Endoscopic Cricopharyngeal Myotomy
Considerations
Anatomy and eponyms
Cricopharyngeus muscle
Effectively the upper esophageal sphincter
Killian triangle (aka Killian-Jamieson triangle / area, Killian's dehiscence / hiatus)
The area of weakness directly superior to the cricopharyngeus and inferior to the thicker fibers of the thyropharyngeus portion of the inferior constrictor muscle
Generally accepted site of herniation of hypopharyngeal diverticula
Killian Jamieson area
A fat-filled lateral dehiscence that transmits the inferior laryngeal nerve and artery forward between the cricopharyngeus muscle above and the upper esophageal fibers below
Diverticuluae here are usually intimately involved with the RLN
Lamier area (aka Laimer / Lannier triangle, Laimer-Hackermann's area)
The area of weakness shaped like an inverted V (triangular) in the posterior esophageal wall between the divergent fibers of the outer longitudinal muscle just below the cricopharyngeus muscle
Zenker's diverticulum (aka pharyngo-esophageal / retropharyngeal / cricopharyngeal / hyopharyngeal pouch / diverticulum)
The most common posterior pharyngeal pulsion diverticulum (false)
Acquired
Located in Killian's triangle
Usually on the left
Usually 50+ years old
Usually Caucasians
2006: Endoscopic cricopharyngeal myotomy: indications and technique
Preparation
Weerda Distending Diverticuloscope
0 degree 4 mm endoscope and camera
Tooth guard
Possible laser ***
Possible Endo-GIA stapler
shorten the anvil so that it is as close as 1 mm to the metal clips
Procedure
Dr. J
Perform DL and identify the esophagus using the anterior commissure laryngoscope
Place and suspend Weerda
Visualize the party wall with the endoscope
Examine for any concurrent lesion, including SCC
Place 3-0 Silk into the lateral aspects of the party wall for retraction
Divide the party wall
Always divide posteriorly and in the midline
If using the stapler, divide until there is less than 10 mm of remaining party wall
Optional: Divide the remainder with the Bovie
If perform cricopharyngeal myotomy with laser for a bar and the anterior mucosa is left intact
Always divide posteriorly and in the midline and avoid the anterior mucosa
KTP laser, 5 watts, ***
Divide the muscle fibers completely, intermittently palpate with either an endo peanut or the endo Bovie
Anteriorly, the esophageal mucosa is left intact
Posteriorly, the buccopharyngeal fascia is exposed
Post-op
In PACU, assess for crepitus
Overnight stay
Watch for mediastinitis - chest pain, fever, tachycardia +/- crepitus by palpation and/or auscultation (Hamman sign)
Nutrition consult prior to discharge
If only the performing cricopharyngeal myotomy with laser for a bar and the anterior mucosa is left intact
Home from PACU
Only water night of surgery, then CLD for 3 days
Dr. R
Diet
CLD for week 1, FLD for week 2, Soft foods for week 3
Clindamycin PO x 1 week
RTC 2-3 weeks
Dr. J
Overnight observation
If open, NGT for 3 days followed by esophagram
Diet
First day or surgery CLD, medications OK, then
CLD x 3 days, FLD x 3 days, purees x 3 days, then soft diet x 1 week, then regular diet
Antibiotics
Unasyn while in hospital (clinda if allergic)
RTC 2 weeks
Complications
Mediastinitis
Esophageal perforation
High-Yield
What major complication is likely with endoscopic repair of a Killian-Jamieson diverticulum versus a Zenker's?
RLN injury