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], 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:

• Endolaryngeal Stent
• Epiglottic Flap Laryngeal Closure
• Tracheoesophageal Diversion
• Laryngotracheal Separation
• Partial Cricoidectomy
• Subperichondrial Cricoidectomy
• Zenker's Diverticulectomy
• Tracheotomy or Tracheostomy

Surgical Options		Procedure
Endolaryngeal Stent	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		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.
Tracheotomy or Tracheostomy		Used for chronic aspiration. The four major types of percutaneous tracheotomy: 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 Diverticulectomy

• 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.

Surgical options	Procedure
Cricopharyngeal Myotomy	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.
Percutaneous Endoscopic Gastrostomy	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.

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