Abstract
Purpose
The purpose of this study was to assess the role of minimally invasive endoscopic diverticulostomy in patients who develop hypopharyngeal diverticulum after cervical spine surgery/fixation.
Materials and methods
This is a retrospective case series of seven patients who underwent endoscopic management of a symptomatic hypopharyngeal diverticulum. The patients were analyzed for diverticulum size, pre-operative and post-operative dysphagia and regurgitation scores, and complications. The overall success with the endoscopic approach was compared to the prior experience with traditional Zenker’s diverticulum.
Results
Of the seven patients with hypopharyngeal diverticulum, four were successfully managed with minimally invasive endoscopic diverticulostomy (57%). These four patients all demonstrated clinically significant improvement in both dysphagia and regurgitation scores at a minimum of 6 months postoperatively. Complications were minimal and consisted of one case with postoperative subcutaneous air. There were no cases of fistula, mediastinitis, or nerve injury.
Conclusions
Minimally invasive endoscopic diverticulotomy can be successfully applied to patients who develop hypopharyngeal diverticulum after cervical spine surgery/fixation.
1
Introduction
Hypopharyngeal diverticulum (HD) was first described in 1769 by Ludlow and is an outpouching of the posterior esophageal wall as a result of pulsion though a weakened posterior constrictor muscle. These diverticula were further characterized by Zenker and von Ziemssen in 1877. Endoscopic management was then developed in 1917 and today Zenker’s diverticula are managed by multiple techniques . Due to the posterior location of these false diverticula, the majority can now be managed by a minimally invasive endoscopic technique utilizing CO2 laser and/or endoscopic stapling diverticulotomy . Alternatively hypopharyngeal traction diverticula can develop in similar locations after cervical spine surgery but are true pharyngeal diverticula. These traction diverticula have been associated with anterior cervical spinal surgery, often presenting as a delayed post-operative complication secondary to adhesions that form at the site of surgery. HD can cause significant dysphagia, weight loss, regurgitation, and aspiration. Several authors have reported experience with the surgical management of these acquired HD .
The management of HD that arises secondary to cervical spine surgery is less clear. Most authors have suggested that an open approach is necessary in this patient population due to thick scar bands that may preclude endoscopic management . The purpose of this project was to assess the safety and effectiveness of the minimally invasive endoscopic techniques in the management of HD that occurs after cervical spine surgery.
2
Materials and methods
Seven patients with a diagnosis of a hypopharyngeal diverticulum after cervical spine surgery underwent an attempt at endoscopic management. The patients underwent either CO2 laser or endoscopic stapling diverticulostomy. A retrospective analysis of each patient’s medical record was used to assess diverticulum size, pre-operative and post-operative symptoms of dysphagia and regurgitation, average weight loss prior to surgery, and any complications post-operatively. Institutional Review Board approval was obtained for the study according to institutional policy. The severity of the symptoms was assessed by assigning a score using a modified patient survey instrument . Dysphagia was scored; 0 (absent), 1 (mild) occasional; 2 (moderate) daily symptoms/require liquids to clear and, 3 (severe) only liquid diet or G tube dependence. Regurgitation was scored; 0 (absent); 1 (mild) occasional symptoms; 2 (moderate) daily symptoms; and 3 (severe) respiratory symptoms, recurrent pneumonia, and/or complications. These scores were obtained prior to surgery and again at ~ 6 months after surgery.
Our technique for performance of the endoscopic diverticulotomy has been previously described . Briefly, a bivalve diverticuloscope (Weerda bivalve; Karl Storz, Culver City, CA) was used to expose the diverticular sac and the esophageal lumen. The operative field, including the diverticular sac was inspected with a 0 ° rigid telescope. The operative procedure was performed under direct telescopic visualization using a video-camera attached to a television monitor. The diverticular wall was then transected using either the C02 laser or the endoscopic stapler technique. Rigid esophagoscopy was then performed and esophageal dilation as needed. Patients were generally kept nothing per mouth status until the next morning after surgery and then advanced to a soft diet as tolerated.
2
Materials and methods
Seven patients with a diagnosis of a hypopharyngeal diverticulum after cervical spine surgery underwent an attempt at endoscopic management. The patients underwent either CO2 laser or endoscopic stapling diverticulostomy. A retrospective analysis of each patient’s medical record was used to assess diverticulum size, pre-operative and post-operative symptoms of dysphagia and regurgitation, average weight loss prior to surgery, and any complications post-operatively. Institutional Review Board approval was obtained for the study according to institutional policy. The severity of the symptoms was assessed by assigning a score using a modified patient survey instrument . Dysphagia was scored; 0 (absent), 1 (mild) occasional; 2 (moderate) daily symptoms/require liquids to clear and, 3 (severe) only liquid diet or G tube dependence. Regurgitation was scored; 0 (absent); 1 (mild) occasional symptoms; 2 (moderate) daily symptoms; and 3 (severe) respiratory symptoms, recurrent pneumonia, and/or complications. These scores were obtained prior to surgery and again at ~ 6 months after surgery.
Our technique for performance of the endoscopic diverticulotomy has been previously described . Briefly, a bivalve diverticuloscope (Weerda bivalve; Karl Storz, Culver City, CA) was used to expose the diverticular sac and the esophageal lumen. The operative field, including the diverticular sac was inspected with a 0 ° rigid telescope. The operative procedure was performed under direct telescopic visualization using a video-camera attached to a television monitor. The diverticular wall was then transected using either the C02 laser or the endoscopic stapler technique. Rigid esophagoscopy was then performed and esophageal dilation as needed. Patients were generally kept nothing per mouth status until the next morning after surgery and then advanced to a soft diet as tolerated.
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