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.
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).
1. Lobule of the auricle
2. Sternal notch
3. Anterior edge of the sternocleidomastoid muscle
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
- 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).
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.
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.
- orotracheal intubation;
- supine position;
- shoulders slightly raised by a sandbag;
- neck extended and rotated to the right for a left cervical approach.
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.
2. Anesthetic unit
3. Thoracoscopic unit (optional)
5. Mayo table
6. Large table
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.
- 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.
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.
The left omohyoid and prethyroid muscles are divided.
The middle thyroid vein is ligated, then divided. A facial vein located cephalad may require division.
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.
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.
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.
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.
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.
The platysma is closed with running 2.0 absorbable sutures. The skin is closed using a 4.0 absorbable continuous subcuticular suture.
- 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°.
- related to anesthesia or to the patient’s general condition:
- aspiration pneumonia;
- cardiac complications depending on the history of the patient;
- thromboembolic 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.
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