Endoscopic CO2 laser cricopharyngeal myotomy

445nm Blue Laser for Cricopharyngeal Myotomy/Zenker's Diverticulotomy: Proof of Concept and Use

OBJECTIVE(S)

Treatment for Zenker's diverticulum and cricopharyngeal dysfunction has evolved to include flexible endoscopic approaches. Currently, no flexible modalities combine the precision cutting of CO2 laser and the hemostasis of knife electrocautery. We present the first series describing fiber-based 445nm blue light (BL) laser for endoscopic cricopharyngeal myotomy/Zenker's diverticulotomy. We describe usage characteristics and laser parameters with rigid esophagoscopy to determine the feasibility of use with flexible endoscopy.

METHODS

Retrospective review and literature review.

RESULTS

The first nine cases of endoscopic diverticulotomy (n = 5) and cricopharyngeal myotomy (n = 4) with BL were reviewed. Rigid exposure was achieved with the Dohlman Slimline diverticuloscope. Mean age was 75.6 years. Average diverticulum depth was 0.89 cm ±1.0 cm. Pulsed mode was used in seven cases with mean of 6.86 W, 54 ms pulse on, and 286 ms pulse pause and overall mean of 6.00 W and 405 J. Complete myotomy with intact buccopharyngeal fascia and without bleeding limiting view was achieved in all patients. One of two patients in whom continuous wave setting was used developed subcutaneous emphysema following vigorous cough on POD0; this resolved after 7 days nothing per oral (NPO). Eight patients were started on oral intake without evidence for leak. Pulsed mode with fiber-to-tissue contact provided effective muscle cutting without disruption of buccopharyngeal fascia. Literature review yielded three articles examining flexible approach with laser for Zenker's and none with BL.

CONCLUSION

BL provides safe and effective fiber-based cutting and hemostasis in endoscopic cricopharyngeal myotomy/Zenker's diverticulotomy. Future use in flexible endoscopic approaches appears feasible, though continuous wave should be avoided.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:4620-4624, 2024.

Association Between Modified Frailty Index and Postoperative Outcomes of Cricopharyngeal Myotomy

OBJECTIVE

The modified 5-item frailty index (mFI-5) is a comorbidity-based risk stratification tool previously validated in patients undergoing several surgical procedures. This study investigates the association between mFI-5 score and cricopharyngeal myotomy (CM) complications.

STUDY DESIGN

Retrospective database review.

SETTING

US hospitals.

METHODS

The National Surgical Quality Improvement Program database was queried for patients who underwent CM between 2005 and 2018. mFI-5 score was determined by assigning 1 point for comorbidities including: diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dependent health status. Univariate and multivariable analyses were conducted to determine associations between mFI-5 score and postoperative complications.

RESULTS

A total of 1075 patients undergoing CMs were queried and stratified into the following groups: mFI = 0 (n = 412 [38.3%]), mFI = 1 (n = 452 [42.0%]), and mFI ≥ 2 (n = 211 [19.6%]). Univariate analysis showed association between higher mFI-5 scores with older age, higher American Society of Anesthesiologists Classification class, obesity, smoking, dyspnea, and systemic sepsis. Higher mFI-5 was associated with a greater proportion of cumulative surgical complications, cumulative medical complications, pneumonia, myocardial infarction, cumulative morbidity, readmissions, unplanned readmissions, and reoperations. Multivariable analyses found associations between greater mFI-5 score and cumulative morbidity (odds ratio [OR] = 1.95, confidence interval [CI]: 1.29-2.96, P = .002), any surgical complication (OR = 1.80, CI: 1.15-2.79, P = .010), readmission (OR = 1.81, CI: 1.01-3.26, P = .047), and reoperations (OR = 1.96, CI: 1.04-3.68, P = .037).

CONCLUSION

Evaluating mFI-5 can help assess the risk of postoperative complications for patients undergoing CM.

LEVEL OF EVIDENCE

Level 4.

Understanding Zenker's Diverticulum Treatment: Transoral CO2 Laser Microsurgery

The authors present a case of a 36-year-old woman with a recurrent throat foreign body sensation and persistent dysphagia. On physical examination, a polypoid mass was visible at the postcricoid region, mobile with swallowing. A barium swallowing test confirmed the diagnosis of Zenker's diverticulum. The patient underwent transoral CO2 laser microsurgery for excision of the pharyngeal pouch. At the four-month evaluation, the patient was remarkably asymptomatic and without evidence of recurrence. This clinical case illustrates in detail the endoscopic view of the pre and postoperative aspects of the pharyngeal pouch, showing a step-by-step transoral CO2 laser microsurgery technique, with video.

Clinical Practice Guidelines for Oropharyngeal Dysphagia

OBJECTIVE

Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one's physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia.

METHODS

Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology.

RESULTS

Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended.

CONCLUSION

This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

New, safe and simple endoscopic cricopharyngeal myotomy with a curved rigid laryngoscope: A case report

Endoscopic cricopharyngeal myotomy (ECPM) is a safe and minimally invasive technique that is used to treat patients whose esophageal inlet fails to open because of specific diseases, such as Wallenberg's syndrome and neuromuscular diseases. The present study described the performance of a new, safe and simple ECPM using a curved rigid laryngoscope, which is used for endoscopic laryngopharyngeal surgery for patients with dysphagia due to pharyngeal residue after swallowing. The patient was an 80-year-old woman with laryngeal palsy caused by lower cranial nerve palsy after cranial base schwannoma surgery. ECPM was performed with a curved rigid laryngoscope. The postoperative course was good; postoperative rehabilitation eliminated the residue after swallowing a thickened solution and mealtimes were shorter than before surgery. This procedure allows the hypopharynx to be widely expanded and it is possible to develop a wider surgical field than when using a direct laryngoscope. In addition, this procedure appears to be relatively easy to perform if the surgeon is familiar with the curved rigid laryngoscope technique.

Peroral endoscopic myotomy for management of cricopharyngeal bars (CP-POEM): a retrospective evaluation

BACKGROUND

Cricopharyngeal bars (CPBs) are a unique etiology of oropharyngeal dysphagia. Symptomatic patients are managed with endoscopic dilation or surgical myotomy. Cricopharyngeal peroral endoscopic myotomy (CP-POEM) is an emerging technique for the management of dysphagia due to CPBs. This study evaluated technical success, clinical success, adverse events, and long-term recurrence following CP-POEM.

METHODS

Consecutive patients who underwent POEM for management of CPBs between May 2015 and December 2020 at four tertiary care centers were included. Primary outcome was clinical success (defined as improvement of dysphagia score to ≤ 1). Secondary outcomes were technical success, rate and severity of adverse events, procedure duration, and symptom recurrence.

RESULTS

27 patients (mean age 69 years; 10 female) underwent CP-POEM during the study period. The most common presenting symptoms at the time of index procedure were dysphagia (26; 96.3 %) and regurgitation (20; 74.1 %). Clinical and technical success were achieved in all patients. Mild/moderate adverse events occurred in two patients (7.4 %). CP-POEM significantly reduced the median dysphagia score.

CONCLUSIONS

CP-POEM was a safe and effective treatment for symptomatic CPBs. Although symptom recurrence was low, long-term outcome data are needed. CP-POEM should be considered as a management option for symptomatic CPBs at centers with POEM expertise.

Endoscopic Management of Postradiation Dysphagia in Head and Neck Cancer Patients: A Systematic Review

OBJECTIVES

To systematically review the success rate and safety profile of the available endoscopic surgical options for radiation-induced dysphagia in head and neck cancer patients following organ preservation treatment, including upper esophageal sphincter (UES) dilation, cricopharyngeus (CP) myotomy (CPM), and CP intramuscular botulinum toxin (Botox) injection.

METHODS

A search of MEDLINE, Scopus, Google Scholar, and Cochrane databases was done to identify articles published between January 1980 and December 2017. Pediatric series, foreign language articles, series with Zenker's diverticulum or following primary surgical treatment including laryngectomy, open UES/CP surgery, or samples with fewer than 5 patients were excluded.

RESULTS

An initial search identified 539 articles. All titles and abstracts were reviewed. One hundred and sixteen potentially relevant articles were inspected in more detail, and 14 retrospective studies met eligibility criteria. Dilation group included 10 studies on anterograde and/or retrograde dilation, with an overall 208 patients. Success rate ranged from 42% to 100%. The endoscopic CPM group included 3 studies with a total of 36 patients, and the success rate ranged from 27% to 90%. In the Botox group, 1 one study with 20 patients met our inclusion criteria, with an overall 65% success rate (13/20). Major complications were only reported in the dilation group, which included esophageal perforation and death.

CONCLUSIONS

The lack of consistency across trials indicates insufficient evidence for guiding clinical practice. This systematic review suggests the need for greater standardization of outcomes and instruments. Future prospective evaluation should use validated patient-rated and clinician-rated assessment tools to optimally measure postoperative swallowing outcomes of head and neck cancer dysphagic patients following organ preservation therapy.

Efficacy of fluoroscopy-guided endoscopic cricopharyngeal myotomy

BACKGROUND

In endoscopic cricopharyngeal myotomy, surgeons sometimes have concerns about performing an adequate incision with only a narrow intra-cavital view from one direction. In order to overcome these issues, fluoroscopic radiography was used during endoscopic cricopharyngeal myotomy.

METHODS

Peri-operative fluoroscopic radiography was utilised to check the position of the diverticuloscope, and to confirm the extent of the incision during surgery. A balloon catheter was used to determine whether the cricopharyngeal muscle was sufficiently resected. Blood loss, peri-operative complications, and functional oral swallowing scale and penetration aspiration scale scores were evaluated.

RESULTS

In 12 out of 15 patients, intra-operative fluoroscopic radiography showed the diverticuloscope positioned in the post-cricoid area, and the cricopharyngeal muscle was raised and the surgery completed without adverse effect. Swallowing functions improved following surgery.

CONCLUSION

Intra-operative fluoroscopy might improve endoscopic cricopharyngeal myotomy by allowing surgeons to confirm the extent of resection, and by reducing peri-operative morbidity and complication rates.

Validity and reliability of a novel patient reported outcome tool to evaluate post-operative dysphagia, odynophagia, and voice (DOV) disability after anterior cervical procedures

Background

Existing evaluative instruments for dysphagia, odynophagia, and voice disturbance are cumbersome, focus pre-dominately on dysphagia, and often require administration by a certified Speech Pathologist. This study was conducted to utilize widely accepted instruments such as the American Speech and Hearing Association's National Outcomes Measurement System (NOMS) and VAS pain scales to validate a novel, patient-reported instrument that quantifies the severity of post-operative dysphagia, odynophagia, and voice disabilities (DOV).

Methods

The DOV was developed and subjected to multiple rounds of face and content validation by representative patient cohorts and a panel of clinical experts. An established, prospective clinical registry was utilized to collect pre and post-operative VAS-swallow related pain and DOV measurements for subjects with recent anterior cervical procedures (n=25 content validation, n=20 criterion validation), or recent lumbar decompressions (n=33). NOMS evaluations were performed by a certified Speech Language Pathologist on the first post-operative day after minimally invasive anterior approaches to cervical reconstruction were performed in the criterion validation cohort.

Results

Content validity: Subjects with a recent anterior cervical procedure reported a significant increase in post-operative dysphagia (pre-op: 0.13±0.35, post-op: 1.08±1.41, p=0.01), odynophagia (pre-op: 0.24±0.69, post-op: 0.84±0.90, p=0.001), and voice (pre-op: 0.10±0.41, post-op: 0.88±0.92, p=0.0004) disturbance. In contrast, subjects with a recent lumbar procedure did not demonstrate a significant increase in post-operative dysphagia, odynophagia, or voice disturbance (p>0.05).Criterion validity: Chi-squared contingency testing for independence between converted NOMS and DOV instrument scores accepted linkage between the two instruments for dysphagia X2(DF: 12, n=20, Expected: 21.03, Observed: 24.4, p: 0.02) and voice X2(DF: 6, n=20, Expected: 12.60, Observed: 21.28, p: 0.002) dimensions. Similarly, converted swallow related VAS and DOV odynophagia instruments demonstrated linkage X2(DF: 9, n=20, Expected: 16.92, Observed: 24.21, p: 0.004).Internal Reliability: Chronbach's alpha coefficient of reliability was 0.74 between all DOV survey dimensions.

Conclusions

The DOV survey is a valid patient-reported instrument to rapidly and reliably detect post-operative swallow and voice dysfunction.

Endoscopic surgical technique for benign fibrotic strictures of the upper esophageal sphincter

A 43-year-old man with complaints of increased difficulty swallowing and weight loss underwent videofluorographic examination of swallowing, which revealed severely reduced cricopharyngeal opening. Endoscopic cricopharyngeal myotomy was carried out using a modified technique (mECPM). A benign fibrotic stricture of the upper esophageal sphincter (UES) was identified under visualization of a distending operating laryngoscope. A vertical midline incision in the strictured mucosa and submucosal resection of the cricopharyngeal muscle were done using a CO₂ laser. The initial vertical mucosal incision was tightly sutured in the horizontal direction with absorbable surgical sutures. Histopathological examination of the cricopharyngeal muscle revealed infiltration of inflammatory cells. The patient started oral intake on postoperative day 7. He has been symptom free for 2 years with an improved body mass index, and postoperative laryngoscopy revealed no salivary retention in the piriform sinuses. The technique presented here provides sufficient opening of the UES by eliminating the problem of restenosis. mECPM will be useful for treating benign fibrotic strictures of the UES.

Management of cricopharyngeal achalasia in an 8-month child using endoscopic cricopharyngeal myotomy

A term baby was transferred to our tertiary care center with desaturations and inability to manage upper airway secretions. Rigid bronchoscopy and swallowing study revealed cricopharyngeal (CP) achalasia. A gastrostomy tube insertion and Botulinum Toxin-A injection were performed at 6 weeks of age. Improvement of symptoms was observed, however were short-lived requiring recurrent injections. Given the symptom severity, at 8 months, a successful endoscopic CP myotomy was performed. Patient was able to tolerate oral feeds as early as 2 months post-operatively. This is the youngest patient, to our knowledge, treated with endoscopic CP myotomy. Intraoperative pictures and video are presented.

Assessment of videofluoroscopic swallow study findings before and after cricopharyngeal myotomy

BACKGROUND

Cricopharyngeal myotomy is a treatment for obstructive cricopharyngeal bar and Zenker's diverticulitis. Little is reported regarding contrast study findings and their correlation with patient symptoms.

METHODS

All patients treated by cricopharyngeal myotomy underwent a preoperative and postoperative videofluoroscopic swallow study (VFSS) and completed the self-reported Eating Assessment Tool (EAT-10). Studies were analyzed quantitatively.

RESULTS

Forty cricopharyngeal myotomies were performed (mean age 76 years; SD 8.72) all for dysphagia. Symptomatic improvement (change in EAT-10 scores) occurred in 95% (38/40). Presurgical versus postsurgical VFSS demonstrated significantly improved pharyngoesophageal segment opening, pharyngeal constriction ratio, and pouch residue (P < .01). Symptomatic improvement was unrelated to the presence of retained barium.

CONCLUSION

Both symptomatic and objective improvement in swallowing measures occurs after cricopharyngeal myotomy. Pouch remnants and retained barium are seen postoperatively but do not correlate with reported symptoms. Routine follow-up barium studies may be needed to establish a new baseline and allow for comparison if future symptom recurrence occurs.

Effectiveness of endoscopic cricopharyngeal myotomy in adults with neurological disease: systematic review

OBJECTIVE

To determine the effectiveness of endoscopic cricopharyngeal myotomy on upper oesophageal sphincter dysfunction in adults with upper oesophageal sphincter dysfunction and neurological disease.

DATA SOURCES

Published and unpublished studies with a quasi-experimental design investigating endoscopic cricopharyngeal myotomy effects on upper oesophageal sphincter dysfunction in humans were considered eligible. Electronic databases, grey literature and reference lists of included studies were systematically searched.

REVIEW METHODS

Data were extracted by two independent reviewers. Methodological quality was assessed independently using the PEDro scale and MINORS tool.

RESULTS

Of 2938 records identified, 2 studies were eligible. Risk of bias assessment indicated areas of methodological concern in the literature. Statistical analysis was not possible because of the limited number of eligible studies.

CONCLUSION

No determinations could be made regarding endoscopic cricopharyngeal myotomy effectiveness in the cohort of interest. Reliable and valid evidence on the following is required to support increasing clinical usage of endoscopic cricopharyngeal myotomy: optimal candidacy selection; standardised post-operative management protocol; complications; and endoscopic cricopharyngeal myotomy effects on aspiration of food and laryngeal penetration, mean upper oesophageal sphincter resting pressure and quality of life.

Management of isolated cricopharyngeal dysfunction: systematic review

OBJECTIVE

A systematic review was performed to evaluate the safety and efficacy of different therapeutic interventions available for the management of isolated cricopharyngeal dysfunction.

METHODS

Studies were identified using the following databases: Ovid (Medline, Embase), the Cochrane Library, PubMed and Google Scholar. An initial search identified 339 articles. All titles and abstracts were reviewed. Fifty-six relevant articles were inspected in more detail; of these, 47 were included in the qualitative analysis.

RESULTS

No relevant randomised trials were found. A range of case series were used to perform a qualitative analysis. Botulinum toxin A injection and cricopharyngeal dilatation were associated with a higher risk of recurrence, but appear to be more suitable in elderly and co-morbid patients. In those patients requiring formal myotomy, endoscopic approaches appear to be as effective but less morbid when compared with classical open surgery.

CONCLUSION

There is good evidence for the safety and efficacy of the different therapeutic options for isolated cricopharyngeal dysfunction. However, further studies are required to compare the efficacy of the various treatment modalities.

Outcomes of endoscopic cricopharyngeal myotomy with CO2 laser surgery: A retrospective study of 47 patients

BACKGROUND

Endoscopic cricopharyngeal myotomy (ECPM) using CO2 laser surgery presents a less invasive treatment technique when compared to transcervical cricopharyngeal myotomy.

METHODS

Forty-seven patients who underwent ECPM from 2002 until 2013 were included in this study. Patient characteristics, and preoperative and postoperative outcome and complications were scored by retrospective chart review and by using the Deglutition Handicap Index (DHI).

RESULTS

Overall, 40 of 47 patients (85%) experienced relief of symptoms postoperatively. Ten patients (25%) developed recurrent symptoms of dysphagia requiring re-laser surgery. All 40 patients were satisfied at the postoperative visit after an average of 1.3 interventions. DHI scores were better in patients with idiopathic dysfunction and neurologic disease, compared to dysfunction because of prior treatment of head and neck cancer. One patient developed mediastinitis that was successfully treated with antibiotics. There was no mortality.

CONCLUSION

ECPM is an effective treatment for cricopharyngeal dysfunction with a low rate of surgical morbidity and complications. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1022-1027, 2016.

Short-term Quality-of-Life Outcomes following Transoral Diverticulotomy for Zenker’s Diverticulum

Objective

To prospectively analyze quality-of-life outcomes following transoral diverticulotomy with cricopharyngeal myotomy (DCPM) for Zenker’s diverticulum (ZD).

Study Design

Prospective single-group study.

Settings

Tertiary academic institution.

Subjects and Methods

A prospective multicenter study performed from January 1, 2012, to July 1, 2014, included 18 patients presenting with ZD undergoing DCPM. Standardized questionnaires—including the 10-item Eating Assessment Tool (EAT-10), Functional Outcome of Swallowing Scale (FOSS), and the Reflux Symptom Index (RSI)—were completed preoperatively and at 3 and 6 months postoperatively. Videofluoroscopic studies were obtained and analyzed by our senior speech-language pathologist, who was blinded to the clinical outcomes.

Results

Eighteen patients were included (11 women; mean age, 72.6 years; range, 53-86 years). All patients had ZD on preoperative videofluoroscopic swallowing studies. The most common comorbidities included hypertension (10 of 18, 55.6%), dyslipidemia (8 of 18, 44.4%), hiatal hernia (6 of 18, 33.3%), and gastroesophageal reflux disease (5 of 18, 27.8%). Median preoperative RSI was 27 (interquartile range [IQR], 22.5-31.5); FOSS, 2 (IQR, 2-3); and EAT-10, 21.5 (IQR, 13.5-27.5). The 3-month questionnaire (88.9% completion) demonstrated an improved median RSI of 5 (IQR, 1-7.5; P < .001), FOSS of 0 (IQR, 0; P < .001), and EAT-10 of 0 (IQR, 0-3; P < .001). Fourteen patients (77.8%) completed the 6-month questionnaire, demonstrating a median RSI of 4 (IQR, 0-8), FOSS of 0 (IQR, 0-0.5), and EAT-10 of 1 (IQR, 0-3). While regurgitation decreased following surgery ( P = .007), nighttime cough did not ( P = .25).

Conclusion

This study supports an improvement in functional outcome and quality of life in patients with ZD undergoing DCPM.

Treatment of cricopharyngeal dysfunction: a comparative pilot study

Background

Cricopharyngeal dysfunction is a narrowing at the level of the upper oesophageal sphincter caused by failed or incomplete sphincter opening as a result of lack of pharyngoesophageal coordination or reduction in the muscular compliance of the upper oesophageal sphincter. Oropharyngeal dysphagia is a typical symptom. Videomanometry allows direct comparison of pressure readings with dynamic anatomy during swallowing.

Methods

This is a prospective randomized pilot study that compares the effect of balloon dilatation and laser myotomy in cricopharyngeal dysfunction. We used videomanometry as an objective measure and the Swedish version of Sydney Swallowing Questionnaire as patient’s self-assessment at baseline and 1 and 6 months after treatment.

Results

The UES sagittal diameter increased from 5.6 mm pre-operatively to 8.4 mm 6 months post-operatively with no differences between treatment groups. Preoperative mean Sydney Swallowing Questionnaire score was 770 and 6 months post-operative score 559, with no difference between the treatments in our cohort.

Conclusion

Cricopharyngeal dysfunction treatment by either laser myotomy or balloon dilatation improved upper oesophageal sphincter opening during at least 6 months.

Trial registration: ISRCTN84905610, date: 081214

Targeted use of endoscopic CO2 laser cricopharyngeal myotomy for improving swallowing function following head and neck cancer treatment

BACKGROUND

Cricopharyngeal dysfunction following head and neck cancer treatment may lead to a significant reduction in oral intake. Carbon dioxide laser is an established procedure for the treatment of non-malignant cricopharyngeal disorders. We report our experience of laser cricopharyngeal myotomy with objective swallowing outcome measures, before and after treatment.

METHODS

We identified 11 patients who had undergone carbon dioxide laser cricopharyngeal myotomy for dysphagia following radiotherapy, with or without chemotheraphy between January 2006 and July 2011. We analysed the swallowing outcomes following carbon dioxide laser cricopharyngeal myotomy by retrospective grading of pre- and post-procedure videofluoroscopic swallowing study of liquids, using the validated Modified Barium Swallow Impairment Profile.

RESULTS

The median Modified Barium Swallow Impairment Profile score was 13 pre-myotomy and 10 post-myotomy. This difference between scores was non-significant (p = 0.41). The median, cricopharyngeal-specific Modified Barium Swallow Impairment Profile variables (14 and 17) improved from 3 to 2, but were similarly non-significant (p = 0.16). We observed the improved Modified Barium Swallow Impairment Profile scores post-procedure in the majority of patients.

CONCLUSION

Endoscopic carbon dioxide laser cricopharyngeal myotomy remains a viable option in treatment-related cricopharyngeal dysfunction; its targeted role requires further prospective study. Objective analysis of the technique can be reported using the validated Modified Barium Swallow Impairment Profile.

Cricopharyngeal achalasia treated with myectomy and post-operative high-resolution manometry

Cricopharyngeal achalasia is an uncommon cause of dysphagia in neonates or children. A nine-year-old female patient was referred to us with a long history of dysphagia, recurrent pulmonary infection and growth stunting. A gastrostomy was introduced to improve her nutritional condition and to minimize potential inflammation in the pharynx. Subsequently, cervical cricopharyngeal myectomy was conducted. The surgical intervention allowed prompt resolution of symptoms without complications. High-resolution manometry post myectomy demonstrated a significant reduction in upper esophageal pressure together with proper relaxation at deglutition. The patient was able to consume solid food and liquid normally, and remained asymptomatic without medications six months after the surgery.

Savary dilation is a safe and effective long-term means of treatment of symptomatic cricopharyngeal bar: a single-center experience

GOALS

Dilation of a cricopharyngeal (CP) bar can be a safe and effective means of nonsurgical treatment as elderly patient population has high morbidity and is at a higher risk of surgical complications.

BACKGROUND

CP bar is a relatively uncommon radiologic finding, which is an infrequent cause of oropharyngeal dysphagia in the elderly population.

METHODS

Patients were included in study from January 2007 to January 2012, if their dysphagia was solely attributed to CP bar on predilation radiologic imaging by either modified barium swallow or barium esophagogram. A functional outcome swallowing score (FOSS) was calculated at 1, 4, and 6 months from initial and last dilation performed.

RESULTS

A total of 31 patients with a mean age of 71.65 (54 to 88) years and mean body mass index 27.81 (15 to 41) were included in the study. Over the time period of 5 years, a total of 53 dilations were performed. The median predilation FOSS was 3. The median postdilation FOSS was 1 at the end of 6 months from last dilation performed. There were no immediate or remote complications.

CONCLUSIONS

On follow-up from first dilation, 65% patients had statistically significant improvement in FOSS lasting for at least 6 months. Savary dilation seems to be a safe and effective treatment for symptomatic CP bar patients.

Endoscopic CO2 laser management of chemoradiation-related cricopharyngeal stenosis

OBJECTIVE

Treatment of head and neck cancer with chemoradiation (CRT) can result in strictures of the cervical esophagus, often at the level of the cricopharyngeus. The objective of this study is to assess the feasibility of endoscopic CO2 laser cricopharyngeal myotomy for stricture ablation in the setting of prior CRT.

METHODS

A retrospective review of patients who underwent endoscopic CO2 laser cricopharyngeal myotomy for dysphagia after radiation for squamous cell carcinoma of the head and neck (SCCHN). Pre- and postoperative barium swallow and swallowing assessment were performed before and after surgery. Outcomes and complication rates were examined.

RESULTS

Endoscopic CO2 laser cricopharyngeal myotomy was performed in 10 patients with dysphagia secondary to cricopharyngeal stenosis/stricture, which developed following treatment for SCCHN with chemoradiation. All patients demonstrated radiographic improvement in stricture, with complete resolution of stricture in 9 of 10 patients. All patients noted improvement in dysphagia with 9 of 10 patients demonstrating significant advancement of diet by modified barium swallow. No complications were observed.

CONCLUSION

Endoscopic CO2 cricopharyngeal myotomy can be performed safely in the setting of prior CRT, with significant improvement in swallowing in select patients. Indications and technical considerations will be discussed.

Cervical oesophagostomy in patients with severe dysphagia following radiotherapy for nasopharyngeal carcinoma

Objective:

This study aimed to investigate the validity and feasibility of cervical oesophagostomy as a treatment for patients with severe dysphagia after radiotherapy for nasopharyngeal carcinoma.

Methods:

The study retrospectively analysed the clinical data, symptoms, physical signs, treatment and outcomes of 12 patients treated with cervical oesophagostomy for severe dysphagia after radiotherapy for nasopharyngeal carcinoma, from 2006 to 2010.

Results:

In all 12 cases, the oesophageal stoma remained stable, without any complications such as pharyngeal fistula or inflammation. No oesophageal stricture or granuloma growth was observed. All patients reported significant improvement in their nutritional status and quality of life after the oesophagostomy surgery.

Conclusion:

Cervical oesophagostomy is a valid and feasible method of treating severe dysphagia following radiotherapy for nasopharyngeal carcinoma. Oesophagostomy shows specific advantages over nasogastric tubing, gastrostomy and jejunostomy. Patients' nutrition and quality of life can be improved significantly if cervical oesophagostomy is executed in a timely fashion, especially in cases with severe trismus and multiple radiation-induced cranial nerve palsies unresponsive to rehabilitation.

Indications and outcomes of endoscopic CO2 laser cricopharyngeal myotomy

OBJECTIVES/HYPOTHESIS

To describe indications, management, and outcomes of endoscopic CO2 laser cricopharyngeal myotomy (CPM).

STUDY DESIGN

Case series with chart review.

METHODS

All patients treated with endoscopic CO2 laser CPM over a 6-year period were identified. A retrospective chart review was performed for surgical indication, history and physical examinations, and swallow evaluations. Swallowing outcomes were assessed using the Functional Outcome Swallowing Scale (FOSS); findings were compared across groups.

RESULTS

Eighty-seven patients underwent endoscopic CO2 laser CPM during the study period for cricopharyngeal dysfunction. Indications included Zenker's diverticulum (ZD) (39), DiGeorge syndrome (two), stroke (five), nerve injury (two), radiation for head and neck cancer (15), idiopathic (16), hyperfunctional tracheoesophageal speech (five) and dysphagia from cricopharyngeus stricture after laryngectomy (three). Mean, median, and mode time to feeding postoperatively were 1.4, 1, and 0 days respectively. Mean, median, and mode hospital stays were 1.8, 1, and 1 day respectively. Overall, FOSS scores improved from 2.6 to 1.6 (P < .001). Improvement was greatest for patients with ZD (2.4 to 1.0) and cricopharyngeal dysfunction from nerve injury (3.3 to 1.8) and least for those with prior radiation (3.9 to 3.2). All patients undergoing CPM for poor tracheoesophageal speech regained speech postoperatively. No patients developed mediastinitis, abscess, or fistula.

CONCLUSIONS

Endoscopic CO2 laser CPM is a safe treatment for cricopharyngeal dysfunction of various causes, though swallowing outcomes may vary depending on the surgical indication. Early feeding postoperatively after CPM is safe and facilitates early hospital discharge.

LEVEL OF EVIDENCE

4.

Comparison of Carbon Dioxide Laser—Assisted versus Stapler-Assisted Endoscopic Cricopharyngeal Myotomy

Objectives:

We directly compared endoscopic carbon dioxide (CO2) laser and stapler treatment methods for both cricopharyngeal hypertrophy (CPH) and Zenker's diverticulum (ZD).

Methods:

We performed a single-institution retrospective chart review of 153 patients who underwent either CO2 laser–assisted or stapler-assisted endoscopic cricopharyngeal myotomy (CPM).

Results:

Isolated CPH was more likely to be treated with the CO2 laser than by stapler techniques. The ZD pouch size decreased significantly after surgery in both laser (p = 0.04) and stapler (p = 0.008) groups. The average duration of the procedure for CPM was longer for the laser than for the stapler (p = 0.01). Both techniques were successful when used in revision procedures. The overall complication rates were not statistically significantly different. Laser surgery trended toward a higher rate of major complications (2.4% versus 0%). Symptomatic recurrence was more likely after stapler surgery (p = 0.002). The rates of revision surgery were similar in the two groups (3.3% for laser and 4.3% for stapler).

Conclusions:

In the treatment of isolated CPH or ZD, stapler-assisted endoscopic surgery results in a shorter operative time, whereas laser-assisted CPM results in a decreased incidence of symptomatic recurrence.

Endoscopic cricopharyngeal myotomy for management of cricopharyngeal achalasia (CA) in an 18-month-old child

A 6-month-old patient presented with dysphagia and failure to thrive. Video fluoroscopic swallow study (VFSS), esophagogastroduodenoscopy, and manometry were diagnostic for CA. A gastrostomy tube was placed at 8 months. Botulinum toxin injection improved symptoms, but within 10 weeks symptoms returned. At 18 months, an uncomplicated endoscopic CPM was performed. A postoperative VFSS demonstrated cricopharyngeal bar resolution. Within 3 months, patient was feeding orally without a G tube. Pediatric CPA treatment options consist of dilation, botox, and transcervical CPM. To our knowledge, this is the youngest patient treated with endoscopic CPM. Intraoperative video and photographs are presented.

Variability of postoperative esophagrams after endoscopic cricopharyngeal myotomy: technique dependence

OBJECTIVES

We illustrate the dependence of postoperative day (POD) 1 esophagram findings on the closure technique used after endoscopic cricopharyngeal myotomy (ECPM).

METHODS

We performed a retrospective chart review of POD 1 fluoroscopic examinations of the cervical esophagus utilizing contrast dye after ECPM to assess radiologic findings associated with three different techniques of addressing the exposed buccopharyngeal fascia (BPF).

RESULTS

Each technique resulted in specific and different findings on the POD 1 esophagram. When the BPF was untreated, the esophagram demonstrated a pseudodiverticulum with free flow of contrast dye. When a fibrin glue seal was used, the esophagram demonstrated a curvilinear focus of contrast dye projected over the retropharyngeal soft tissue persisting after the swallow, similar to a leak. When fibrin glue application was combined with single-suture reapproximation of the mucosal incision, the pattern was similar to esophagrams performed 6 weeks after myotomy.

CONCLUSIONS

Different techniques used to address the exposed BPF following ECPM result in specific findings on the POD 1 esophagram. Recognition of these imaging differences and open communication with the fluoroscopist will avoid a misdiagnosis of a pharyngeal leak, which might cause an unnecessary delay of oral feeding and hospital discharge.

Carbon dioxide laser-assisted endoscopic cricopharyngeal myotomy with primary mucosal closure

OBJECTIVES

Carbon dioxide laser-assisted endoscopic cricopharyngeal myotomy (ECPM) has emerged as a viable therapy for dysphagia. The risks of the procedure include pharyngoesophageal perforation and mediastinitis, which may discourage adoption of this technique. To address these complications, we examined outcomes of ECPM with primary mucosal closure.

METHODS

A case series of 7 patients who underwent ECPM between 2006 and 2008 were reviewed for length of operation, length of hospitalization, postoperative complications, and outcomes by use of the M. D. Anderson Dysphagia Index (MDADI) and the Functional Outcome Swallowing Scale (FOSS). The results were compared to those of a control group of 7 patients treated during the same period via open cricopharyngeal myotomy.

RESULTS

All patients who had ECPM were treated successfully without complications. The operative times averaged 128 minutes. The hospitalization averaged 2.1 days. Statistically significant improvements in swallowing were seen (MDADI score from 51.3 to 77.7, p < 0.0006; FOSS score from 3.7 to 1.3, p < 0.0005), and were similar to those in the patients who had the open procedure (FOSS score from 3.0 to 1.0, p <0.006). Trends toward decreased blood loss, a shorter hospital stay, and a lower complication rate were observed in the patients who had ECPM.

CONCLUSIONS

ECPM is beneficial as a primary treatment for cricopharyngeal dysfunction. Closure of the mucosal defect may help reduce the incidence of postoperative cervical emphysema and mediastinitis, and does not appear to compromise functional outcome.

Congenital cricopharyngeal achalasia in a 4.5-year-old managed by cervical myotomy: a case report

INTRODUCTION

Congenital cricopharyngeal achalasia (CCA) is a rare disorder in children characterized by inappropriate contraction of the cricopharyngeus muscle, resulting in the inability to relax the upper esophageal sphincter during deglutition. We report the diagnostic process and management of a relatively older patient who underwent cricopharyngeal myotomy at the age of 4.5 years.

METHODS

A retrospective review of the case and clinical follow-up was performed.

RESULTS

This young patient had a long history of dysphagia, choking, nasal reflux and recurrent pneumonia and croup since birth and was diagnosed with CCA at 22 months of age. She underwent balloon dilation of the cricopharyngeus muscle shortly thereafter with only transient relief of her symptoms of feeding difficulty (choking and aspiration). The parents were reluctant for her to undergo further interventions until 2 years later when they consented to cricopharyngeal myotomy. She underwent transcervical myotomy at age 4.5 years and had complete relief of her symptoms. She had no post-operative complications and has done well for nearly 12 months following myotomy.

DISCUSSION

Our patient is one of the oldest children reported to have undergone myotomy, recovered quickly, and had no difficulty swallowing at any time following surgery. We suggest transcervical cricopharyngeal myotomy as the preferred treatment due to its lasting effects and repeated success in relieving dysphagia in young patients with CCA.

Transoral resection of short segment Zenker's diverticulum and cricopharyngeal myotomy: an alternative minimally invasive approach

OBJECTIVES/HYPOTHESIS

Transoral treatment of cricopharyngeal bar and small Zenker's diverticulum remains a challenge. We propose a new transoral approach for transoral cricopharyngeal myotomy (TOCPM) for patients with cricopharyngeal spasm and pharyngeal bar, and for transoral resection of diverticula (TORD) with cricopharyngeal myotomy in the patient with small (<3 cm) Zenker's diverticulum.

METHODS

A retrospective review was conducted of 45 patients with cricopharyngeal spasm (21) and Zenker's diverticulum (24), where 14 patients were considered suitable for TORD and TOCPM. TOCPM used the Weerda laryngoscope (Karl Storz, Tuttlingen, Germany) to expose the cricopharyngeal bar using a microscope; the mucosa is cut and then the muscle is transected using monopolar cautery. A 0 degrees endoscope is inserted through the incision to ensure complete myotomy. Incision closure is by interrupted 4-0 Vicryl sutures (Ethicon Inc., Somerville, NJ) and fibrin glue. For the TORD procedure, the diverticular sac is everted and then resected using scissors. Through the sac opening, the TOCPM is completed. The sac opening is then closed as described in TOCPM. The patients are kept without food for 24 hours, followed by feeding and discharge. Modified barium swallow (MBS) evaluated functional results.

RESULTS

Fourteen patients underwent TOCPM (eight), and TOCPM+TORD (six). There was one case of TOCPM that was aborted due to excessive bleeding, which prevented full myotomy. The rest did well. All were discharged the next day. Two poor results from the TOCPM and TOCPM+TORD group were due to poor esophageal motility. The remainder of patients had resolution of dysphagia and normalized MBS. No patient developed stricture or complications.

CONCLUSIONS

Short segment Zenker's diverticulum and cricopharyngeal bar can now be addressed completely with a transoral approach. Because there is complete closure of the mucosal incision, prolonged hospitalization can be avoided.

Cricopharyngeal myotomy for the treatment of cricopharyngeal achalasia

Three cases of cricopharyngeal achalasia are being presented. The preoperative diagnosis was established by a contrast swallow. Cricopharyngeal myotomy was performed in all patients. One child died in the postoperative period because of respiratory failure secondary to aspiration pneumonitis, whereas in the other two, symptoms were relieved, and they remain asymptomatic on follow-up.