1

Introduction

The upper esophageal sphincter (UES) is the muscular gatekeeper of the esophagus. Composed mainly of the cricopharyngeus muscle (CP), the UES is under tonic contraction in order to prevent reflux and aerophagia. During the normal physiologic process of swallowing, the sphincter relaxes, to facilitate deglutition and the passage of the food bolus. Derangement of the UES, caused by a variety of entities, can lead to a spectrum of symptoms from dysphagia to life threatening aspiration.

There are a variety of approaches available for treatment of UES dysfunction. These include various forms of mechanical dilatation and intramuscular Botox injection. However, the only method available to obtain a definitive cure is cricopharyngeal myotomy (CPM). Traditionally, this is accomplished through an open, left sided, cervical approach, which allows for exposure and subsequent division of the muscle. Although this method is successful, risks include recurrent laryngeal nerve injury and pharyngocutaneous fistula. The first description of an endoscopic approach was by Halvorson in 1994 where a potassium-titanyl-phosphate laser was used to incise the muscle . Since that time, the use of a CO2 laser has gained popularity and the procedure has been shown to be safe, efficient, and elicits good swallowing outcomes .

We aimed to evaluate the outcome of endoscopic cricopharyngeal myotomy for treatment of CP hyperfunction using a cohort of patients undergoing an open myotomy as a control. Our primary outcome measures included operative time, length of hospital stay, complication rate, and symptomatic outcomes. We hypothesize that the endoscopic procedure is faster to complete with similar symptomatic outcomes than the open method.

2

Methods

Workup of patients presenting with dysphagia to our practice is performed in an algorithmic manor. We begin with a thorough history and physical exam. If this leads to concern for a Zenker’s diverticulum, barium swallow is obtained. High resolution esophageal manometry is also ordered on all patients to assess the status of the CP and function of the esophagus. Esophageal dilation is offered as first order treatment if there is suspicion for CP hyperfunction.

After approval from the Thomas Jefferson University Institutional Review Board, we performed a retrospective review of all patients undergoing CPM in our practice. Patients were identified by accessing the senior authors’ surgical databases between January 2010–March 2015. We included all patients undergoing open or endoscopic CPM at our institution during the study period and who had a minimum of one month follow-up. All patients found to have a Zenker’s diverticulum were excluded. This was done in an attempt to evaluate treatment of upper esophageal pathology limited to cricopharygeal hyperfunction.

With evaluation of patient records, we recorded demographic data, primary diagnosis, any secondary esophageal diagnoses, preoperative symptomatic status, preoperative manometry data, open versus endoscopic approach, operative time, length of hospital course, time to initiation of oral intake, complications, and postoperative symptomatic status for both groups. No validated dysphagia questionnaire was used to assess postoperative symptoms. In lieu of this, postoperative symptom status was gauged by reviewing clinic notes and individual patient assessment of their swallowing function. Patients were grouped into three categories; no change in dysphagia, improved dysphagia, or no residual dysphagia.

The continuous variables, including age, preoperative upper esophageal sphincter resting pressure, surgical case length, time to oral intake, length of hospital stay, and length of follow-up, were assessed using a Mann-Whitney U test to compare the open and endoscopic cohorts. The categorical variables, including gender and complications, were assessed using a Fisher’s exact test. Postoperative symptom status was assessed using a Χ ² test.

In this series, the open procedure was performed through a left sided transcervical approach. An esophageal bougie is placed to make the esophagus more readily visible and the myotomy easier to perform. The myotomy is performed sharply with a scalpel until the entirety of the CP is incised with some extension above the superior and below the inferior extent of the muscle. 22 of the endoscopic procedures were performed with the CO2 laser and 19 with the Diode (fiber) laser. The myotomy was deemed complete when the buccopharyngeal fascia is in view and muscle completely transected. Mucosal closure was accomplished with a barbed knotless suture in 37 cases. In the remaining 4 cases, the surgical wound was left open.

2

Methods

Workup of patients presenting with dysphagia to our practice is performed in an algorithmic manor. We begin with a thorough history and physical exam. If this leads to concern for a Zenker’s diverticulum, barium swallow is obtained. High resolution esophageal manometry is also ordered on all patients to assess the status of the CP and function of the esophagus. Esophageal dilation is offered as first order treatment if there is suspicion for CP hyperfunction.

After approval from the Thomas Jefferson University Institutional Review Board, we performed a retrospective review of all patients undergoing CPM in our practice. Patients were identified by accessing the senior authors’ surgical databases between January 2010–March 2015. We included all patients undergoing open or endoscopic CPM at our institution during the study period and who had a minimum of one month follow-up. All patients found to have a Zenker’s diverticulum were excluded. This was done in an attempt to evaluate treatment of upper esophageal pathology limited to cricopharygeal hyperfunction.

With evaluation of patient records, we recorded demographic data, primary diagnosis, any secondary esophageal diagnoses, preoperative symptomatic status, preoperative manometry data, open versus endoscopic approach, operative time, length of hospital course, time to initiation of oral intake, complications, and postoperative symptomatic status for both groups. No validated dysphagia questionnaire was used to assess postoperative symptoms. In lieu of this, postoperative symptom status was gauged by reviewing clinic notes and individual patient assessment of their swallowing function. Patients were grouped into three categories; no change in dysphagia, improved dysphagia, or no residual dysphagia.

The continuous variables, including age, preoperative upper esophageal sphincter resting pressure, surgical case length, time to oral intake, length of hospital stay, and length of follow-up, were assessed using a Mann-Whitney U test to compare the open and endoscopic cohorts. The categorical variables, including gender and complications, were assessed using a Fisher’s exact test. Postoperative symptom status was assessed using a Χ ² test.

In this series, the open procedure was performed through a left sided transcervical approach. An esophageal bougie is placed to make the esophagus more readily visible and the myotomy easier to perform. The myotomy is performed sharply with a scalpel until the entirety of the CP is incised with some extension above the superior and below the inferior extent of the muscle. 22 of the endoscopic procedures were performed with the CO2 laser and 19 with the Diode (fiber) laser. The myotomy was deemed complete when the buccopharyngeal fascia is in view and muscle completely transected. Mucosal closure was accomplished with a barbed knotless suture in 37 cases. In the remaining 4 cases, the surgical wound was left open.