Combination of surgical and endoscopic approach for Zenker's diverticulum
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《血管的通路杂志》
Department of Thoracic Surgery Haut-Levêque Hospital, and Universite Victor Segalen of Bordeaux II, Bordeaux University Hospital, avenue de Magellan, 33604 Pessac, France
Abstract
A simple technique to improve external surgical treatment of Zenker's diverticulum is presented. A rigid esophageal endoscopy is performed just before the operation. The diverticulum is explored and washed. A single lumen tracheal tube is inserted into the esophageal lumen to serve as a stent. The technique is safe and easy and improves the bacterial control of the operation field.
Key Words: Zenker's diverticulum; Surgery; Esophageal diverticula; Dysphagia
1. Introduction
Since the first description of cure of Zenker's diverticulum by Ludlow in 1769 [1] and by Zenker and von Ziemssen in 1877 [2], numerous surgical techniques have been described to treat pharyngoesophageal diverticulum and controversy remains between endoscopic or surgical treatment [3].
We here report a simple technique which combines endoscopic and external surgical approach.
2. Technique
The operation is performed under general anesthesia. Induction and orotracheal intubation are conducted with the patient in a semi-sitting position to avoid aspiration by diverticulum's contents. Then, the patient is laid down as the tracheal intubation protects his bronchial tree against aspiration.
Rigid esophagoscopy is performed by the surgeon. The diverticulum is explored. Diverticular contents are cleared out and the pouch is cleaned with sterile water. Then, the esophageal lumen is carefully penetrated by the esophagoscope and a cervicothoracic esophageal exploration is done. A gastric catheter is pulled through the channel of the endoscope, down to the stomach. The rigid esophagoscope is withdrawn leaving the catheter in the esophageal lumen. Afterwards, an orotracheal single lumen tube (size no. 7 French) is slipped onto the catheter and gently pushed into the esophageal lumen. It sometimes requires rotational movements to push down the orotracheal tube. Thus, the orotracheal tube is used as a bougie (Fig. 1).
Then the standard operation is carried out through a left cervical incision as previously reported [4,5]. The diverticulum is freed and its neck located. Myotomy is done upward and downward from the neck of the diverticulum. It encompasses division of the cricopharyngeus muscle, hypopharynx and esophageal muscle fibers for 1 cm above and extended more than 4 cm under the neck of the diverticulum. The neck of the diverticulum is afterwards stapled using a linear stapler and the diverticular pouch resected. When the diverticulum is smaller than 2 cm the pouch is left. The myotomy is left wide open under the resection line.
A small multi-perforated drainage is placed beside the esophagus and put on suction.
A water soluble contrast swallow is performed on the 3rd postoperative day before resuming oral feeding (Fig. 2).
3. Results
Between January 1987 and August 2005 we have treated 92 patients [6] (sex ratio 29/63, mean age 69 years). Wound infection without fistula was observed in two cases and an esophagocutaneous fistula in one case. A permanent control of the symptoms was obtained in all patients except one. Operative time including endoscopy is 60 min on average.
4. Discussion
Rigid endoscopy performed just before surgery encompasses two advantages: First, it allows emptying the pouch of debris of food, to clean the sac and so to reduce the risk of infection which is closely related to the amount of bacterial flora in the operative field.
Second, the risk of perforation is reduced as penetration of the upper esophageal sphincter is performed under visual control. Lastly, any other mucosal disease however rare, such as carcinoma of the diverticulum is ruled out.
Calibration of the esophageal lumen makes easier esophageal dissection, and helps to release the pouch from fascias and to locate the cricopharyngeal muscle. The color of the tube inserted within the esophagus appears clearly under the mucosal plane. It helps to perform an easy dissection of the circular muscular fibers from the mucosa and to open the myotomy down to the posterior mediastinum. Furthermore, the esophageal tube serves as a stent, avoiding stenosis of the esophageal lumen when positioning the stapler during diverticulectomy. Maloney bougie, as described in previous techniques, is not always easy to place within the esophageal lumen through the contracted superior esophageal sphincter. Our technique performed preoperatively, under visual control, and then slipping down the intubation tube around the gastric tube, appears in our experience simple and safe.
It seems to us that the risk of anesthesia is equal to endoscopic treatment alone. Lastly, we have not found any anatomical patient's morphotypes which render esophagoscopy impossible as it was described for elective endoscopic technique [3].
In conclusion, it is a simple technique to improve quality and safety of external surgical approach for Zenker's diverticulum. We still advocate the surgical approach which is the only one technique allowing sufficient myotomy to ensure satisfying long-term results.
References
Ludlow A. A case of obstructed deglutition from a preternatural bag formed in the pharynx. In: Johnson W, Caldwell T. Medical observations and inquiries by a society of physicians in London 2 1769;London: 3: 85–101. In:.
Zenker FA, von Ziemssen H. Krankheiten des Oesophagus. In: von Ziemssen H. Handbuch der speciellen Pathologie und Therapie Leipzig: FC Vogel, 1877:7:(suppl) 1–87. In:.
Gutschow CA, Hamoir M, Rombaux P, Otte JB, Goncette L, Collard JM. Management of pharyngoesophageal (Zenker's) diverticulum: which technique. Ann Thorac Surg 2002; 74:1677–1683.
Harrison MS. The aetiology diagnosis, and surgical treatment of pharyngeal diverticula. J Laryngol 1958; 72:525–534.
Lerut T, van Raemdonck D, Guelinckx P, Dom R, Geboes K. Zenker's diverticulum: is a myotomy of the cricopharyngeus useful How long should it be Hepatogastroenterol 1992; 39:127–131.
Jougon J, Le Taillandier de Gabory L, Raux F, Delcambre F, Mc Bride T, Velly JF. Pl Plea in favour of external approach of Zenker's diverticulum: 73 cases reported. Ann Chir 2003; 128:167–172.(Jacques Jougon, Gilbert D)
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A simple technique to improve external surgical treatment of Zenker's diverticulum is presented. A rigid esophageal endoscopy is performed just before the operation. The diverticulum is explored and washed. A single lumen tracheal tube is inserted into the esophageal lumen to serve as a stent. The technique is safe and easy and improves the bacterial control of the operation field.
Key Words: Zenker's diverticulum; Surgery; Esophageal diverticula; Dysphagia
1. Introduction
Since the first description of cure of Zenker's diverticulum by Ludlow in 1769 [1] and by Zenker and von Ziemssen in 1877 [2], numerous surgical techniques have been described to treat pharyngoesophageal diverticulum and controversy remains between endoscopic or surgical treatment [3].
We here report a simple technique which combines endoscopic and external surgical approach.
2. Technique
The operation is performed under general anesthesia. Induction and orotracheal intubation are conducted with the patient in a semi-sitting position to avoid aspiration by diverticulum's contents. Then, the patient is laid down as the tracheal intubation protects his bronchial tree against aspiration.
Rigid esophagoscopy is performed by the surgeon. The diverticulum is explored. Diverticular contents are cleared out and the pouch is cleaned with sterile water. Then, the esophageal lumen is carefully penetrated by the esophagoscope and a cervicothoracic esophageal exploration is done. A gastric catheter is pulled through the channel of the endoscope, down to the stomach. The rigid esophagoscope is withdrawn leaving the catheter in the esophageal lumen. Afterwards, an orotracheal single lumen tube (size no. 7 French) is slipped onto the catheter and gently pushed into the esophageal lumen. It sometimes requires rotational movements to push down the orotracheal tube. Thus, the orotracheal tube is used as a bougie (Fig. 1).
Then the standard operation is carried out through a left cervical incision as previously reported [4,5]. The diverticulum is freed and its neck located. Myotomy is done upward and downward from the neck of the diverticulum. It encompasses division of the cricopharyngeus muscle, hypopharynx and esophageal muscle fibers for 1 cm above and extended more than 4 cm under the neck of the diverticulum. The neck of the diverticulum is afterwards stapled using a linear stapler and the diverticular pouch resected. When the diverticulum is smaller than 2 cm the pouch is left. The myotomy is left wide open under the resection line.
A small multi-perforated drainage is placed beside the esophagus and put on suction.
A water soluble contrast swallow is performed on the 3rd postoperative day before resuming oral feeding (Fig. 2).
3. Results
Between January 1987 and August 2005 we have treated 92 patients [6] (sex ratio 29/63, mean age 69 years). Wound infection without fistula was observed in two cases and an esophagocutaneous fistula in one case. A permanent control of the symptoms was obtained in all patients except one. Operative time including endoscopy is 60 min on average.
4. Discussion
Rigid endoscopy performed just before surgery encompasses two advantages: First, it allows emptying the pouch of debris of food, to clean the sac and so to reduce the risk of infection which is closely related to the amount of bacterial flora in the operative field.
Second, the risk of perforation is reduced as penetration of the upper esophageal sphincter is performed under visual control. Lastly, any other mucosal disease however rare, such as carcinoma of the diverticulum is ruled out.
Calibration of the esophageal lumen makes easier esophageal dissection, and helps to release the pouch from fascias and to locate the cricopharyngeal muscle. The color of the tube inserted within the esophagus appears clearly under the mucosal plane. It helps to perform an easy dissection of the circular muscular fibers from the mucosa and to open the myotomy down to the posterior mediastinum. Furthermore, the esophageal tube serves as a stent, avoiding stenosis of the esophageal lumen when positioning the stapler during diverticulectomy. Maloney bougie, as described in previous techniques, is not always easy to place within the esophageal lumen through the contracted superior esophageal sphincter. Our technique performed preoperatively, under visual control, and then slipping down the intubation tube around the gastric tube, appears in our experience simple and safe.
It seems to us that the risk of anesthesia is equal to endoscopic treatment alone. Lastly, we have not found any anatomical patient's morphotypes which render esophagoscopy impossible as it was described for elective endoscopic technique [3].
In conclusion, it is a simple technique to improve quality and safety of external surgical approach for Zenker's diverticulum. We still advocate the surgical approach which is the only one technique allowing sufficient myotomy to ensure satisfying long-term results.
References
Ludlow A. A case of obstructed deglutition from a preternatural bag formed in the pharynx. In: Johnson W, Caldwell T. Medical observations and inquiries by a society of physicians in London 2 1769;London: 3: 85–101. In:.
Zenker FA, von Ziemssen H. Krankheiten des Oesophagus. In: von Ziemssen H. Handbuch der speciellen Pathologie und Therapie Leipzig: FC Vogel, 1877:7:(suppl) 1–87. In:.
Gutschow CA, Hamoir M, Rombaux P, Otte JB, Goncette L, Collard JM. Management of pharyngoesophageal (Zenker's) diverticulum: which technique. Ann Thorac Surg 2002; 74:1677–1683.
Harrison MS. The aetiology diagnosis, and surgical treatment of pharyngeal diverticula. J Laryngol 1958; 72:525–534.
Lerut T, van Raemdonck D, Guelinckx P, Dom R, Geboes K. Zenker's diverticulum: is a myotomy of the cricopharyngeus useful How long should it be Hepatogastroenterol 1992; 39:127–131.
Jougon J, Le Taillandier de Gabory L, Raux F, Delcambre F, Mc Bride T, Velly JF. Pl Plea in favour of external approach of Zenker's diverticulum: 73 cases reported. Ann Chir 2003; 128:167–172.(Jacques Jougon, Gilbert D)