CASE 1                                                                                           

Figure 1. Small Zenker's diverticulum confirmed by modified barium swallow.

 

A 77-year-old female presented with a six month history of progressive dysphagia to solids. She noted regurgitation of undigested food several hours after meals, and suffered from chronic bad breath and belching. The patient underwent a modified barium swallow which demonstrated a 3 x 2 cm upper esophageal (Zenker's) diverticulum.

 

Patient profile 

• 77-year-old female with solid food dysphagia, regurgitation of undigested food, and foul breath for six months.
• Modified barium swallow revealed a 3 x 2cm. Zenker's diverticulum (Figure 1).
• Surgical management options, including open versus endoscopic approaches, were discussed with the patient. The patient elected to undergo endoscopic repair.

Figure 2. The Weerda bivalve diverticuloscope (Karl Storz).

Surgical Course

• The patient was intubated with a standard 6.0 endotracheal tube.
• The upper teeth were protected with a rubber tooth guard.
• A Weerda bi-valve scope (diverticuloscope) (Figure 2) was coated with a thin film of surgical lubricating jelly and passed behind the larynx into the upper esophagus.
• The Weerda scope was slowly withdrawn while opening the mouth of the scope to reveal the take-off of the diverticular pouch above the cricopharyngeus muscle.
• The Weerda scope was then positioned to straddle the cricopharyngeus with the upper limb of the scope in the esophagus and the lower limb in the diverticulum pouch.
• The patient's eyes were then covered with moist gauze, and the head and neck draped with moistened towels.
• Suction tubing was attached to the scope, and a microscope brought into the field to magnify the cricopharyngeus muscle.
• An Omniguide laser fiber inserted into a long, straight laser holder was brought into the field and set at 8 to 10 watts.
•  While hovering 1 cm over the cricopharyngeus, a 2 cm. cut was made in the mucosa and submucosal thereby revealing the underlying fibers of the cricopharyngeus. A blackened platform suction in the non-dominate hand was used to place gentle tension on the tissues.
• The cricophageal muscle fibers that form the wall between the diverticular pouch and the esophagus were then progressively divided with the laser fiber down to the base of the diverticulum thereby opening the pouch and allowing direct drainage into the esophagus.Bleeding was controlled by increasing the distance between the tissues and laser fiber, or by use of an extended tip suction cautery device.

Postoperative Results

• The patient was admitted to the hospital for a 23-hour observation for IV fluids while NPO (nothing by mouth). The patient was monitored for signs of esophageal leakage such as severe odynophagia, neck crepitus, tachycardia, and leukocytosis.
• The patient started a clear liquid diet on post-operative day one without difficulty and was discharged to home. She continued the clear liquid diet through POD 3.
• The patient started a soft solid diet on POD 4 for 1 week, followed by normal diet.
• Two weeks following surgery, the patient was enjoying a normal solid diet without dysphagia, regurgitation, or halitosis.

 

CASE 2                                                                                           

 

A 67-year-old female with a history of mild dysarthria from a stroke presented with a one year history of progressive dysphagia to solids. The patient had the sensation that pills and dry foods such as bread or chicken would get stuck in her upper throat. The sensation would pass with repeated swallows with additional water. She denied difficulty with liquids, or coughing during swallow. She denied signs of acid reflux. A modified barium swallow revealed failure of relaxation of the upper esophageal sphincter with a cricopharyngeal bar obstructing approximately 50% of the lumen of the upper esophagus.

 

Patient profile

•  67-year-old female with dysphagia to pills and dry solid foods.
•  Patient requires multiple sips of liquids and swallows to get food to pass upper throat.
•  Modified barium swallow and direct esophagoscopy showed poor relaxation of the upper esophageal sphincter with evidence of cricopharyngeal bar (Figure 3 A&B).
• Surgical management options, including upper esophageal dilation versus endoscopic or open cricopharyngeal myotomy were discussed.

Surgical Course

• The patient was intubated with a standard 6.0 endotracheal tube.
• A Weerda bi-valve scope (diverticuloscope) was passed behind the larynx into the upper esophagus and slowly withdrawn while opening the mouth of the scope to reveal the bar of the cricopharyngeus muscle.
• The Weerda scope was suspended into place, and the patient prepared for laser surgery with moist towel and eye protection.
• An Omniguide laser fiber inserted into a long, straight laser holder was brought into the field and set at 8 to 10 watts.
•  While hovering 1 cm over the cricopharyngeus, a 2 cm. cut was made in the mucosa and submucosal thereby revealing the underlying fibers of the cricopharyngeus. A blackened platform suction in the non-dominate hand was used to place gentle tension on the tissues.
• The cricophageal muscle fibers that form the bar were divided with the laser allowing flattening of the posterior esophageal wall and thereby increasing the esophageal lumen. Bleeding was controlled by increasing the distance between the tissues and laser fiber, or by use of an extended tip suction cautery device.

Postoperative Results

• The patient was admitted to the hospital for a 23-hour observation for IV fluids while NPO (nothing by mouth). The patient was monitored for signs of esophageal leakage such as severe odynophagia, neck crepitus, tachycardia, and leukocytosis.
• The patient started a clear liquid diet on post-operative day one without difficulty and was discharged to home. She continued the clear liquid diet through POD 3.
• The patient started a soft solid diet on POD 4 for 1 week, followed by normal diet.
• Two weeks following surgery, the patient was enjoying a normal solid diet without the sensation of blockage.

 

CASE 3                                                                                           

 

A 76-year-old man with a history of total laryngectomy and radiation for cancer presented with a four month history of progressive dysphagia to solids. The patient had the sensation that solid food would get stuck in his upper throat. A modified barium swallow demonstrated a shelf of tissue at the base of tongue where the pharynx was sutured at laryngectomy which would catch solid food and prevent smooth passage of the bolus into the esophagus. Esophagoscopy was performed to rule-out recurrent cancer as a cause of dysphagia and to confirm the presence of the tissue shelf.

 

Patient profile

• 76-year-old man with dysphagia to solid foods after laryngectomy and radiation therapy.
• Modified barium swallow showed tissue shelf at the base of tongue preventing smooth passage of solid food bolus.
• Surgical management options, including upper esophageal dilation versus endoscopic laser therapy were discussed.

Figure 4. Shelf of scar tissue obstructing bolus flow in the hypopharynx after laryngectomy.

Surgical Course

• The patient was intubated through his laryngectomy stoma.
•  The patient's neck and pharynx were palpated and found to be without evidence of tumor.
• A Dedo laryngoscope was used to perform a complete upper endoscopy, confirming the presence of the soft tissue shelf (Figure 4).
• The Dedo scope was suspended into place, and the patient prepared for laser surgery with moist towel and eye protection.
• An Omniguide laser fiber inserted into a long, straight laser holder was brought into the field and set at 8 to 10 watts.

Figure 5. Scar tissue after removal by laser fiver.

• While hovering 1 cm over the tissue, the shelf was removed with a large U shaped cut, thereby creating an open passage from the base of the tongue to the upper esophagus (Figure 5). Bleeding was controlled by increasing the distance between the tissues and laser fiber, or by use of an extended tip suction cautery device. 

Postoperative Results

• The patient was discharge to home immediately following the procedure. He was maintained on a liquid diet for three days followed by a normal diet, and a 1 week course of antibiotics.
• The patient reported no solid food dysphagia one week after the procedure and was able to consume a variety of complex solid foods.

 

DISCUSSION                                                                                    

 

Cricopharyngeal achalasia is a relatively common disorder in older adults characterized by the sensation of inhibited passage of pills and solid foods. Although the underlying etiology of cricopharyngeal achalasia is varied, the final common pathology involves loss of innervation to the cricopharyngeal muscle that results in muscle atrophy which is replaced by scar. As a result, a cricopharyngeal bar is formed that fails to relax during swallow thereby inhibiting passage of the bolus.  The upper pharynx must squeeze hard in an effort to get the bolus to pass resulting in an area of high pressure in the pharynx above the cricopharyngeus. Prolonged exposure to these high pressures may result in the formation of Zenker's diverticulum which forms by the herniation of the pharyngeal mucosa through the normally weak midline raphe of the pharyngeal wall. Zenker diverticula are characterized by more severe dysphagia, chronic cough, regurgitation of undigested food, and halitosis. The modified barium swallow is the test of choice, and can readily identify a cricopharyngeal bar or Zenker's diverticula if present.

 

Division of the cricopharyngeal muscle and scar is the key feature in the surgical management of both cricopharyngeal bar and Zenker's diverticula. Cricopharyngeal myotomy expands the diameter of the upper esophagus and allows unimpeded bolus flow from the pharynx to the esophagus in both conditions. Recent evidence has shown endoscopic cricopharyngeal myotomy to be as effective as open myotomy but with a more rapid recovery and fewer significant surgical complications. The CO2 laser fiber or a scope-mounted CO2 laser allows a controlled layer by layer division of the cricopharyngeus muscle in a bloodless plane. The laser is preferred for Zenker's pouches less than 3cm. in depth. Larger Zenker's pouches that are greater than 3cm. in depth can be managed using an 35 mm endoscopic stapler which seals the edges of the cut and may therefore have a lower risk of a potential esophageal leak.

 

The CO2 laser is likewise a valuable tool for resection of scar tissue in the upper and lower the pharynx, such as those that result from laryngectomy and radiation therapy for upper aerodigestive cancer. The laser allows for rapid healing of the pharyngeal tissues and immediate resumption of a liquid diet followed by solid food within days.

 

M. Boyd Gillespie, MD

Associate Professor

M. Boyd Gillespie, M.D.