Dysphagia surgery
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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]
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, airway protection, and [indication 3]
Surgical Treatment of Oropharyngeal Dysphagia
Surgical treatments are usually only recommended as a last resort and is dependent on the underlying cause of dysphagia.
Endolaryngeal Stent
- Two types: Weisberger and Huebsch Laryngeal Stent and Eliachar and Nguyen Laryngeal Stent
- Weisberger and Huebsch Laryngeal Stent[1]
- 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
- Weisberger and Huebsch Laryngeal Stent[1]
Epiglottic Flap Laryngeal Closure
- Supraglottic laryngeal closure involves blocking off the entrance to the glottis which helps prevent aspiration
- A suprahyoid skin incision is made above the glottis to access the hypopharynx
- Epiglottis is used to cover the glottic inlet and sewn to aryepiglottic folds posteriorly
- Bilateral rotational flaps of mucosa from the pyriform sinuses is used to cover the epiglottis
Tracheoesophageal Diversion
- 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
- 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
- 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
- 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
- Zenker's Diverticulectomy
- Surgery is the most definitive therapy for the Zenker's diverticulum..
- 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
- Vocal fold augmentation/injection
- Thryoplasty medialization
- Arytenoid adduction
- Partial or total laryngectomy
- Laryngotracheal separation
- Supralaryngetomy
- Palatoplasty
- Cricopharyngeal Myotomy
- Percutaneous endoscopic gastrostomy
Surgical Treatment of Esophageal 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.
- Cricopharyngeal myotomy technique is as follows:[13][14]
- Oblique, transverse, or S-shaped cervical incision is made preferably on the left side on the neck
- Dissection the sternocleidomastoid muscle and carotid sheath are retracted
- Laryngopharynx is then mobilized by blunt dissection to expose the cricopharyngeus muscle
- 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 muscles
- Intact esophageal mucosa should be visualized after myotomy
- Prevent fistula or mediastinitis any esophageal mucosa damage should be repaired
- Peptic stricture
- Esophageal rings and webs
- Esophageal cancer
- Achalasia
- Spastic motility disorders
- Diffuse esophageal spasm
- Nutcracker esophagus
- Hypertensive lower esophageal sphincter
- Nonspecific spastic esophageal motility disorders
References
- ↑ Eisele, David W. (1991). "Surgical approaches to aspiration". Dysphagia. 6 (2): 71–78. doi:10.1007/BF02493482. ISSN 0179-051X.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Krespi YP, Quatela VC, Sisson GA, Som ML (1984). "Modified tracheoesophageal diversion for chronic aspiration". Laryngoscope. 94 (10): 1298–301. PMID 6482627.
- ↑ 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.
- ↑ 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.
- ↑ Fantoni A, Ripamonti D (1997). "A non-derivative, non-surgical tracheostomy: the translaryngeal method". Intensive Care Med. 23 (4): 386–92. PMID 9142576.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.