Dysphagia surgery

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^[1]	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.
Endolaryngeal Stent^[1]	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^[2]^[3]		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^[4]		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^[5]		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^[6]^[7]		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^[8]		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:^[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

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^[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.
Percutaneous Endoscopic Gastrostomy^[15]	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.

Video

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.
↑ Gauderer MW, Ponsky JL, Izant RJ (1980). “Gastrostomy without laparotomy: a percutaneous endoscopic technique”. J Pediatr Surg. 15 (6): 872–5. PMID 6780678.

Template:WH Template:WS

[Eisele1991-1] Eisele, David W. (1991). “Surgical approaches to aspiration”. Dysphagia. 6 (2): 71–78. doi:10.1007/BF02493482. ISSN 0179-051X.

[pmid6614762-2] 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.

[Castellanos2016-3] 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.

[Lindeman1975-4] 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.

[SnydermanJohnson2016-5] 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.

[KrespiPelzer2016-6] 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.

[pmid6482627-7] Krespi YP, Quatela VC, Sisson GA, Som ML (1984). “Modified tracheoesophageal diversion for chronic aspiration”. Laryngoscope. 94 (10): 1298–301. PMID 6482627.

[EiseleSeely1995-8] 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.

[pmid3996056-9] 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.

[pmid9142576-10] Fantoni A, Ripamonti D (1997). “A non-derivative, non-surgical tracheostomy: the translaryngeal method”. Intensive Care Med. 23 (4): 386–92. PMID 9142576.

[BelangerAkulian2014-11] 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.

[pmid2343371-12] 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.

[YipLeonard2006-13] 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.

[LuckeMeffert2008-14] 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.

[pmid6780678-15] Gauderer MW, Ponsky JL, Izant RJ (1980). “Gastrostomy without laparotomy: a percutaneous endoscopic technique”. J Pediatr Surg. 15 (6): 872–5. PMID 6780678.

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