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{{Dysphagia}}
{{Dysphagia}}


{{CMG}}; {{AE}} {{FT}}, {{HQ}}
{{CMG}}; {{AE}} {{HQ}}, {{FT}}


==Overview==
==Overview==
Surgery is not the first-line treatment option for patients with dysphagia. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]
Surgery is not the first-line treatment option for patients with dysphagia. Surgery is usually reserved for patients with either dysphagia leading to life-threatening [[aspiration]] and airway protection.


==Indications==
==Surgical Treatment of Oropharyngeal Dysphagia==  
Surgical treatments are usually only recommended as a last resort and is dependent on the underlying cause of dysphagia. Surgical options for oropharyngeal dysphagia include:
* Endolaryngeal Stent
* Epiglottic Flap Laryngeal Closure
* Tracheoesophageal Diversion
* Laryngotracheal Separation
* Partial Cricoidectomy
* Subperichondrial Cricoidectomy
* [[Zenker's diverticulum surgery|Zenker's Diverticulectomy]]
* [[Tracheotomy]] or [[Tracheostomy]]
{| class="wikitable"
! colspan="2" |Surgical Options
!Procedure
|-
| rowspan="2" |Endolaryngeal Stent<ref name="Eisele1991">{{cite journal|last1=Eisele|first1=David W.|title=Surgical approaches to aspiration|journal=Dysphagia|volume=6|issue=2|year=1991|pages=71–78|issn=0179-051X|doi=10.1007/BF02493482}}</ref>
|Weisberger and Huebsch Laryngeal stent
|
*Using endoscopic guidance, three percutaneous sutures are passed into the [[Trachea|tracheal]] [[lumen]]
*One [[suture]] is used as a guide to transorally place the [[stent]] in its desired location.
*While the other two [[Suture|sutures]] are used to secure the stent in place.
|-
|Eliachar and Nguyen laryngeal stent
|
* [[Laryngotracheal groove|Laryngotracheal]] stent placed under rigid bronchoscopic guidance that allowed for continued [[phonation]].
* The presence of a domed one-way valve that rises above the level of the [[vocal cords]] in the Eliachar stent permits air to escape from the [[lungs]], but blocks passage of materials beyond the [[glottis]].
|-
| colspan="2" |Epiglottic Flap Laryngeal Closure<ref name="pmid6614762">{{cite journal| author=Brookes GB, McKelvie P| title=Epiglottopexy: a new surgical technique to prevent intractable aspiration. | journal=Ann R Coll Surg Engl | year= 1983 | volume= 65 | issue= 5 | pages= 293-6 | pmid=6614762 | doi= | pmc=2494386 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6614762  }} </ref><ref name="Castellanos2016">{{cite journal|last1=Castellanos|first1=Paul F.|title=Method and Clinical Results of a New Transthyrotomy Closure of the Supraglottic Larynx for the Treatment of Intractable Aspiration|journal=Annals of Otology, Rhinology & Laryngology|volume=106|issue=6|year=2016|pages=451–460|issn=0003-4894|doi=10.1177/000348949710600602}}</ref>
|
* Supraglottic laryngeal closure involves blocking off the entrance to the [[glottis]] which helps prevent [[aspiration]].


*Surgery is not the first-line treatment option for patients with dysphagia. Surgery is usually reserved for patients with either:
* A [[suprahyoid]] skin incision is made above the [[glottis]] to access the [[hypopharynx]].
**[Indication 1]  
* [[Epiglottis]] is used to cover the [[glottic]] inlet and sewn to [[aryepiglottic folds]] posteriorly.
**[Indication 2]
*Bilateral rotational flaps of [[mucosa]] from the [[Pyriform fossa|pyriform]] sinuses is used to cover the [[epiglottis]].
**[Indication 3]
|-
| colspan="2" |Tracheoesophageal Diversion<ref name="Lindeman1975">{{cite journal|last1=Lindeman|first1=Roger C.|title=DIVERTING THE PARALYZED LARYNX: A REVERSIBLE PROCEDURE FOR INTRACTABLE ASPIRATION|journal=The Laryngoscope|volume=85|issue=1|year=1975|pages=157–180|issn=0023-852X|doi=10.1288/00005537-197501000-00012}}</ref>
|
* Midline incision below the level of the [[cricoid cartilage]] is made to expose the [[trachea]] and completely transected between the third and fourth rings.
* End-to-side tracheoesophageal anastomosis is performed with the proximal [[Trachea|tracheal]] segment and anterior cervical [[esophagus]].
* The distal trachea is brought out to the skin.
|-
| colspan="2" |Laryngotracheal Separation<ref name="SnydermanJohnson2016">{{cite journal|last1=Snyderman|first1=Carl H.|last2=Johnson|first2=Jonas T.|title=Laryngotracheal Separation for Intractable Aspiration|journal=Annals of Otology, Rhinology & Laryngology|volume=97|issue=5|year=2016|pages=466–470|issn=0003-4894|doi=10.1177/000348948809700506}}</ref>
|
* Oversewing the proximal tracheal stump in layers and reinforcing the closure with rotated [[Sternothyroid muscle|sternothyroid muscle flap]].
* Laryngotracheal separation obviated the need for an esophageal anastomosis, but left a blind proximal tracheal pouch instead.
|-
| colspan="2" |Partial Cricoidectomy<ref name="KrespiPelzer2016">{{cite journal|last1=Krespi|first1=Yosef P.|last2=Pelzer|first2=Harold J.|last3=Sisson|first3=George A.|title=Management of Chronic Aspiration by Subtotal and Submucosal Cricoid Resection|journal=Annals of Otology, Rhinology & Laryngology|volume=94|issue=6|year=2016|pages=580–583|issn=0003-4894|doi=10.1177/000348948509400611}}</ref><ref name="pmid6482627">{{cite journal| author=Krespi YP, Quatela VC, Sisson GA, Som ML| title=Modified tracheoesophageal diversion for chronic aspiration. | journal=Laryngoscope | year= 1984 | volume= 94 | issue= 10 | pages= 1298-301 | pmid=6482627 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6482627  }} </ref>
|
* Lateral approach is used to access the posterior [[larynx]].
* The posterior attachments of the thyroid cartilage are cut to approach the posterior cricoid cartilage.
* The posterior [[Cricoid cartilage|cricoid perichondrium]] is elevated and the posterior half of the cricoid lamina is carefully removed with small rongeurs.
* Concurrently a [[Cricopharyngeal muscle|cricopharyngeal]] and [[Inferior constrictor muscle|inferior constrictor]] myotomy is performed.
* The goal is to create a larger hypopharyngeal inlet to facilitate swallowing while at the same time decreasing the diameter of the laryngeal inlet to help prevent [[aspiration]].
|-
| colspan="2" |Subperichondrial Cricoidectomy<ref name="EiseleSeely1995">{{cite journal|last1=Eisele|first1=David W.|last2=Seely|first2=Daniel R.|last3=Flint|first3=Paul W.|last4=Cummings|first4=Charles W.|title=How I do it: Head and neck and plastic surgery: Subperichondrial cricoidectomy: An alternative to laryngectomy for intractable aspiration|journal=The Laryngoscope|volume=105|issue=3|year=1995|pages=322–325|issn=0023852X|doi=10.1288/00005537-199503000-00019}}</ref>
|
*Cervical vertical midline incision is made to expose the anterior [[cricoid cartilage]].
*[[Cricoid]] is removed with biting forceps
*Inner perichondrium and mucosa are closed forming a [[Subglottic airway|subglottic pouch.]]
*Outer perichondrium forms a muscle flap intercalated between the subglottic pouch and the [[tracheostomy]].
|-
| colspan="2" |[[Tracheotomy]] or [[Tracheostomy]]
|
* Used for chronic [[aspiration]].
* The four major types of percutaneous tracheotomy:<ref name="pmid3996056">{{cite journal| author=Ciaglia P, Firsching R, Syniec C| title=Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. | journal=Chest | year= 1985 | volume= 87 | issue= 6 | pages= 715-9 | pmid=3996056 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3996056  }} </ref><ref name="pmid9142576">{{cite journal| author=Fantoni A, Ripamonti D| title=A non-derivative, non-surgical tracheostomy: the translaryngeal method. | journal=Intensive Care Med | year= 1997 | volume= 23 | issue= 4 | pages= 386-92 | pmid=9142576 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9142576  }} </ref><ref name="BelangerAkulian2014">{{cite journal|last1=Belanger|first1=Adam|last2=Akulian|first2=Jason|title=Interventional Pulmonology in the Intensive Care Unit: Percutaneous Tracheostomy and Gastrostomy|journal=Seminars in Respiratory and Critical Care Medicine|volume=35|issue=06|year=2014|pages=744–750|issn=1069-3424|doi=10.1055/s-0034-1395504}}</ref><ref name="pmid2343371">{{cite journal| author=Griggs WM, Worthley LI, Gilligan JE, Thomas PD, Myburg JA| title=A simple percutaneous tracheostomy technique. | journal=Surg Gynecol Obstet | year= 1990 | volume= 170 | issue= 6 | pages= 543-5 | pmid=2343371 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2343371  }} </ref>
** Ciaglia's dilation over guidewire
** Grigg's modification employing guidewire dilating forceps
** Fantoni's translaryngeal tracheotomy, in which the tracheostomy tube is pulled from inside the trachea to outside at once without the need for serial dilation
** PercuTwist method, which utilizes a screw-in dilator
|}
Other surgical options for oro-pharyngeal dysphagia include:
* [[Zenker's diverticulum surgery|Zenker's Diverticulectomy]]


==Surgical Treatment of Oropharyngeal Dysphagia==
Surgical treatments are usually only recommended as a last resort and is dependent on the underlying cause of dysphagia.
* [[Zenker's diverticulum|Zenker's Diverticulectomy]]
**[[Surgery]] is the most definitive therapy for the [[Zenker's diverticulum]]..
**Please click here to read about the management of Zenker's Diverticulum.
* [[Tracheotomy]]
* [[Tracheostomy]]
* Vocal fold augmentation/injection
* Vocal fold augmentation/injection
* Thryoplasty medialization
* Thryoplasty medialization
Line 31: Line 88:
* [[Myotomy|Cricopharyngeal Myotomy]]
* [[Myotomy|Cricopharyngeal Myotomy]]
* [[Percutaneous endoscopic gastrostomy]]
* [[Percutaneous endoscopic gastrostomy]]
==Contraindications==


==Surgical Treatment of Esophageal Dysphagia==
==Surgical Treatment of Esophageal Dysphagia==
* Surgical treatment of esophageal dysphagia is dependent on the underlying cause of dysphagia.
* Surgical treatment of esophageal dysphagia is dependent on the underlying cause of dysphagia.
* Please click on each medical condition listed below to read about the management.  
{| class="wikitable"
** [[Esophageal stricture procedure|Peptic stricture]]
!Surgical options
** [[Plummer-Vinson syndrome|Esophageal rings and webs]]
!Procedure
** [[Esophageal cancer]]
|-
** [[Achalasia]]
|Cricopharyngeal Myotomy<ref name="YipLeonard2006">{{cite journal|last1=Yip|first1=Helena T.|last2=Leonard|first2=Rebecca|last3=Kendall|first3=Katherine A.|title=Cricopharyngeal Myotomy Normalizes the Opening Size of the Upper Esophageal Sphincter in Cricopharyngeal Dysfunction|journal=The Laryngoscope|volume=116|issue=1|year=2006|pages=93–96|issn=0023-852X|doi=10.1097/01.mlg.0000184526.89256.85}}</ref><ref name="LuckeMeffert2008">{{cite journal|last1=Lucke|first1=C.|last2=Meffert|first2=O.|last3=Weiß|first3=D.|title=Cricopharyngeale Achalasie beim Schlaganfallpatienten|journal=DMW - Deutsche Medizinische Wochenschrift|volume=109|issue=20|year=2008|pages=792–795|issn=0012-0472|doi=10.1055/s-2008-1069275}}</ref>
**Spastic motility disorders
|
***[[Diffuse esophageal spasm]]
* Oblique, transverse, or S-shaped cervical incision is made preferably on the left side on the [[neck]].
***[[Nutcracker esophagus]]
* Dissection the [[sternocleidomastoid muscle]] and [[carotid sheath]] are retracted.
***Hypertensive lower esophageal sphincter
* [[Laryngopharynx]] is then mobilized by blunt dissection to expose the [[cricopharyngeus muscle]].
***Nonspecific spastic esophageal motility disorders
* Intraluminal esophageal foley catheter or the cuff of a second endotracheal tube inserted into the [[esophagus]] can be inflated to visualize the horizontal fibers of the [[Cricopharyngeus muscle|cricopharyngeus muscles]].
* Intact [[esophageal]] mucosa should be visualized after [[myotomy]].
* Prevent [[fistula]] or [[mediastinitis]] any esophageal mucosa damage should be repaired.
|-
|Percutaneous Endoscopic Gastrostomy<ref name="pmid6780678">{{cite journal| author=Gauderer MW, Ponsky JL, Izant RJ| title=Gastrostomy without laparotomy: a percutaneous endoscopic technique. | journal=J Pediatr Surg | year= 1980 | volume= 15 | issue= 6 | pages= 872-5 | pmid=6780678 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6780678  }} </ref>
|
*[[Stomach]] is insufflated with [[air]].
*Using the transilluminated [[skin]] the [[stomach]] is punctured with a needle and a guidewire is introduced over the needle.
*Guidewire and endoscope are then withdrawn through the [[mouth]].
*[[Gastrostomy|Gastrostomy tube]] is passed over the guidewire through the esophagus into the [[stomach]].
|}
 
====Video====
{{#ev:youtube|y30FlOMUbFs}}
{{#ev:youtube|YjkZ6mQJ4JU}}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}
[[Category:Needs overview]]
[[Category:Needs overview]]
[[Category:Needs content]]
[[Category:Needs content]]
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[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
[[Category:Otolaryngology]]
[[Category:Otolaryngology]]
[[Category:Primary care]]
{{WH}}
{{WS}}

Latest revision as of 21:30, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2], Feham Tariq, MD [3]

Overview

Surgery is not the first-line treatment option for patients with dysphagia. Surgery is usually reserved for patients with either dysphagia leading to life-threatening aspiration and airway protection.

Surgical Treatment of Oropharyngeal Dysphagia

Surgical treatments are usually only recommended as a last resort and is dependent on the underlying cause of dysphagia. Surgical options for oropharyngeal dysphagia include:

Surgical Options Procedure
Endolaryngeal Stent[1] Weisberger and Huebsch Laryngeal stent
  • Using endoscopic guidance, three percutaneous sutures are passed into the tracheal lumen
  • One suture is used as a guide to transorally place the stent in its desired location.
  • While the other two sutures are used to secure the stent in place.
Eliachar and Nguyen laryngeal stent
  • Laryngotracheal stent placed under rigid bronchoscopic guidance that allowed for continued phonation.
  • The presence of a domed one-way valve that rises above the level of the vocal cords in the Eliachar stent permits air to escape from the lungs, but blocks passage of materials beyond the glottis.
Epiglottic Flap Laryngeal Closure[2][3]
  • Supraglottic laryngeal closure involves blocking off the entrance to the glottis which helps prevent aspiration.
Tracheoesophageal Diversion[4]
  • Midline incision below the level of the cricoid cartilage is made to expose the trachea and completely transected between the third and fourth rings.
  • End-to-side tracheoesophageal anastomosis is performed with the proximal tracheal segment and anterior cervical esophagus.
  • The distal trachea is brought out to the skin.
Laryngotracheal Separation[5]
  • Oversewing the proximal tracheal stump in layers and reinforcing the closure with rotated sternothyroid muscle flap.
  • Laryngotracheal separation obviated the need for an esophageal anastomosis, but left a blind proximal tracheal pouch instead.
Partial Cricoidectomy[6][7]
  • Lateral approach is used to access the posterior larynx.
  • The posterior attachments of the thyroid cartilage are cut to approach the posterior cricoid cartilage.
  • The posterior cricoid perichondrium is elevated and the posterior half of the cricoid lamina is carefully removed with small rongeurs.
  • Concurrently a cricopharyngeal and inferior constrictor myotomy is performed.
  • The goal is to create a larger hypopharyngeal inlet to facilitate swallowing while at the same time decreasing the diameter of the laryngeal inlet to help prevent aspiration.
Subperichondrial Cricoidectomy[8]
  • Cervical vertical midline incision is made to expose the anterior cricoid cartilage.
  • Cricoid is removed with biting forceps
  • Inner perichondrium and mucosa are closed forming a subglottic pouch.
  • Outer perichondrium forms a muscle flap intercalated between the subglottic pouch and the tracheostomy.
Tracheotomy or Tracheostomy
  • Used for chronic aspiration.
  • The four major types of percutaneous tracheotomy:[9][10][11][12]
    • Ciaglia's dilation over guidewire
    • Grigg's modification employing guidewire dilating forceps
    • Fantoni's translaryngeal tracheotomy, in which the tracheostomy tube is pulled from inside the trachea to outside at once without the need for serial dilation
    • PercuTwist method, which utilizes a screw-in dilator

Other surgical options for oro-pharyngeal dysphagia include:

Surgical Treatment of Esophageal Dysphagia

  • Surgical treatment of esophageal dysphagia is dependent on the underlying cause of dysphagia.
Surgical options Procedure
Cricopharyngeal Myotomy[13][14]
Percutaneous Endoscopic Gastrostomy[15]
  • Stomach is insufflated with air.
  • Using the transilluminated skin the stomach is punctured with a needle and a guidewire is introduced over the needle.
  • Guidewire and endoscope are then withdrawn through the mouth.
  • Gastrostomy tube is passed over the guidewire through the esophagus into the stomach.

Video

{{#ev:youtube|y30FlOMUbFs}} {{#ev:youtube|YjkZ6mQJ4JU}}

References

  1. ↑ Eisele, David W. (1991). "Surgical approaches to aspiration". Dysphagia. 6 (2): 71–78. doi:10.1007/BF02493482. ISSN 0179-051X.
  2. ↑ Brookes GB, McKelvie P (1983). "Epiglottopexy: a new surgical technique to prevent intractable aspiration". Ann R Coll Surg Engl. 65 (5): 293–6. PMC 2494386. PMID 6614762.
  3. ↑ Castellanos, Paul F. (2016). "Method and Clinical Results of a New Transthyrotomy Closure of the Supraglottic Larynx for the Treatment of Intractable Aspiration". Annals of Otology, Rhinology & Laryngology. 106 (6): 451–460. doi:10.1177/000348949710600602. ISSN 0003-4894.
  4. ↑ Lindeman, Roger C. (1975). "DIVERTING THE PARALYZED LARYNX: A REVERSIBLE PROCEDURE FOR INTRACTABLE ASPIRATION". The Laryngoscope. 85 (1): 157–180. doi:10.1288/00005537-197501000-00012. ISSN 0023-852X.
  5. ↑ Snyderman, Carl H.; Johnson, Jonas T. (2016). "Laryngotracheal Separation for Intractable Aspiration". Annals of Otology, Rhinology & Laryngology. 97 (5): 466–470. doi:10.1177/000348948809700506. ISSN 0003-4894.
  6. ↑ Krespi, Yosef P.; Pelzer, Harold J.; Sisson, George A. (2016). "Management of Chronic Aspiration by Subtotal and Submucosal Cricoid Resection". Annals of Otology, Rhinology & Laryngology. 94 (6): 580–583. doi:10.1177/000348948509400611. ISSN 0003-4894.
  7. ↑ Krespi YP, Quatela VC, Sisson GA, Som ML (1984). "Modified tracheoesophageal diversion for chronic aspiration". Laryngoscope. 94 (10): 1298–301. PMID 6482627.
  8. ↑ Eisele, David W.; Seely, Daniel R.; Flint, Paul W.; Cummings, Charles W. (1995). "How I do it: Head and neck and plastic surgery: Subperichondrial cricoidectomy: An alternative to laryngectomy for intractable aspiration". The Laryngoscope. 105 (3): 322–325. doi:10.1288/00005537-199503000-00019. ISSN 0023-852X.
  9. ↑ Ciaglia P, Firsching R, Syniec C (1985). "Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report". Chest. 87 (6): 715–9. PMID 3996056.
  10. ↑ Fantoni A, Ripamonti D (1997). "A non-derivative, non-surgical tracheostomy: the translaryngeal method". Intensive Care Med. 23 (4): 386–92. PMID 9142576.
  11. ↑ Belanger, Adam; Akulian, Jason (2014). "Interventional Pulmonology in the Intensive Care Unit: Percutaneous Tracheostomy and Gastrostomy". Seminars in Respiratory and Critical Care Medicine. 35 (06): 744–750. doi:10.1055/s-0034-1395504. ISSN 1069-3424.
  12. ↑ Griggs WM, Worthley LI, Gilligan JE, Thomas PD, Myburg JA (1990). "A simple percutaneous tracheostomy technique". Surg Gynecol Obstet. 170 (6): 543–5. PMID 2343371.
  13. ↑ Yip, Helena T.; Leonard, Rebecca; Kendall, Katherine A. (2006). "Cricopharyngeal Myotomy Normalizes the Opening Size of the Upper Esophageal Sphincter in Cricopharyngeal Dysfunction". The Laryngoscope. 116 (1): 93–96. doi:10.1097/01.mlg.0000184526.89256.85. ISSN 0023-852X.
  14. ↑ Lucke, C.; Meffert, O.; Weiß, D. (2008). "Cricopharyngeale Achalasie beim Schlaganfallpatienten". DMW - Deutsche Medizinische Wochenschrift. 109 (20): 792–795. doi:10.1055/s-2008-1069275. ISSN 0012-0472.
  15. ↑ Gauderer MW, Ponsky JL, Izant RJ (1980). "Gastrostomy without laparotomy: a percutaneous endoscopic technique". J Pediatr Surg. 15 (6): 872–5. PMID 6780678.

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