Surgery of the upper esophageal sphincter (open technique)

The description of the surgery of the upper esophageal sphincter (open technique) covers all aspects of the surgical procedure used for the management of pharyngoesophageal 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: exposure of sphincter, cricomyotomy, closure. Consequently, this operating technique is well standardized for the management of this condition.

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Surgery   of   the   upper   esophageal   sphincter   (open   technique)

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Abstract
The description of the surgery of the upper esophageal sphincter (open technique) covers all aspects of the surgical procedure used for the management of pharyngoesophageal 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: exposure of sphincter, cricomyotomy, closure.
Consequently, this operating technique is well standardized for the management of this condition.
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2002-05
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WeBSurg.com, May 2002;2(05).
URL: http://www.websurg.com/doi-ot02en249.htm

Surgery   of   the   upper   esophageal   sphincter   (open   technique)

1. Introduction
In 1926, spasticity of the cricopharyngeal muscle was recognized as an etiopathologic factor in a pharyngo-esophageal diverticulum, also known as Zenker’s diverticulum. The first myotomy of the cricopharyngeal muscle for treatment of upper dysphagia was reported in 1951 (Kaplan, 1951).
Oropharyngeal dysphagia is a symptom caused by difficulty in propelling a solid or liquid food bolus from the oral cavity to the cervical esophagus.
Treatment often consists of myotomy of the posterior pharyngo-esophageal junction (including the cricopharyngeal muscle), whether the cause of Zenker’s diverticulum is neurogenic or idiopathic.
The surgical technique is basically the same whether a pharyngo-esophageal diverticulum exists or not. Surgery helps overcome the functional obstruction to swallowing (Duranceau, 1995).
2. Anatomy
• Topographic anatomy
The landmarks for the incision are as follows:
1. Lobule of the auricle
2. Sternal notch
3. Anterior edge of the sternocleidomastoid muscle
• Local anatomy
1. Platysma
2. Sensitive cutaneous nerve
3. Omohyoid muscle
4. Prethyroid muscles
5. Middle thyroid vein
6. Inferior thyroid artery
7. Left lobe of the thyroid gland
8. Deep cervical fascia
9. Cervical esophagus, region of the cricopharyngeal muscle
10. Inferior and posterior oropharynx
• Pathophysiology
Difficulty in propelling food from the oropharynx to the cervical esophagus results in 3 types of symptoms:
- nasopharyngeal regurgitation;
- oropharyngeal regurgitation;
- laryngotracheal aspiration (Duranceau, 1995).
These 3 symptoms originate from a functional obstruction at the level of the cricopharyngeal muscle. A defect, a lack of coordination in muscle relaxation or an incomplete yet coordinated relaxation may account for it. This latter mechanism was shown by Cook in 1992 to be the cause of Zenker’s diverticulum (Cook et al., 1992).
3. Indications
Cricomyotomy is indicated when the functional exploration (radiological investigation, manometry, endoscopy) of a dysphagia identifies the obstruction at the level of the cricopharyngeal muscle (Duranceau, 1997).
The cause of such dysphagia may be:
- neurogenic: stroke, amyotrophic lateral sclerosis;
- myogenic: oculopharyngeal dystrophy;
- structural: idiopathic dysfunction of the upper esophageal sphincter with or without a pharyngoesophageal diverticulum.

Four prognostic factors are positively associated with good, functional surgical results (Duranceau, 1995):
- unimpaired voluntary contraction during swallowing;
- normal tongue movement during swallowing;
- intact phonation;
- absence of dysarthria.

The procedure is contraindicated if the patient is in poor general health.
4. Preop period
- radiological studies: cine contrast swallow studies with both anterior posterior and lateral imaging (Duranceau, 1995) are essential for the diagnosis;
1. Anterior view
2. Lateral view
- nuclear imaging: not essential, but provides useful quantitative information for long-term postoperative follow-up, especially for cases other than Zenker’s diverticulum (Taillefer and Duranceau, 1988);
- endoscopy: especially to rule out mechanical etiologic factors such as cancer or foreign bodies;
- esophageal manometry with assessment of the swallowing: essential to confirm diagnoses other than Zenker’s diverticulum (Castell, 1995; Mason, 1998).

Pulmonary functions should be assessed. Patients often suffer from inhalation pneumonia that should be treated before surgery.

The surgeon should make sure the patient is well hydrated to prevent deep venous thrombosis. Thromboprophylaxis, either pharmacologic (heparin) or mechanical (sequential pneumatic compressions) is highly recommended.

5. Operating room set-up
• Patient
- general anesthesia (standard anesthetic monitoring with ECG and oximeter);
- orotracheal intubation;
- supine position;
- shoulders slightly raised by a sandbag;
- neck extended and rotated to the right for a left cervical approach.
• Team
1. The surgeon stands on the left of the patient, facing the site of the incision.
2. The assistant stands opposite the surgeon, on the patient’s right.
3. The scrub nurse stands on the surgeon’s left. He or she may also stand opposite, on the assistant’s right side.
4. Anesthesiologist
• Equipment
1. Table
2. Anesthetic unit
3. Thoracoscopic unit (optional)
4. Monitors
5. Mayo table
6. Large table
6. Instruments
1. Surgical loupe
2. Peanuts
3. Nasogastric tube
4. Esophageal bougie

- surgical loupes (magnification of 2.5 or 3.5) are recommended;
- No. 15 blade and electrocautery on low power during myotomy;
- peanuts mounted on a grasper to provide countertraction during myotomy;
- standard instruments for dissection, opening and closure;
- esophageal Maloney bougie (or similar 36 French bougie);
- nasogastric tube and 50 mL syringe for air leak testing at the site of the myotomy.
7. Major principles
The procedure consists of the complete removal of the functional cricopharyngeal obstruction. Dissection is performed through an open left cervical incision. It goes down to the retropharyngeal and retro-esophageal space, beyond the deep cervical fascia, to access the whole posterior area of the pharyngo-esophageal junction (1). The myotomy creates a 6 X 1 cm muscular flap that will be resected. It includes, from the esophagus to the pharynx:
- 2 cm of the proximal portion of the cervical esophagus;
- 2 cm of the cricopharyngeal muscle;
- 2 cm of the proximal portions of the inferior and posterior oropharynx.
The mucosa is preserved. If a diverticulum is present and is less than 4 cm long, it is attached to the posterior wall of the pharynx (2); if it is longer, (3) it is resected with a residual cuff that will be attached in a similar fashion.
8. Exposure/sphincter
• Incisions
1. Transverse cutaneous cervical nerve
The skin incision is made cephalad, from the sternal notch, alongside the first two thirds of the anterior edge of the left sternocleidomastoid muscle.
The platysma is divided. The transverse cutaneous cervical nerve is identified. It should be preserved depending on the anatomical variations, to avoid postoperative dysesthesia in the area of the mandible.
• Divisions
• Muscles
1. Omohyoid muscle
The left omohyoid and prethyroid muscles are divided.
• Veins
1. Middle thyroid vein
The middle thyroid vein is ligated, then divided. A facial vein located cephalad may require division.
• Approaches
• Laryngeal nerve
1. Lateral ligature of the inferior thyroid artery to preserve the recurrent laryngeal nerve
Just below the divided prethyroid muscles, the inferior thyroid artery is identified. It should be ligated as lateral as possible to avoid any trauma to the recurrent laryngeal nerve.
• Deep cervical fascia
The assistant retracts the larynx medially and ventrally to put tension on the deep cervical fascia, which is divided.
9. Cricomyotomy
• Cricomyotomy
• Posterior rotation
1. Cricoid cartilage
The anesthesiologist introduces a 36F esophageal bougie through the patient’s mouth into the proximal third of the esophagus.
The assistant exposes the posterior wall of the pharyngo-esophageal junction by pulling upward and rotating to the right the left side of the larynx with the left lobe of the thyroid gland. This maneuver with the bougie in place puts slight tension on the muscle and facilitates the myotomy.
The myotomy consists of the resection of a rectangular muscular flap of the posterior pharyngo-esophageal junction. This is done cautiously, to avoid perforation of the mucosa, by alternating low power cautery with myotomy and lifting of the flap with a cold blade to ensure hemostasis and perfect visualization of the mucosa.
• Dissection/diverticulum
1. Cricoid cartilage
2. Diverticulum
If there is a Zenker’s diverticulum, it is left intact and its neck is progressively dissected until the mucosa is reached. The upper limit of the myotomy is approximately 1 cm above the neck of the diverticulum on the posterior wall of the pharynx.
The muscular flap is resected.
• Control of airtightness
Control of airtightness is systematically achieved through the airways. The Maloney bougie is removed and replaced by a nasogastric tube. The lateral openings of the tube are placed at the level of the myotomy. The anesthesiologist then administers a few syringes of air (30-50 mL) while the surgeon inspects the operating cavity filled with water for air leaks. Any leak should be closed using a 3.0 or 4.0 absorbable suture. The test is repeated until there are no leaks. The tip of the nasogastric tube is then pushed down into the stomach.
• Diverticulum
• Less than 4 cm
1. Diverticulum
2. Posterior and superior surface of the pharynx
If the diverticulum is less than 4 cm, it is attached with 3 or 5 stitches of polypropylene or silk sutures to the posterior and superior wall of the pharynx.
• More than 4 cm
1. Mechanical suture
2. Suspension of the cuff
If the diverticulum is more than 4 cm, it is resected and sutured transversely with a 3.5 mm mechanical stapler. A 1 cm distal cuff is preserved and used for attachment to the upper limit of the pharyngeal myotomy. Control of airtightness is then achieved after replacement of the bougie by the nasogastric tube as previously described.
10. Closure
Hemostasis is performed with electrocautery. If bleeding occurs during or after myotomy, especially at the level of the pharynx, hemostasis with a 4.0 absorbable suture is recommended. Any extensive coagulation done on the stripped mucosa after myotomy may result in late necrosis and fistulae.
The platysma is closed with running 2.0 absorbable sutures. The skin is closed using a 4.0 absorbable continuous subcuticular suture.
11. Postop period
- the patient is mobilized as soon as possible;
- bedhead with a Fowler 30° tilt until postoperative day 1.
If there is a possibility of fistulae, a barium swallow is carried out with multiple incidences.
A liquid diet is administered on the first postoperative days. The patient returns progressively to a soft diet by the end of the first postoperative week, then to a normal diet.
If there are symptoms of gastroesophageal reflux, the Fowler tilt is maintained between 15° and 30°.

12. Complications
Complications (Sideris, 1999)
- related to anesthesia or to the patient’s general condition:
- aspiration pneumonia;
- cardiac complications depending on the history of the patient;
- thromboembolic complications.

Surgical complications
- bleeding or intraoperative-postoperative hematomas;
- intraoperative mucosal perforations to be repaired whenever identified intraoperatively;
- fistulae if the perforation is not identified intraoperatively or later on. Symptoms are swelling or unusual pain when patient resumes a liquid diet, and unexplained fever.

Whenever fistulae are suspected, a radiological investigation should be carried out.
If this indicates a small and blind fistula, the patient should remain NPO and be treated with antibiotics.
If the fistula is more serious or food intake has already been resumed, a surgical exploration should be conducted and the leak repaired, with drainage and primary closure of the wound. Antibiotics should be administered for 7 to 14 days depending on the clinical course of the patient.

Follow-up is done 4 to 6 weeks after the procedure. There is no long-term follow-up after surgery for Zenker’s diverticulum that has become asymptomatic again. If the primary disease was an oculopharyngeal dystrophy or a stroke, the patient should be followed up at least once a year.
13. Reference
Castell JA, Castell DO, Duranceau CA, Topart P. Manometric characteristics of the pharynx, upper
esophageal sphincter, esophagus, and lower esophageal sphincter in patients with oculopharyngeal
muscular dystrophy. Dysphagia 1995;10:22-6.
Cook IJ, Gabb M, Panagopoulos V, Jamieson GG, Dodds WJ, Dent J et al. Pharyngeal (Zenker's)
diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology 1992;103:1229-
35.
Duranceau A. Oropharyngeal dysphagia and disorders of the upper esopharyngeal sphincter. Ann
Chir Gynaecol 1995;84:225-33.
Duranceau A. Cricopharyngeal myotomy in the management of neurogenic and muscular dysphagia.
Neuromuscul Disord 1997;7 Suppl 1:S85-9.
Kaplan S. Paralysis of deglutition, a post poliomyelitis complication treated by section of the
cricopharyngeus muscle. Ann Surg 1951;133:572-3.
Mason RJ, Bremner CG, DeMeester TR, Crookes PF, Peters JH, Hagen JA et al. Pharyngeal
swallowing disorders: selection for and outcome after myotomy. Ann Surg 1998;228:598-608.
Taillefer R, Duranceau AC. Manometric and radionuclide assessment of pharyngeal emptying before
and after cricopharyngeal myotomy in patients with oculopharyngeal muscular dystrophy. J Thorac
Cardiovasc Surg 1988;95:868-75.