngeal constrictor and cricopharyngeus recorded by transcutaneous electrodes at rest and during deglutition has shown different dysfunction patterns. Ambulatory 24 h double probe pH monitoring and the triple sensor combination pH test demonstrate clinical correlation between pH results and symptoms in patients suffering from dysphagia related to laryngopharyngeal reflux. Transoral cricopharyngeal myotomy for the treatment of cricopharyngeus dysmotility is now established as a safe and effective method. The development of new devices has enhanced the procedure's efficacy and the overall success rate without major complications.

SUMMARY

Diagnosis of cricopharyngeus dysfunction is based on anamnesis and videoradiograph findings. In doubtful cases manofluorography and electromyography should be performed. Endoscopic cricopharyngeal myotomy is a safe and effective treatment option for patients with cricopharyngeus dysphasia.

Endoscopic myotomy of the cricopharyngeal muscle with CO2 laser surgery

BACKGROUND

Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. Several treatment modalities are available, such as external myotomy of the muscle, dilatation, and local infiltration with botulinum toxin. Recently, endoscopic transmucosal myotomies using a CO2 laser have been described.

METHODS

Endoscopic cricopharyngeal myotomy using a CO2 laser was performed in 10 consecutive patients with dysphagia supposedly caused by cricopharyngeal muscle dysfunction without Zenker's diverticulum. All patients received prophylactic antibiotics and a feeding tube. Assessment was composed of clinical observation, a questionnaire, and a physical examination including flexible endoscopy and videofluoroscopy.

RESULTS

In all the patients, the procedure was feasible and without complications. Improvement of the complaints occurred in most patients. One patient had recurrent dysphagia and required a second endoscopic procedure.

CONCLUSIONS

Endoscopic laser surgery seems to be a safe and effective technique to treat cricopharyngeal dysfunction.

[Zenker's diverticulum. The endoscopic-microscopic, staple-assisted esophagodiverticulostomy]

BACKGROUND

The endoscopic-microscopic staple-assisted esophagodivertikulostomy of Zenker's diverticulum is a new modification of endoscopic operation techniques which minimizes complications and is able to speed up the patient's convalescence.

PATIENTS AND METHODS

A total of 22 out of 32 patients with Zenker's diverticulum underwent surgery. The operation involves cutting the wall between the diverticular sac and the oesophagus and, at the same time, closing the mucosal wound edges using the "closed" surgery method.

RESULTS

All operations were effective and uncomplicated. A total of 28 operations were performed on 22 patients. The operations due to relapse were predominantly necessary among younger patients, of whom three were operated endoscopically and three through the cricopharyngeal myotomy.

CONCLUSIONS

The "closed" endoscopic-microscopic staple-assisted esophagodivertikulostomy of Zenker's diverticulum avoids opening the retropharyngeal and retrooesophageal areas and allows a quick convalescence in the mostly elderly patients. This technique is effective, safe and has no major complications.

Carbon dioxide laser diverticulostomy: a new treatment for Zenker diverticulum

In the United States, the traditional treatment for hypopharyngeal (Zenker) diverticulum has been single-stage transcutaneous diverticulectomy. Complications following this procedure include mediastinitis, vocal cord paralysis, esophageal stenosis, fistula, and recurrent or persistent diverticula. The development of endoscopic equipment has led to a new era of surgery for this condition. Magnification of anatomic landmarks allows for better precision during surgery and reduces both surgical procedure time and postoperative complications. Additional techniques, such as diathermy, bipolar coagulation, stapler, and laser surgery, all of which decrease intraoperative bleeding, lend further support to the procedure. In several randomized controlled clinical trials, endoscopic laser treatment of diverticulum has demonstrated the best results in terms of decreased morbidity and fewer complications. Thus, laser approaches for treating Zenker diverticulum deserve consideration.

Pathogenesis and methods of treatment of Zenker's diverticulum

In the literature, various theories concerning the cause of Zenker's diverticulum have been propounded. I believe that an anatomic predisposition plays a prominent role in the pathogenesis. This conclusion will be discussed in light of a study of the literature and characteristics of a series of 646 patients with Zenker's diverticulum. The current methods of treatment by an external surgical approach, as well as the (micro)endoscopic procedures, are described.

Pharyngeal pouch (Zenker's diverticulum)

Pharyngeal pouches occur most commonly in elderly patients (over 70 years) and typical symptoms include dysphagia, regurgitation, chronic cough, aspiration, and weight loss. The aetiology remains unknown but theories centre upon a structural or physiological abnormality of the cricopharyngeus. A diagnosis is easily established on barium studies. Treatment is surgical via an endoscopic or external cervical approach and should include a cricopharyngeal myotomy. Unfortunately pharyngeal pouch surgery has long been associated with significant morbidity, partly due to the surgery itself and also to the fact that the majority of patients are elderly and often have general medical problems. External approaches are associated with higher complication rates than endoscopic procedures. Recently, treatment by endoscopic stapling diverticulotomy has becoming increasingly popular as it has distinct advantages, although long term results are not yet available. The small risk of developing carcinoma within a pouch that is not excised remains a contentious issue and is an argument for long term follow up or treating the condition by external excision, particularly in younger patients.

Microendoscopic treatment of the hypopharyngeal diverticulum with the CO2 laser

BACKGROUND AND OBJECTIVE

The hypopharyngeal (Zenker's) diverticulum is a herniation of mucosa and submucosa on the posterior wall of the pharynx. The only treatment is surgical.

STUDY DESIGN/MATERIAL AND METHODS

Between 1976 and 1993, 109 patients with a hypopharyngeal diverticulum were operated on at the Department of Otorhinolaryngology, Head and Neck Surgery, University of Kiel, either transcutaneously combined with a cricopharyngeal myotomy (n = 76), or microendoscopically (n = 37) using the CO2 laser. Results and complications of both techniques were evaluated and compared.

RESULTS

With both surgical procedures, > 90% of the patients were treated successfully. The rate of postoperative complications was generally low. In comparison to the microendoscopic procedure, serious complications were found to be more frequent in patients treated with the conventional transcutaneous diverticulectomy.

CONCLUSION

The laser surgical tissue bridge dissection is a less invasive, quick, relatively safe, and effective procedure requiring only short hospitalisation. Therefore, the laser surgical tissue bridge dissection can be considered as the method of choice for the treatment of the hypopharyngeal diverticulum.

Pharyngeal pouch carcinoma: real or imaginary risks?

Pharyngeal pouch or Zenker's diverticulum presents to the otolaryngologist with symptoms of dysphagia. As supported by the published literature, the condition is more frequently seen in Northern Europe, especially the United Kingdom, than elsewhere in the world. The cause of the reported increased incidence in the United Kingdom is not known, but may be dietary. Surgical management is the treatment of choice and is directed at the cricopharyngeus muscle by either an external or an internal approach. There is a real risk of carcinoma or carcinoma in situ developing in a treated or untreated pharyngeal pouch. Excision of the pouch sac is recommended in younger patients, less than 65 years, and in patients who have a large pouch. If endoscopic diverticulotomy is performed, then long-term patient symptom follow-up is to be advocated.

The "sign of the rising tide" during swallowing fiberoscopy: a specific manifestation of Zenker's diverticulum

Pooling of secretions in the hypopharynx is a common sign of an impaired upper esophageal sphincter. Until now, no specific manifestation, observed by flexible laryngoscopy, of Zenker's diverticulum has been reported. Direct visualization of the diverticulum can be missed during flexible laryngoscopic examination. In this series of 12 patients with hypopharyngeal diverticulum, we have described a manifestation of Zenker's diverticulum obtained on videofiberoscopy during cream swallowing. We have called it the "sign of the rising tide" because it describes the backup of cream visible in the hypopharynx as a wave after its complete disappearance. Barium swallow study is necessary to confirm the presumptive diagnosis. This relevant manifestation seems to be specific for Zenker's diverticulum, since it is not observed in other upper esophageal sphincter disorders, and it disappears when surgical treatment is successful.

Endoscopic laser myotomy in the treatment of pharyngeal diverticula

The endoscopic approach is a simple and cost-effective option in the treatment of hypopharyngeal diverticula. Whereas almost a third of all endoscopic myotomies performed by UK otolaryngologists are carried out with the stapling technique, CO2 laser diverticulotomy has not been given as much consideration (Koay et al., in press). We report on the first British series of 15 patients treated between 1985 and 1993 with microscopic laser diverticulotomy. The follow-up period was four to 11 years. Complications occurred in three patients, two patients required a repeat myotomy and 11 patients have been satisfied with their swallow since the operation. Our results are similar to those of larger studies. The laser technique is more established than the stapling gun myotomy and it has the advantage of superior visualization. It may also be used in small pouches which do not admit the insertion of a stapling gun.

Endoscopic stapling diverticulotomy for pharyngeal pouch

Fifteen endoscopic stapling diverticulotomy procedures were performed on 14 patients. Our preliminary results show the technique to be fast. effective and safe. Most patients resumed oral intake within 6 h post-operatively and were discharged from hospital within 24 h. The technique has many advantages over both the external diverticulectomy and the traditional Dohlman's procedure. The short operating time and short hospital stay are an advantage. Our follow-up period was between 1 and 12 months. Long-term results require evaluation.

Endoscopic CO2 laser cricopharyngeal myotomy

Cricopharyngeal dysfunction due to various causes can lead to severe upper pharyngeal dysphagia with or without laryngeal penetration. Resurgence of Dohlman's endoscopic diverticulotomy for Zenker's diverticulum has been brought about by the development of the diverticuloscope, improved intravenous analgesia, and the advent of the laser. Recent use of videofluoroscopy for swallowing documents a frame-by-frame picture of swallowing with special focus on the cricopharyngeal function and its stages of malfunction. The "cricopharyngeal crescent" (cricopharyngeal bar) as termed by Jackson is visible during endoscopy and can be incised in layers under the operating microscope with the CO2 or contact Nd:YAG laser. This paper introduces the staging of cricopharyngeal dysfunction regarding its initiation and progression in correlation with its symptoms and videofluoroscopic pictures. It also reports the application of endoscopic laser cricopharyngeal myotomy for 44 patients with cricopharyngeal dysfunction besides 4 with Zenker's diverticulum. This procedure is found to be effective, safe, brief, and prompt in restoring swallowing.

Transmucosal cricopharyngeal myotomy with the potassium-titanyl-phosphate laser in the treatment of cricopharyngeal dysmotility

Cricopharyngeal dysfunction is a relatively uncommon disorder that is widely misunderstood. Cricopharyngeal dysmotility is thought to represent abnormal function of the upper esophageal or cricopharyngeal sphincter. The cause of this dysfunction is related to uncoordinated pharyngeal swallowing, achalasia, or a combination of these factors. Unfortunately, standard diagnostic tests have not consistently demonstrated a failure of the cricopharyngeal sphincter to malfunction; therefore, cricopharyngeal myotomy has been suggested as a diagnostic and therapeutic tool in the treatment of dysmotility. Our report focuses on the current trends in the diagnosis and treatment of cricopharyngeal dysfunction. We also present a case report of a transmucosal cricopharyngeal myotomy performed with the potassium-titanyl-phosphate (KTP) laser. The KTP laser was found to be relatively safe and effective and did not demonstrate significant morbidity. Our conclusion was that a transmucosal cricopharyngeal myotomy with the KTP laser may represent a viable alternative for patients with cricopharyngeal dysmotility.

Microendoscopic laser diverticulotomy for hypopharyngeal diverticulum

Progressive dysphagia due to a pharyngeal pouch eventually requires surgical treatment. Thirty-four patients treated by laser diverticulotomy in a 6-year period were reviewed for age, length of hospitalization, associated medical problems, postoperative course, and results. The operative technique is described in detail, and a new, slimmer diverticuloscope is introduced. Microendoscopic laser diverticulotomy offers excellent visualization by means of the operating microscope together with a double-lipped diverticuloscope and is a minimally invasive, relatively simple, controlled procedure with proven, predictable results and few complications. It can be recommended as the treatment of choice for patients of all ages, whether the pouch is large or small.

Laser treatment of pharyngeal pouch

The symptoms of pharyngeal pouch become more troublesome, eventually requiring surgical treatment. Excision of the pouch and cricopharyngeal myotomy through a neck incision was the operation of choice until Dohlman described endoscopic diathermy operative treatment 30 years ago. The diathermy technique has been largely superseded by endoscopic microsurgical division of the cricopharyngeus muscle in the party wall using carbon dioxide laser. This operation is now established as a precise, accurate and safe procedure providing reliable relief of symptoms with minimal risk to the patient. Fifteen patients treated by the microsurgical laser procedure in the past 5 years are reported.