Association of the "Jet Phenomenon" with Positive Symptom Outcome Following Surgical Treatment of Cricopharyngeus Muscle Dysfunction.

OBJECTIVES: Cricopharyngeus muscle dysfunction (CPMD) is a common cause for progressive dysphagia and can lead to dietary restriction, reduced nutrition, weight loss, and pneumonia. Controversy exists whether CPMD is best managed with primary surgical treatment of the cricopharyngeus muscle and who represents a good surgical candidate. METHODS: Retrospective review of patients diagnosed with CPMD who underwent surgical treatment were evaluated through prospectively collected pre- and postoperative Eating Assessment Tool-10 (EAT-10) and Functional Oral Intake Scale (FOIS). Videofluoroscopic swallowing studies (VFSS) were reviewed for presence or absence of a high-pressure barium stream through the upper esophageal sphincter, termed the jet phenomenon (JP). RESULTS: We identified 42 patients with CPMD who underwent surgical treatment and had serial Eating Assessment Tool (EAT-10) measures obtained pre- and postoperatively. Mean EAT-10 scores improved by 12.1 points (95%CI = 8.6-15.6), p < 0.0001. There was a significantly greater improvement among patients with JP (|∆EAT-10|= 17.0, 95%CI = 12.5-21.4) compared to those without (|∆EAT-10|= 6.2, 95%CI = 1.6-10.8), p = 0.0013. Patients with JP also showed improved FOIS score (p = 0.0023) while those without JP did not. CONCLUSION: This study provides the initial report on the utility of JP as a VFSS feature that is strongly associated with improved outcomes following surgical treatment of CPMD. Further work determining the physiologic correlates responsible for JP will help clarify its predictive capabilities. LEVEL OF EVIDENCE: Level 3.

An international study on the use of peroral endoscopic myotomy in the management of Zenker's diverticulum.

BACKGROUND AND AIMS: The novel use of peroral endoscopic myotomy (POEM) in the treatment of Zenker's diverticulum (ZD) was recently described in case reports. The aim of this study is to report a multicenter experience with the POEM technique in the management of ZD. METHODS: This is a multicenter international retrospective study involving 10 centers. The Zenker's POEM technique was performed using principles of submucosal endoscopy. RESULTS: Seventy-five patients (73.3 ± 1.2 years, 33 women) were included with a mean Charleson comorbidity index of 4 ± .2. The mean size of ZD was 31.3 ± 1.6 mm (range, 10-89). The overall technical success rate was 97.3% (73/75). There were 2 technical failures because of the inability to locate the septum and failed tunnel creation. Adverse events occurred in 6.7% (5/75): 1 bleed (mild) conservatively managed and 4 perforations (1 severe, 3 moderate). The mean procedure time was 52.4 ± 2.9 minutes, and mean length of hospital stay was 1.8 ± .2 days. Clinical success was achieved in 92% (69/75) with a decrease in mean dysphagia score from 1.96 to .25 (P < .0001). The median length of follow-up was 291.5 days (interquartile range, 103.5-436). At the 12-month follow-up, 1 patient reported symptom recurrence. CONCLUSIONS: Endoscopic management of ZD using the POEM technique is novel and feasible with promising efficacy and safety results. Long-term follow-up is needed to ensure durability of response. In addition, comparative studies with other treatment modalities are warranted.

Quality of Life in Treating Persistent Neurogenic Dysphagia with Cricopharyngeal Myotomy.

Neurological impairment is an important cause of dysphagia. This study analyzed whether quality of life (QoL) is improved after coblation-assisted endoscopic cricopharyngeal myotomy (CAECPM) for patients with persistent neurological dysphagia who meet the criteria by using the Chinese version of the Swallow Quality-of-Life Questionnaire (CSWAL-QOL). 22 patients with dysphagia for more than 6 months after stroke or lateral skull base surgery were screened. All patients exhibited a poor response to conservative treatment such as swallowing rehabilitation. Videofluoroscopic swallowing studies (VFSS) showed a restricted cricopharyngeal opening. The preoperative CSWAL-QOL score was 377.7 (311.3-493.0) out of 1000; the postoperative score was 641.7 (293.7-758.3) out of 1000; the preoperative median dysphagia frequency was 41.4 (25.7-61.4) out of 100; and the postoperative median score was 64.3 (24.3-80.0). A significant difference was found between preoperative and postoperative scores together with dysphagia frequency (P < 0.05). Among all the variables, laryngeal elevation ability was statistically significantly correlated with efficacy of CAECPM (P = 0.01). These values indicate that quality of life could be improved after CAECPM for patients with persistent neurological dysphagia, who have cricopharyngeal achalasia. The ability of laryngeal elevation has significant influence. The CSWAL-QOL can be used to assess different aspects of the swallow-related quality of life of these patients.

A long-term prospective study of the efficacy and safety of endoscopic septotomy using the LigaSure® system for the treatment of Zenker's diverticulum.

BACKGROUND AND OBJECTIVES: endoscopic septotomy of the cricopharyngeal muscle (ESCM) is a technique used for the treatment of Zenker's diverticulum (ZD). The experience with computerized vascular sealing systems (LigaSure® type) is limited. The objective of this study was to evaluate the efficacy and safety of ESCM using LigaSure®. METHODS: this was a long-term prospective study of 18 patients with ZD, who were referred to our hospital due to ESCM between 2010 and 2016. The severity of the symptoms was determined using the Dakkak-Bennett validated scale for dysphagia and the rest with numerical scales. The rates of relapse and retreatment were evaluated. RESULTS: ESCM with LigaSure® was performed in 17 cases, one case was excluded due to technical difficulties. The median age was 72 years and regurgitation, dysphagia and respiratory symptoms were found in 100%, 89% and 56% of cases, respectively. The median size of the diverticulum was 28 mm (20-60 mm). The median time of the procedure was 35 minutes (25-45 minutes). There were four complications, two hemorrhages and two perforations. The median follow-up was 13 months (range: 12-82 months). Clinical improvements were observed for all symptoms and were maintained 12 months after treatment (p < 0.05). There was no relapse during follow-up in 13 patients. A complete section was not achieved and clinical relapse occurred after a median time of seven months that required retreatment in the remaining patients. CONCLUSIONS: ESCM with LigaSure® may be a safe and effective technique in long-term follow-up situations, with low rates of relapse.

Results of surgical treatment of cervical esophageal diverticula.

On the basis of 20 years' experience, the authors present the immediate and long-term results of operative treatment of Zenker's diverticulum. Comparison of two methods of surgery - diverticulopexia (in 21 patients) and excision (in 16), both associated with upper esophageal sphincter myotomy - shows good immediate and longterm results (from 1 to 19 years), with disappearance of symptoms (dysphagia) in all patients. There was no perioperative mortality. Postoperative complications were most commonly of pulmonary origin and were observed in a third of patients in both groups. In two patients from the group treated with excision, a leak from the suture line occurred, which healed spontaneously. These two patients had transient dysphagia in the postoperative period. On the basis of this analysis, the authors conclude that diverticulopexia is a safer surgical procedure than excision, giving less complications and a very good long-term functional result.

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.

Nutcracker and jackhammer esophagus treatment: a three-case survey, including two novel cases of eosinophilic infiltration into the muscularis propria.

Nutcracker esophagus and jackhammer esophagus are largely unknown motility disorders, also sometimes called hypertensive and hypercontractile peristalsis, respectively. There is currently no standardized diagnostic or management plan for these diseases. Here, we report on three patients with jackhammer/nutcracker esophagus who were treated with either peroral endoscopic myotomy or a systemic steroid regimen, focusing particularly on two novel presentations of nutcracker and jackhammer esophagus involving eosinophilic infiltration into the muscularis propria, and their responses to both interventions.

Large diameter fully covered self-expanding metal stent placement for palliation of proximal malignant esophageal strictures.

In patients with malignant esophageal strictures within 6 cm from the upper esophageal sphincter, self-expanding metal stents placement represents a challenge because there is an increased risk of complications. The aim of this study was to assess the safety and effectiveness of large-diameter WallFlex(®) fully covered self-expanding metal stents for palliation of patients with proximal malignant esophageal strictures. From March 2010 to December 2012, 12 patients with proximal strictures (4-6 cm from the upper esophageal sphincter) and six with very proximal strictures (<4 cm from the upper esophageal sphincter) were palliated with this fully covered self-expanding metal stent and included in the study. Technical success was 100% and clinical success was 94%. The mean baseline dysphagia score was 3.2, and 1 week after stenting it improved significantly to 1.3 (P < 0.001). Early complications occurred in four patients, more frequently in patients with very proximal strictures as compared with patients with proximal strictures (P = 0.02). Late complications occurred in five patients, and there were no differences between patients with very proximal strictures or proximal strictures (P = 0.245). The mean survival after stent placement was 119 days, and no differences between patients with very proximal strictures versus proximal strictures were found (P = 0.851). There was no stent-related mortality or 30-day mortality. Our results suggested that a large-diameter fully covered self-expanding metal stent is an effective and secure device for palliation of patients with proximal malignant esophageal strictures.

[Treatment of upper esophageal sphincter achalasia as a little-known chapter of surgery].

It is presented the results of survey and treatment of 32 patients with upper esophageal sphincter achalasia. In 29 of them achalasia was consequence of stroke in brain stem (Zakharchenko-Wallenberg syndrome). 28 patients were operated using P. Chodoch method in 7 cases and author's technique of myotomy with pharyngoesophageal junction plasty in 21 patients. Plastic myotomy gives excellent and good results in 81% of observations due to preservation of innervation of muscles providing function of epiglottis and pharyngeal constrictors. Severe condition of patients and elderly age are indication for P. Chodoch myotomy.

Cricopharyngeal achalasia and upper oesophageal endoscopic myotomy (CP-POEM).

Cricopharyngeal achalasia (CPA), also known as cricopharyngeal bar, is a rare motor disorder affecting the upper oesophageal sphincter. This comprehensive literature review focuses on clinical aspects that can assist physicians in daily decision-making. The diagnosis of CPA is primarily based on symptoms of upper dysphagia and radiological identification of a posterior bar. However, the diagnostic process is not standardized and necessitates a multimodal approach, including radiological, endoscopic, and manometric studies performed by various specialists. Treatment options for CPA include botulinum toxin injection, endoscopic balloon dilatation, open or endoscopic surgery, and cricopharyngeal peroral endoscopic myotomy (CP-POEM). CP-POEM is the latest indication for POEM and has shown promising results with minimal adverse events, though high-quality evidence is still lacking.

Ultrasonographic Evaluation of Upper Esophageal Sphincter for Dysphagia During the Acute Postoperative Phase of Anterior Cervical Surgery.

STUDY DESIGN: A retrospective study. OBJECTIVE: To verify the pathophysiology of dysphagia during the acute postoperative phase of anterior cervical surgery and to identify its predictive features, using ultrasonographic (US) examination for upper esophageal sphincter (UES). SUMMARY OF BACKGROUND DATA: There are no clinical studies investigating dysphagia after anterior cervical surgery, using US examination for UES. MATERIALS AND METHODS: We enrolled patients who underwent anterior cervical spine surgery between August 2018 and March 2022. Dysphagia was evaluated using the Eating Assessment Tool-10 (EAT-10) questionnaires. The US examination was performed preoperatively and 2 weeks postoperatively. Three US parameters for morphologic measurements (outer diameter, inner diameter, and muscle thickness) and 4 for functional measurements (displacement, time to relax, passing duration, and time to contract) were assessed. To verify the pathophysiology of postoperative dysphagia, we examined the change in the ratios of US parameters (=US parameter 2 weeks postoperatively /US parameter at baseline ) and the existence of significant correlations with change in the EAT-10 score (=EAT-10 2 weeks postoperatively -EAT-10 at baseline ). To identify the predictive features, the baseline US parameters were compared between dysphagia (+) and dysphagia (-) groups. RESULTS: A total of 46 patients (mean age, 61.3 y; 78.3% male) were included for analysis. A greater increase of the EAT-10 score after surgery was positively correlated with change ratios of the muscle thickness and time to contract and negatively with change ratio of the inner diameter. The dysphagia (+) group exhibited significantly greater inner diameter and smaller muscle thickness at baseline than the dysphagia (-) group. CONCLUSION: Dysphagia during the acute postoperative phase of anterior cervical surgery is caused by the physical narrowing of the inner lumen due to muscle thickening of the UES and sphincter contractile dysfunction. In addition, a baseline UES morphology characterized by a greater inner diameter and a thinner muscle layer is predictive of postoperative dysphagia.

Surgical treatment of Zenker's diverticulum.

BACKGROUND: Different surgical techniques have been indicated for the management of Zenker's diverticulum (ZD), including diverticulectomy, diverticulopexy, and diverticular inversion, with or without myotomy, and myotomy alone. More recently, minimally invasive techniques (such as the transoral endoscopic approach) have become increasingly reliable for this disorder. We therefore conducted this systematic review in order to gain a profound understanding of the current trend and evidence in surgical management of ZD. METHODS: Medline and PubMed were searched to identify studies on surgical intervention of ZD published in English between January 1990 and March 2011. RESULTS: We identified 6,915 patients from 93 studies evaluating the effect of the surgical intervention for ZD. No randomized controlled trials comparing one technique with another were identified. CONCLUSION: Diverticulectomy with myotomy has become the mainstream treatment option for ZD. In certain selected patients, endoscopic diverticulotomy may offer some advantages over open surgery, such as less trauma and a lower complication rate. It is important to individualize optimal therapy for each patient. More randomized controlled trials with long-term follow-up results are required to draw a valid conclusion on the best surgical intervention modality for ZD.

[Cricopharyngeal bar and Dysphagia]. / Cricopharyngeal Bar und Dysphagie.

BACKGROUND: The term Cricopharyngeal Bar (CPB) describes a posterior indentation at the pharyngoesophageal junction which becomes apparent during a Video Fluoroscopic Swallowing Exam (VFSE, modified barium swallow). The eff ect CPBs might have on swallowing is still under debate. This paper intends to review appearance, eff ects and the associated therapy of CPBs. METHOD: For this systematic review a selective literature research in PubMed has been carried out. RESULTS: CPBs are usually diagnosed during VFSE. As VFSEs are mostly carried out in dysphagic patients, CBPs were also associated with dysphagia. Even though, CPBs are often related to dysphagia, they do also appear in patients without dysphagia. Therefore, the appearance of a CBP does not automatically represent the cause of dysphagic symptoms. Its impact on swallowing might, however, depend on the dimension of the protrusion as well as the weakening and dysfunction of the inferior pharyngeal constrictor muscle. DISCUSSION: CBPs often present as an incidental finding during a modified barium swallow. A relation to dysphagia can only be assumed for severe CPBs. Therapy options include cricopharyngeal myotomy or esophago-gastro endoscopy using either bougies or balloons.

Peroral endoscopic myotomy and septotomy for Zenker diverticulum.

Zenker diverticulum (ZD) is the most common hypopharyngeal diverticulum seen often in septuagenarian and octogenarian males. Oropharyngeal dysphagia is the most common presenting symptom. Treatment of ZD has been advancing with the introduction of a wide variety of accessory devices, primarily focusing on obliteration of the septum by complete transection of the cricopharyngeus muscle to recreate the common cavity and restore normal pharyngo-esophageal bolus outflow. This review aimed to provide an overview of the various surgical and endoscopic treatment options for ZD, while focusing specifically on Zenker peroral endoscopic myotomy.

Pharyngeal dysphagia in inflammatory muscle diseases resulting from impaired suprahyoid musculature.

Dysphagia has previously been reported in the inflammatory myopathies (IMs): inclusion body myositis (IBM), dermatomyositis (DM), and polymyositis (PM). Patients report coughing, choking, and bolus sticking in the pharynx. Myotomy has been the treatment of choice, with variable success reported. We sought to determine underlying causes of dysphagia in IM patients using instrumental evaluation. Eighteen subjects participated in the study: four with DM, six with PM, and eight with IBM. They underwent simultaneous videofluoroscopy and manometry, yielding 214 swallows for analysis regarding function of the upper esophageal sphincter (UES), swallow initiation, hyolaryngeal excursion, and pharyngeal residue. Penetration and aspiration were also recorded. UES failed to relax in two participants. High incidence of pharyngeal dysphagia was noted; 72% of participants demonstrated abnormalities, including delayed swallow initiation (24%), decreased hyolaryngeal excursion (22%), pyriform residue (17%), and penetration (22%). Dysphagia in IM patients appears to be more due to impaired muscle contraction and reduced hyolaryngeal excursion than the often held belief of failed UES relaxation. The distinction between mechanisms causing patients' dysphagia should be examined, particularly if CP myotomy is being considered as it may be contraindicated for patients with normal UES relaxation. More studies investigating IM patients pre- and post-myotomy are needed.

Cricopharyngeal Myotomy in Inclusion Body Myositis: Comparison of Endoscopic and Transcervical Approaches.

OBJECTIVE: Inclusion body myositis (IBM) is a progressive inflammatory myopathy with dysphagia as a debilitating sequalae. Otolaryngologists are consulted for surgical candidacy when there are findings of cricopharyngeal dysfunction. We aim to compare transcervical cricopharyngeal myotomy (TCPM) versus endoscopic cricopharyngeal myotomy (ECPM) in the IBM population with particular focus on objective swallow study outcomes, complications, and recurrence rates. METHODS: A retrospective cohort study was performed on IBM patients who underwent TCPM or ECPM (1981-2020) in the Department of Otolaryngology at a tertiary academic center with a high volume IBM referral base. Videofluoroscopic swallow studies, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and follow-up visits. Baseline patient characteristics, intraoperative data, and postoperative course were recorded. RESULTS: Forty-one patients were identified (18 TCPM; 23 ECPM). There was no significant difference in the recurrence rates, complications, hospitalization length, operative time, or return to preoperative diet between approaches. For the 12 patients (11 ECPM; 1 TCPM) that had subjective swallow data, there was a statistically significant difference in the pre and postoperative scores for EAT-10, RSI, and FOSS (P < .05). There was a statistically significant improvement in the degree of narrowing between pre and postoperative imaging for both approaches (P < .05). CONCLUSION: Both TCPM and ECPM are safe approaches for the management of dysphagia in patients with IBM with objective evidence of cricopharyngeal dysfunction. Cricopharyngeal myotomy is a durable technique that has demonstrated improved subjective and objective outcomes in this patient population. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2426-E2431, 2021.

Early Adverse Events Following Transcervical Hypopharyngeal Diverticulum Surgery.

OBJECTIVE: To describe rates of short-term morbidity following transcervical surgical treatment of hypopharyngeal diverticulum (HD) and analyze predictors of adverse events. METHODS: The 2005 to 2017 National Surgical Quality Improvement Program database was queried to identify patients diagnosed with HD undergoing open transcervical diverticulectomy. RESULTS: A total of 597 patients with a mean age of 71.4 ± 12.3 years were included. Thirty-day adverse events were experienced by 63 (10.6%) subjects, including 6.5% unplanned reoperations, 4.2% surgical complications, 4.4% medical complications, 2.7% readmissions, and 0.7% deaths. Medical complications notably included pneumonia (2.0%), reintubation (1.2%), sepsis (1.2%), intubation >48 hours (0.5%), urinary tract infection (0.5%), or deep vein thrombosis (0.5%), while surgical complications included organ/space infection (2.0%) and superficial (1.3%) or deep (1.0%) surgical site infection. Gender, race, functional status, diabetes, dyspnea, hypertension, steroid use, and recent weight loss were not associated with adverse events. Length of operation and hospitalization were both higher among those with adverse events (127.4 ± 107.9 vs 95.7 ± 59.8 minutes, P = 0.027, and 7.4 ± 7.4 vs 2.8 ± 3.6 days, P < 0.001). On multivariable logistic regression, high American Society of Anesthesiologists (ASA) class (OR = 2.02, P = 0.017), smoking (OR = 2.10, P = 0.044), and operation time (OR = 1.01; P = 0.005) were independent predictors of adverse events. Obesity was not associated with length of stay, readmission/reoperation, or complications. However, increased age was associated with shorter operations (P = 0.020), higher length of hospitalization (P < 0.001), and higher mortality (P = 0.027) and readmission rates (P = 0.023). CONCLUSION: Understanding clinical factors associated with complications following open surgery for HD such as ASA score, smoking status, length of operation, and age can help optimize surgical outcomes for at-risk patients.