Endoscopic stapling division of a pharyngoesophageal (Zenker's) diverticulum

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摘要

The description of the endoscopic stapling division of a pharyngoesophageal (Zenker's) diverticulum covers all aspects of the surgical procedure used for the management of Zenker's diverticulum.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way.
Consequently, this operating technique is well standardized for the management of this condition.

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2002-06

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WeBSurg.com, Jun 2002;2(06).
URL: http://www.websurg.com/doi-ot02en229.htm

Endoscopic stapling division of a pharyngoesophageal (Zenker's) diverticulum

1. Introduction

Symptoms
There are 2 distinct categories of patients who seek consultation for pharyngoesophageal symptoms related to Zenker's diverticulum. Some patients complain of severe pharyngoesophageal symptoms even if they only have a very small diverticulum. Other patients are seen only after a large diverticulum has developed, without their having experienced pharyngoesophageal discomfort during the initial phase of the process. This clinical observation suggests that removal of the sac or its anchorage to the pharynx or the prevertebral fascia is critical in managing a large diverticulum. By contrast, the roles of the cricopharyngeus muscle in the genesis of symptoms and cricomyotomy in the relief of symptoms are more significant in the subset of patients who complain of severe dysphagia even though they have a very small diverticulum.

Pathophysiology
Development of a pulsion diverticulum through the posterior hypopharyngeal wall between the inferior constrictor muscle of the pharynx and the cricopharyngeus muscle results when the latter muscle does not comply (Cook et al., 1992a) in relation to local fibrosis (Cook et al., 1992b; Lerut et al., 1992), giving rise to a high intrapharyngeal pressure on deglutition. Consequently, myotomy of the structures that form the upper esophageal sphincter (UES), ie the cricopharyngeus muscle itself and the muscle fibers within the wall of the proximal cervical esophagus, may be the critical step in managing the anatomic abnormality. Proximal esophageal myotomy has been applied with success (Sideris et al., 1999; Hauters et al., 1998), either in an isolated fashion (very small, <=1 cm diverticulum) or in combination with the anchorage of the diverticular sac to the posterior pharyngeal wall or the prevertebral fascia (larger, >1 cm diverticulum) according to the principle that the sac is the consequence of a muscular disease rather than the disease itself.
However, despite the implication of UES dysfunction in the genesis of the diverticulum, excellent results have been achieved after resection of the pouch without myotomy (Michot et al., 1978). This suggests that symptoms in relation to the existence of a well-developed pharyngoesophageal diverticulum are due mainly to the presence of the pouch itself, which retains ingested material and pushes the cervical esophagus forward so as to collapse it against the trachea.

2. Indications

Indications
- a diverticulum whose common wall is >=3 cm at endoscopic examination under general anesthesia;
- patients with a past history of previous neck surgery (carotid endarterectomy, thyroid lobectomy, etc);
- patients referred for failure of a transcervical approach to the diverticulum in order to avoid cervical re-exploration and above all, inadvertent injury to the left inferior laryngeal nerve with subsequent vocal cord palsy;
- toothless elderly people are good candidates for the endoscopic approach because transoral introduction of the diverticuloscope is much easier.

Contraindications
- a diverticulum whose common wall is <3 cm at endoscopic examination under general anesthesia,
- a patient with a narrow oropharyngeal channel precluding introduction of the diverticuloscope into the hypopharynx and cervical esophagus. Any potential candidate for the endoscopic approach should be asked to introduce 3 fingers into the mouth before the operation. Unsuccessful introduction of the 3 fingers is a good predictive factor of the inability to fit the diverticuloscope in the pharynx.

3. Preop period

1. Common wall
- barium swallow study including side views of the neck is performed at the outpatient clinic a few days before the operation to estimate the actual length of the common wall between the diverticulum and the cervical esophagus. The preoperative estimation of the length of the common wall depends on correction factors for magnification or reduction. In addition, superimposition of the bottom of the diverticulum and the clavicle may make precise evaluation difficult.
- the day before the operation, the patient is restricted to a liquid diet and is instructed to drink a large volume of beverages to clean the diverticular lumen.
- topical antibiotics are administered for decontamination of the oropharynx.

4. Operating room set-up

• Patient

The patient is placed in the recumbent position on the operating table, head hyperextended.
After a short-acting general anesthetic such as propofol or alfentanil has been given, a small-diameter endotracheal tube is introduced transnasally.

• Team

The surgeon stands at the patient’s head. The scrub nurse stands either on the right or on the left of the surgeon. No assistant is present.
1. Surgeon
2. Anesthesiologist

• Equipment

1. Instrument table
2. Operating table
3. Monitor connected to a video-camera similar to that used for video-laparoscopic or thoracoscopic procedures

5. Instrumentation

1. a 30 mm endoscopic stapler, the distal tip of which has been modified. The distal part of the anvil is sawed off to reduce the length of the spur (at the most equal to 3 mm) at the bottom of the diverticulum after concomitant division and suture of the common wall. This modification does not change the basic characteristics of the stapler, which still has a section length of 27 mm and a stapling length of 30 mm.

2. 5 mm 0° endoscope

3. a diverticuloscope. This diverticuloscope has 2 lips that can be angulated and approximated to fit each patient's unique oropharyngeal anatomy. It was designed to allow the introduction of the linear stapler alongside a light conductor and a 5 mm diameter telescope. The end of the instrument is angulated to allow connection to the side of the video-camera, and so it cannot interfere with the stapler. The telescope is attached to the diverticuloscope by means of a multidirectional screwing system to provide optimal vision of the common wall to be cut and sutured.

6. Surgical procedure

• Exposure

1. Upper lip
2. Esophagus
3. Common wall
4. Bottom of the diverticulum
5. Lower lip
The double-lipped diverticuloscope is introduced into the mouth and the pharynx under direct vision. The larynx is lifted forward, and the diverticular opening is identified. The lower lip of the diverticuloscope is inserted into the diverticular sac and the upper lip into the cervical esophageal lumen. The lips are moved away from each other to expose the wall between the 2 lumina. If there are difficulties in identifying the common wall and esophageal lumen, it may be helpful to insert a catheter into the esophageal lumen under visual control. The saliva retained in the diverticular sac is suctioned and the mucosa is carefully inspected for any mucosal abnormality that would require the taking of biopsy samples.

• Stapling

1. Esophageal lumen
2. Common wall
3. Diverticular sac
The modified linear stapler is introduced into the pharynx through the diverticuloscope. The 2 forks of the stapler are placed across the common wall, ie the anvil into the diverticular sac and the cartridge of staples into the cervical esophageal lumen. After midline approximation of the forks, the trigger of the gun is squeezed to permit forward displacement of the knife and the delivery of 3 rows of staples on each side. After the forks are separated, the stapler is removed as the cricopharyngeus muscle forces the stapled wound edges to retract laterally. The muscle, which is located within the common wall, has also been divided. The medial slit thus becomes a V-shaped opening between the 2 lumina. Additional cartridges can be applied across the distal segment of the common wall to complete its division. When hemostasis of the wound edges is ensured, the diverticuloscope is removed and the patient is awakened.

• Stapling conditions

The common wall between the diverticulum and the cervical esophagus must be long enough to be cut over a distance of 3 cm or more. In this way, a sufficiently long myotomy (Lerut et al., 1992; Sideris et al., 1999; Bremner and DeMeester, 1999; Orringer, 1980) can be achieved, including division of both the cricopharyngeus muscle and muscle fibers within the proximal esophageal wall. A general principle holds for widening the diameter of any soft tubular structure: the longer the longitudinal section of the wall, the greater the gain in diameter. For practical purposes, the common wall of the diverticulum must allow placement of one or more cartridges of the stapler. The length of the common wall is best evaluated endoscopically during the operative procedure, when the striated muscles of the neck, the pharynx and the cervical esophagus are relaxed by the anesthesia. In addition, the stapling procedure permits the bottom of the diverticulum to be pushed downward and the common wall to be stretched, providing a cut length somewhat greater than that which has been estimated on preoperative roentgenograms. Recently, Cook et al. (2000) suggested the placement of retraction sutures through the lateral edges of the common wall with the suturing device, so that some tension can be applied when the forks are reinserted for a second or third cut in large diverticula.
Another reason for not approaching a small (<3 cm) diverticulum endoscopically is that endoscopic identification of the opening of the sac into the pharyngeal lumen may be difficult because the lips of the diverticuloscope can collapse this opening into a simple slit by stretching the oropharyngeal wall. This can lead to the catching of the lower lip of the diverticuloscope in the slit with subsequent perforation of the sac.

7. Postop period

• Postop period

The patient is allowed to drink a few hours after the end of the operation and a soft diet is begun at the latest on the first postoperative day.
Before discharge, dietary restrictions for the first postoperative week are explained. Healthy young patients can be discharged on the same day or after a 24-hour in-hospital stay whereas elderly patients are discharged after a few days.

• Without residual spur

1. Common wall
A barium swallow study is performed as an outpatient procedure 1 to 2 weeks after surgery. Optimal radiological results are achieved when lateral X-rays do not show any residual spur at the bottom of the common cavity.

• With residual spur

1. Common wall
2. Residual spur
Usually, a small residual spur is present with stasis of a very small amount of contrast medium at the bottom of the diverticulum (Ong et al., 1999). The presence of such a small residual spur may result from partial division of the common wall. However, we may conceive that the fibrotic tissue that sometimes is present in the immediate vicinity of an old diverticulum may hamper spontaneous re-alignment of the posterior diverticular wall with the esophageal mucosa despite proper endoscopic division of the common wall.

8. Discussion

Effectiveness of the procedure
Evaluation of the endoscopic stapling technique of division of a diverticulum must take into account the fact that most so-called minimally invasive surgical procedures that were devised in the last decade of the 20th century were very appealing from a purely technical standpoint. They were applied widely under the assumption that they could provide patients with long-term outcomes as good as those that had been obtained through conventional operations for years, while also minimizing cosmetic sequellae and shortening hospital stays.

Results
Endoscopic stapling division of a pharyngoesophageal diverticulum has been shown to improve pharyngeal clearance of a radio-labelled meal and to lower resistance to bolus flow through the UES in comparison with the preoperative situation (Perrachia et al., 1998). Astonishingly good postoperative clinical data have been reported by some surgical teams (Perrachia et al., 1998; Omote et al., 1999), so the endoscopic stapling division technique has been presented as the treatment of choice for any patient seeking consultation for a Zenker's diverticulum. However, other authors (Cook et al., 2000; Philippsen et al., 2000; Van Eeden et al., 1999) have reported less impressive data, indicating that a substantial number of patients cannot achieve complete symptomatic relief and still have occasional pharyngoesophageal complaints at follow-up. While all the series published reported success rates ranging from 90% to 100% when combining both categories of patients, only 50% to 75% of patients were totally asymptomatic.

Analysis of failures
There are several reasons for incomplete symptomatic relief after endoscopic management of a pharyngoesophageal diverticulum. A first cause of failure is the existence of a very short common wall to be cut (<3 cm), a condition that precludes a sufficiently long esophageal myotomy. A second reason for failure is the maintenance of the wrinkled diverticular wall, ie a rather large amount of non-contractile tissue at the level where normally, peristaltic esophageal contractions start. This is particularly true after division of the common wall of a large diverticulum. A third reason is an insufficient division of the common wall, which leaves a long residual spur at the bottom of the common cavity with persistence of stasis. In this respect, application of the modified 30 mm stapler allows the cutting of the common wall over its whole length, only leaving a 3 mm spur at the bottom of the common cavity, ie just enough to avoid perforation.

9. Conclusions

The endoscopic stapling technique of division of the common wall of a pharyngoesophageal diverticulum is safe and can be applied to patients with a diverticulum >=3 cm, unless the existence of a narrow oropharyngeal channel precludes the introduction of the diverticuloscope into both diverticular and esophageal lumina. It allows early postoperative discharge without neck scarring. This procedure can even be done ambulatorily in healthy patients.

However, our own experience of 184 patients who were treated using 6 different operative techniques indicates clearly that any patient seeking consultation for a pharyngoesophageal diverticulum must be informed preoperatively of the higher risks of minor residual symptoms after an endoscopic approach, as opposed to a transcervical operation. Consequently, the endoscopic stapling technique of division of a pharyngoesophageal diverticulum should be reserved for high-risk elderly patients, those with a history of previous neck surgery and those with a giant diverticulum that would require an extended upper mediastinal dissection if approached from the neck. In young people, however, the transcervical myotomy-pexy technique seems to be the procedure of choice because it offers better chances of complete symptomatic relief than the endoscopic approach while requiring a similarly short postoperative hospital stay and also allowing oral feeding as early as a few hours after the operation.

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