Hello, rlf123-ga!
You have asked numerous questions relative to the medical syndrome of
pharyngeal pouch! I have tried to compile information that will help
to provide a better understanding of the symptoms, surgical techniques
and the success/complication statistics following treatment.
Unfortunately, I could find no references relative to growth rates.
I have presented overview information along with additional
references under your specific questions. It is important to stress
that the following information should not substitute for medical
advice. Your mother-in-law's condition is unique in respect to her age
and overall health. The information I have referenced should simply
provide background knowledge for you to consider as you seek
additional medical opinions.
==========
OVERVIEW
==========
WHAT IS PHARYNGEAL POUCH?
=========================
"Pharyngeal pouch is a condition where there is a swelling of the
pharyngeal wall which protrudes between 2 of the layers of cartilage.
Instead of food passing down from the pharynx into the oesophagus, it
enters the pouch and sometime later is regurgitated, so that
undigested food appears in the throat some time after a meal. This
requires surgery."
http://www.thehealthyforum.com/bodymapssec/throat_ppf.html
==
ZENKER'S DIVERTICULUM [PHARYNGEAL POUCH]
This is protrusion of the mucosa through the Killian's dehiscence, a
weak area of the posterior pharyngeal wall between the oblique fibres
of thyropharyngeus and the transverse fibres of the cricopharyngeus at
the lower end of the inferior constrictor muscle. These fibres along
with the upper circular fibres of the oesophageous form a
physiological sphincter of upper oesophagus. It has been seen that is
these patients there is incomplete relaxation of the sphincter during
swallowing, early cricopharygeal contraction and abnormalities of the
pharyngeal contraction waves.
Clinical features : This condition is more commonly seen in elderly
population and the female to male ratio is 2:1.
In the early phase when the diverticulum is small, patients may
complain of feeling of something in the throat or slight regurgitation
on swallowing. As the diverticulum enlarges regurgitation symptom
becomes more severe. They start complaining that they bring up
undigested food material hours after meal especially on bending down
or turning over in bed at night. They may even wake up in the night as
a result of tightness in the throat and fit of cough. Occasionally
they may present with recurrent chest infection as a result of
aspiration of liquid brought up from the pouch. Further enlargement of
the pouch will cause a gurgling noises in the neck with swallowing and
the patients may present with a swelling in the neck. The swelling is
usually on the left side of the neck because as the pouch enlarges the
resistance of the vertebral column behind cause it to turn laterally
to the left.
Treatment : Surgery in indicated when the pouch is associated with
progressive symptoms or the abnormalities of the upper oesophageal
sphincter mechanism is causing considerable dysphagia.
http://www.edu.rcsed.ac.uk/photoalbum/ph50.htm
Esophageal Pouches
------------------
"Esophageal pouches (diverticula) are abnormal protrusions from the
esophagus that in rare cases cause swallowing difficulties.
"There are three types of esophageal pouches: pharyngeal pouch or
Zenker's diverticulum, midesophageal pouch or traction diverticulum,
and epiphrenic pouch. Each has a different cause, but probably all are
related to uncoordinated swallowing and muscle relaxation, as may
occur in disorders such as esophageal spasm and achalasia."
"A large pouch can fill with food that may be regurgitated later, when
the person bends over or lies down. This may cause food to be inhaled
into the lungs during sleep, resulting in aspiration pneumonia.
Rarely, the pouch enlarges and causes swallowing difficulty."
"A video x-ray or cineradiograph (an x-ray that produces a moving
image as a person swallows barium) is used to diagnose a pouch."
*** Treatment is not usually needed.
"If symptoms are severe, however, the pouch can be removed surgically.
When esophageal spasm or achalasia is present, treatment of sphincter
tightness may be needed."
From "Abnormal Propulsion of Food." Contributor: Joel E. Richter, MD.
Merck Manual Second Edition
http://www.merck.com/pubs/mmanual_home2/sec09/ch120/ch120c.htm
====
Heartburn as a symptom of regurgitated food
--------------------------------------------
"The patient, a 66-year-old gentleman, first presented to our
Otolaryngology department in April 1996 with a 6-month history of
dysphagia for solids and heartburn associated with regurgitation of
food. Flexible endoscopy had been arranged prior to referral, and this
showed a large pharyngeal pouch at 20 cm."
From "Stapler failure in pharyngeal diverticulectomy: a suggested
modification in surgical technique," by H. KUBBA AND S. S.
MUSHEERHUSSAIN. (1998)
http://www.rcsed.ac.uk/journal/vol43_1/4310011.htm
**********
Q. Is it advisable to have an operation to remove it when the pouch is
small, even if it is not causing any major problem at the moment?
===============================================================================
"A pharyngeal pouch only needs to be treated if the patient has
significant symptoms or if it has complications such as aspiration,
ulceration or carcinoma. Leaving the pouch alone is a reasonable
management option especially if the patient is not medically fit for
surgery."
From "Pharyngeal Pouches." ENT Nursing
http://www.entnursing.com/pharyngealpouch.htm
==
"Treatment: Depends on size of pouch and age of patient."
From "Pharyngeal pouch." Surgical Tutor.org.
http://www.surgical-tutor.org.uk/default-home.htm?system/hnep/pharyngeal_pouch.htm~right
==
"Treatment is not usually needed. If symptoms are severe, however, the
pouch can be removed surgically. When esophageal spasm or achalasia is
present, treatment of sphincter tightness may be needed."
From "Abnormal Propulsion of Food." Contributor: Joel E. Richter, MD.
Merck Manual Second Edition
http://www.merck.com/pubs/mmanual_home2/sec09/ch120/ch120c.htm
==
Treatment : Surgery in indicated when the pouch is associated with
progressive symptoms or the abnormalities of the upper oesophageal
sphincter mechanism is causing considerable dysphagia.
http://www.edu.rcsed.ac.uk/photoalbum/ph50.htm
============================================================
OVERVIEW OF MAJOR SURGICAL OPTIONS TO TREAT PHARYNGEAL POUCH
=============================================================
Treatment Options include:
Diverticulectomy
Dohlman's procedure
Diverticulectomy
------------------
Following rigid endoscopy the pouch is packed with gauze
A 32 Fr bougie is placed with in the oesophagus
Collar incision made at level of cricoid cartilage
Fascia at anterior border of sternomastoid is divided
Pouch is identified anterior to prevertebral fascia
Pouch is then excised an defect closed
Cricopharyngeal myotomy is performed to prevent recurrence
Patient should be feed via a nasogastric tube for a week postoperatively
Complications include:
Recurrent laryngeal nerve palsy
Cervical emphysema
Mediastinitis
Cutaneous fistula
Dohlman's procedure
--------------------
Is an endoscopic procedure
A double-lipped oesophagoscope is used
Wall between the diverticulum and oesophageal wall is exposed
Hypopharyngeal bar divided with diathermy or laser
From "Pharyngeal pouch." Surgical Tutor.org.
http://www.surgical-tutor.org.uk/default-home.htm?system/hnep/pharyngeal_pouch.htm~right
===
"Before starting the operation the pharyngeal pouch is completely
emptied by the anaesthetist and packed with ribbon gauze soaked in
acriflavine solution. A large bore oesophageal bougie is inserted and
left in place so that when the pouch is excised, closure of the
pharyngeal defect will not result in narrowing of the lumen."
"The neck is opened by a left-sided collar incision at the level of
the cricoid cartilage. The pouch is identified by acriflavine colour
lying beneath the fascia and behind the pharynx. The middle thyroid
vein is ligated and divided. The pouch is dissected from the
surrounding area until the lateral pharyngeal wall. It is excised and
the defect closed in two layers. If the sac is very small it can be
invaginated into the pharyngeal lumen and the muscle is closed with
interrupted sutures. Then a complete crico-pharyngeal myotomy is
performed. The wound is closed after leaving a suction drain."
"Nowadays the ideal procedure is Dohlmans endoscopic stapling
diverticulotomy carried out by minimal access surgery usually by the
ENT surgeon."
From The Royal College of Surgeons of Edinburgh
http://www.edu.rcsed.ac.uk/photoalbum/ph130.htm
==
"Surgical intervention consists of two parts. The first is to treat
the cause of the pouch i.e. reducing the resistance of the
cricopharyngeus and secondly to treat the pouch itself. This can be
achieved either by an open procedure or by an endoscopic approach.
The simplest procedure is dilatation of the cricopharyngeus. This
relieves the symptoms temporarily and carries the risk of perforation
although this is rare. If uncomplicated the patient recovers quickly
and can commence sterile water the following day.
** The endoscopic approach is the preferred method of many surgeons currently.
A specialised oesophagoscope is used which has two blades distally.
One blade passes down the oesophagus whilst the other passed into the
pouch. This allows the wall/bar separating the pouch and oesophagus to
be identified. Contained within the wall of this bar of tissue is the
cricopharyngeus muscle. This wall can then be divided by various means
such diathermy (Dohlman), laser or by a stapling device. This
procedure does not get rid of the pouch but opens up the neck of the
pouch so that any food that enters the pouch can drain freely into the
oesophagus. At the same time the cricopharyngeus muscle is divided
reducing the risk of recurrence.
** Although most surgeons prefer the endoscopic approach some still
prefer the open approach.
It is a useful technique for particularly large pouches or for failure
of the endoscopic method. In the open approach the pouch is dealt with
through a neck incision. The pouch is first inspected endoscopically
and concomitant pathology excluded. The pouch is then packed with
antiseptic gauze to help identify it intraoperatively. At operation
the pouch is identified and dissected free from the surrounding
structures. The pouch is then either excised and removed or inverted
into the oesophagus. The cricopharyngeus muscle (cricopharyngeal
myotomy) is then divided."
From "Pharyngeal Pouches." ENT Nursing
http://www.entnursing.com/pharyngealpouch.htm
***********
Q. How should operation be done? Through the neck or by the endoscopic
technique? Is Dohlman's procedure the preferred option? How
successful is this operation? Is the success rate affected by age and
gender? Would it be done as a routine or are there too many side
effects to make it not worthwhile?
===============================================================================
The following abstracts from PubMed should help to answer the above questions:
"Delayed oesophageal perforation following endoscopic stapling of a
pharyngeal pouch."
Nix PA. J Laryngol Otol. 2001 Aug;115(8):668.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11535155&dopt=Abstract
"Endoscopic stapling of pharyngeal pouches is gaining popularity and
is said to be a quick procedure with minimal morbidity and mortality.
So far, there have been few reported cases of any severe complications
following this procedure."
==
"Endoscopic diverticulotomy for the treatment of Zenker's
diverticulum: results in 102 patients with staple-assisted endoscopy."
Narne S, Cutrone C, Bonavina L, Chella B, Peracchia A. Ann Otol
Rhinol Laryngol. 1999 Aug;108(8):810-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10453792&dopt=Abstract
"Endoscopic diverticulotomy for the treatment of Zenker's diverticulum
has been reported infrequently in the literature and has engendered
considerable controversy. Between March 1992 and September 1996, we
attempted to treat 102 patients with endoscopic treatment for
pharyngoesophageal diverticula. In 98 patients, the endoscopic surgery
was successfully completed........."We therefore recommend endoscopic
diverticulotomy, considering that the procedure is relatively safe and
effective, with minimal patient discomfort, and the results are equal
to those of the external approach. This procedure offers the
advantages of short hospitalization, rapid convalescence, brief
operative time, absence of skin incision. predictable resolution of
symptoms, and reduced morbidity."
==
"Long-term results of endoscopic stapling diverticulotomy for
pharyngeal pouches." Raut VV, Primrose WJ. Otolaryngol Head Neck Surg.
2002 Sep;127(3):225-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12297814&dopt=Abstract
OBJECTIVE: The aim of the present study was to evaluate the long-term
success of endoscopic stapling as a primary procedure for the
treatment of pharyngeal pouches. METHODS: This study is a
retrospective case review of 25 patients with pharyngeal pouches
treated by endoscopic stapling (23 stapled, 2 abandoned) over a 4-year
period (1994 to 1998) at a University teaching hospital in the United
Kingdom. Outcome measures used were relief of symptoms over a
long-term follow-up of 2 to 5 years. RESULTS: Of the 25 patients
analyzed, 12 patients (48%) have remained asymptomatic after their
initial stapling. Eight patients (32%) were relieved of their symptoms
after revision stapling. The overall long-term success rate for
endoscopic stapling was 80% (20 of 25 patients)
CONCLUSION: Reduced morbidity and few complications in the elderly
make endoscopic stapling a favored primary technique of treating
pharyngeal pouches. Open surgery is recommended only in healthy
patients with very large pouches.
==
"A retrospective review of pharyngeal pouch surgery in 56 patients."
Mirza S, Dutt SN, Minhas SS, Irving RM. Ann R Coll Surg Engl. 2002
Jul;84(4):247-51
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12215027&dopt=Abstract
"We retrospectively reviewed 56 consecutive patients treated
surgically for a pharyngeal pouch at our institution between 1989-1999
(10 years). Various surgical procedures were performed including
endoscopic stapling (20), external excision (23), Dohlman's procedure
(9), pouch inversion (3), cricopharyngeal myotomy only (3), and pouch
suspension (1). There were 12 patients (18%) with complications and
one mortality (2%). Four patients (7%) had a recurrence with 2
requiring further surgery. Over the latter 3 years, endoscopic
stapling has emerged as the primary procedure for pharyngeal pouch
surgery in our unit; with the advantages of an earlier commencement of
diet and earlier hospital discharge. However, results were not as good
as for external excisions. Furthermore, there were difficulties with 3
cases that commenced as endoscopic stapling procedures but had to he
converted to external excisions due to inaccessibility in one case and
iatrogenic perforations in two cases. As with any new technique,
problems may occur and a learning curve has been appreciated in our
unit. Surgeons must he prepared, with informed consent, to convert to
an external approach should difficulties arise during endoscopic
stapling.
** Elderly and frail patients who are at risk from a general
anaesthetic may benefit from endoscopic stapling.
** External excision of pharyngeal pouches may be more appropriate in
the young, the medically fit, and when malignancy is a concern."
====
"An audit of pharyngeal pouch surgery using endoscopic stapling. The
patient's viewpoint." Weller MD, Porter MJ, Rowlands J. Eur Arch
Otorhinolaryngol. (2003 Oct 9)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14551789&dopt=Abstract
"We report an audit designed to assess patient satisfaction resulting
from pharyngeal pouch surgery using an endoscopic stapler. A personal
series of 16 patients all operated on by the senior author over a
3-year period is reported. Information was gathered using a
retrospective telephone questionnaire to establish pre- and
postoperative symptoms, complications of surgery and patient
satisfaction.
** This showed endoscopic pharyngeal pouch surgery to be successful in
the majority of cases.
** Eighty-seven percent of patients felt better as a result of surgery.
** Seventy-five percent had no symptoms postoperatively.
** This series shows that surgery on pharyngeal pouches results in
significant improvement in patient symptoms with minimal morbidity and
mortality."
===
"Pharyngeal pouch surgery: a five year review." Siddiq MA, Patel PJ.
Rev Laryngol Otol Rhinol (Bord). 2000;121(1):37-40
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10865482&dopt=Abstract
"The treatment of pharyngeal pouch varies widely. Our aim was to
establish current and recent practice in pharyngeal pouch surgery in
our department and set guidelines for future management. A
retrospective audit over a 5-year period was performed with all data
derived from patient notes. 28 procedures were performed on 24
patients with a mean age of 72 years. Over two thirds of these
patients (68%) underwent an endoscopic procedure (stapling or
diathermy) and the remainder underwent excision (14%), inversion
(10%), cricopharyngeal myotomy (4%) or dilatation (4%). The primary
diagnostic investigation performed was a barium swallow in 17 cases,
but in 7 cases, referred by gastroenterologists, an
oesophagogastroscopy was performed despite characteristic presenting
features in all cases. The average inpatient stay was similar for
endoscopic and excision procedures (5.5 and 5 days respectively), but
longer for inversion procedures (9 days). This was influenced mainly
by operative complications. 2 endoscopic stapling procedures were
complicated by perforations and 1 patient developed hoarseness after
an inversion procedure. The mean follow up time was one month at which
stage all asymptomatic patients were discharged.
** 2 patients treated by endoscopic stapling and 1 patient treated by
inversion complained of persistent symptoms and required further
surgery.
** We conclude that endoscopic stapling was the commonest procedure used.
** Also it was felt that large pouches should be treated by excision,
** small pouches by cricopharyngeal myotomy
** and the remainder by endoscopic stapling.
===
"Long-term clinico-radiological assessment of endoscopic stapling of
pharyngeal pouch: a series of cases." Jaramillo MJ, McLay KA, McAteer
D. J Laryngol Otol. 2001 Jun;115(6):462-6
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11429069&dopt=Abstract
"The endoscopic division of the pharyngeal pouch wall with a
mechanical stapling device has become increasingly popular. When
compared to open excision, the reduced operative time, early
resumption of oral intake, and short in-patient stay with no early
recurrence of symptoms, are the proposed advantages. Small pouches or
thick walled pouches are not suitable for stapling. From December 1996
to December 1999, 32 patients were admitted to the Aberdeen Royal
Infirmary for endoscopic stapling of a pharyngeal pouch. Five patients
were unsuitable for stapling. In addition, three patients were treated
for pouch recurrence after an external approach. Two patients required
repeat stapling at a later date. Our results are encouraging in terms
of short operation time and hospital admission, improvement of
symptoms and minimal complication rate. Fifteen patients were assessed
24 months after the procedure with satisfaction surveys and contrast
swallow X-rays. Subjective improvement was sustained throughout this
period, despite radiological evidence of persistence of the pharyngeal
pouch."
===
"Comparison of the endoscopic stapling technique with more established
procedures for pharyngeal pouches: results and patient satisfaction
survey." van Eeden S, Lloyd RV, Tranter RM. J Laryngol Otol. 1999
Mar;113(3):237-40.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10435131&dopt=Abstract
** "Pharyngeal pouch surgery by the external approach has been shown
to be effective but has a relatively high complication rate. We
compared the outcome of 17 patients who had cricopharyngeal myotomy
alone or combined with excision/inversion/suspension, simple pouch
excision and Dohlman's procedure with 17 patients who had the
relatively new Endo GIA-30 endoscopic stapling technique. Results were
obtained retrospectively by postal questionnaire and medical records.
** We conclude that endoscopic stapling shortens the return to normal
diet and in-patient stay. These patients also experience better
swallowing and are generally more satisfied with the procedure. We
have accepted endoscopic stapling as the method of choice for the
treatment of pharyngeal pouches."
==
"Management of pharyngoesophageal (Zenker's) diverticulum: which
technique?" Gutschow CA, Hamoir M, Rombaux P, Otte JB, Goncette L,
Collard JM. Ann Thorac Surg. 2002 Nov;74(5):1677-82;
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12440629&dopt=Abstract
CONCLUSIONS: Open techniques afford better symptomatic relief than
endoscopic techniques, especially in patients with small diverticula.
Endoscopic stapling and division is safer than laser division.
Although very effective at midterm, resection without myotomy
predisposes to the development of postoperative fistula and to
recurrence of the pouch after many years.
===
"Endoscopic stapled diverticulotomy: treatment of choice for Zenker's
diverticulum." Philippsen LP, Weisberger EC, Whiteman TS, Schmidt JL.
Laryngoscope. 2000 Aug;110(8):1283-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10942127&dopt=Abstract
CONCLUSIONS: Compared with the traditional open technique, the
endoscopic stapled diverticulotomy technique is safe, quick, and
effective and requires a shorter length of stay in the hospital.
Therefore it has become our treatment of choice for elderly, high-risk
patients with a large (>2 cm) hypopharyngeal (Zenker's) diverticulum.
==
"Long-term follow-up of endoscopic stapled diverticulotomy." Counter
PR, Hilton ML, Baldwin DL. Ann R Coll Surg Engl. 2002 Mar;84(2):89-92.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11995771&dopt=Abstract
We report a consecutive series of 31 patients who underwent endoscopic
stapled diverticulotomy. The patients' notes were reviewed
retrospectively to gather data on their original admission and a
postal survey was conducted to establish patient satisfaction, their
ability to swallow and re-operation data. Three patients were lost to
follow-up. Nine of the remaining 28 died at a median of 18 months. The
remaining 21 were followed up for a median of 59 months. The data
showed that, at 5 years, 94.4% of patients had an improvement in their
swallowing, and 50% had an entirely normal swallow.
** In order to achieve this result, 19% of patients required a second
procedure, and one patient (3.2%) required a third (open) procedure.
Endoscopic stapled diverticulotomy has well-established, short-term
advantages. This series shows that it has a good long-term outcome
that is similar to established open techniques and probably better
than other techniques of endoscopic diverticulotomy, i.e. diathermy or
laser
COMPLICATIONS
==============
From "Pharyngeal Pouches." ENT Nursing
http://www.entnursing.com/pharyngealpouch.htm
"The most important complication after treatment of a pharyngeal pouch
is a leak of contents into the surrounding tissues leading to a
mediastinitis. This manifests itself as pyrexia, tachycardia and chest
pain. Any of these signs or symptoms should be noted and the
appropriate people informed immediately as this is a potentially fatal
condition."
"Complications include: bleeding (primary and secondary),
mediastinitis, surgical emphysema, fistulae, oesophageal stenosis and
recurrence."
"In large pouches treated endoscopically a second (or more) procedure
may be required."
===
From "Dysphagia." Surgical Tutor.org.
http://www.surgical-tutor.org.uk/default-home.htm?tutorials/pharyngeal.htm~right
"As pharyngeal pouches usually arise in the elderly, their management
is often determined by the general fitness of the patient and the
presence of any co-morbid conditions. The standard treatment is
surgical and this can be achieved by either an external or endoscopic
approach.
* At present there is no consensus as to which approach is the optimal treatment.
External procedures involve a lateral cervical approach, identifying
the pouch and performing a cricopharyngeal myotomy. The pouch can be
inverted or excised. Endoscopic procedures involve the division of the
muscular septum between the oesophagus and the pouch (e.g. Dohlman's
procedure) without excising the pouch. The septum can be divided using
either electrocautery, laser or an endoscopic stapling device.
Surgery for a pharyngeal pouch, particularly if an external approach
is used, is often associated with a significant risk of complications
and peri-operative mortality rates of 2% have been reported.
Complications reported after pharyngeal pouch surgery include
recurrent laryngeal nerve damage, pouch perforation, mediastinitis,
pharyngeal fistula, and pharyngeal stenosis.
==
"Pharyngeal pouch (Zenker's diverticulum)." Siddiq MA, Sood S,
Strachan D. Postgrad Med J. 2001 Aug;77(910):506-11
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11470929&dopt=Abstract
"Pharyngeal pouches occur most commonly in elderly patients (over 70
years) and typical symptoms include dysphagia, regurgitation, chronic
cough, aspiration, and weight loss. The aetiology remains unknown but
theories centre upon a structural or physiological abnormality of the
cricopharyngeus. A diagnosis is easily established on barium studies.
Treatment is surgical via an endoscopic or external cervical approach
and should include a cricopharyngeal myotomy."
** Unfortunately pharyngeal pouch surgery has long been associated
with significant morbidity, partly due to the surgery itself and also
to the fact that the majority of patients are elderly and often have
general medical problems.
** External approaches are associated with higher complication rates
than endoscopic procedures.
Recently, treatment by endoscopic stapling diverticulotomy has
becoming increasingly popular as it has distinct advantages, although
long term results are not yet available.
** The small risk of developing carcinoma within a pouch that is not
excised remains a contentious issue and is an argument for long term
follow up or treating the condition by external excision, particularly
in younger patients
===
Complications - Size of Pharyngeal Pouch
-----------------------------------------
"Zenker's diverticulum: analysis of surgical complications from
diverticulectomy and cricopharyngeal myotomy." Feeley MA, Righi PD,
Weisberger EC, Hamaker RC, Spahn TJ, Radpour S, Wynne MK.
Laryngoscope. 1999 Jun;109(6):858-61
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=99295945
OBJECTIVE: To identify risk factors for postoperative complications in
patients undergoing diverticulectomy and cricopharyngeal (CP) myotomy
for Zenker's diverticulum.
MATERIALS AND METHODS: A chart review was conducted of all patients
with a Zenker's diverticulum who were treated with diverticulectomy
and cricopharyngeal myotomy at three tertiary care centers in central
Indiana between 1988 and 1998.
RESULTS: Of the 24 patients identified, 9 developed postoperative
complications (2 medical and 7 surgical).
** Statistical analysis of multiple potential risk factors revealed
that only diverticulum size greater than 10 cm2 at surgery placed the
patient at increased risk for postoperative surgical complications. To
our knowledge, this is the first report that has specifically
addressed diverticulum size as an independent risk factor for
postoperative surgical complications following diverticulectomy and CP
myotomy.
CONCLUSIONS: Given our findings, we recommend considering
diverticulopexy rather than diverticulectomy in a patient with a
Zenker's diverticulum greater than 10 cm2 in size if a cervical
approach is the selected treatment.
==
Also read:
"Radiographic findings and complications after surgical or endoscopic
repair of Zenker's diverticulum in 16 patients." Sydow BD, Levine MS,
Rubesin SE, Laufer I. AJR Am J Roentgenol. 2001 Nov;177(5):1067-71
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11641171&dopt=Abstract
*********
Q. Does having the muscles in the throat dilated under general
anaesthetic help with this complaint?
===============================================================================
Surgical throat muscle dilation, called "Cricopharyngeal myotomy", is
a component of the two-part surgical treatment for pharyngeal pouch.
"Surgical intervention consists of two parts. The first is to treat
the cause of the pouch i.e. reducing the resistance of the
cricopharyngeus and secondly to treat the pouch itself. This can be
achieved either by an open procedure or by an endoscopic approach."
From "Pharyngeal Pouches." ENT Nursing
http://www.entnursing.com/pharyngealpouch.htm
==
"Cricopharyngeal myotomy is a mandatory component of surgery for
Zenker's diverticulum."
From "Influence of surgery on deglutitive upper oesophageal sphincter
mechanics in Zenker's diverticulum." DW Shaw, IJ Cook, GG Jamieson, M
Gabb, ME Simula and J Dent.
Gut, Vol 38, 806-811 http://gut.bmjjournals.com/cgi/content/abstract/38/6/806
==
"Treatment is surgical via an endoscopic or external cervical approach
and should include a cricopharyngeal myotomy."
From "Pharyngeal pouch (Zenker's diverticulum)." M A Siddiq, S Sood, D
Strachan. Postgrad Med J 2001;77:506-511 (2000)
http://pmj.bmjjournals.com/cgi/content/abstract/77/910/506
*********
Q. Would a pouch be the cause of any pain on swallowing in the upper
back of the throat?
===============================================================================
"Although the pouch may present with a palpable lump in the neck, this
is very rare. Pouches are typically painless and pain may signify
ulceration of the mucosa or carcinoma within the pouch."
From "Pharyngeal Pouches." ENT Nursing
http://www.entnursing.com/pharyngealpouch.htm
**********
Q. Do people make a good recovery after operation or is there still a
sensation in the throat where the pouch was closed?
===============================================================================
The abstracts presented above provided some good statistics regarding
freedom from symptoms after surgery. However, continuing sensation
related to "a clump of staples" is described below:
"The surgical treatment of a pharyngeal pouch with endoscopic stapling
diverticulotomy is a relatively new concept. Long-term results and
complications are yet to be fully studied.
** We describe a patient who developed persistent pharyngeal pain and
foreign body sensation due to retention of a clump of staples at the
cricopharyngeal sphincter. This complication has not been reported
before. This case highlights the need for repeat endoscopy rather than
a barium swallow X-ray if the patients are symptomatic after stapling
procedures."
From "Persistent foreign body sensation and pharyngeal pain due to
retention of staples: an interesting sequelae of endoscopic stapling
procedure." Arunachalam PS, Cameron DS. J Laryngol Otol. 2001
May;115(5):425-7
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11410142&dopt=Abstract
**********
Q. Could the pouch and the muscular pain on swallowing be connected?
====================================================================
"In the initial stages they present with a foreign body sensation in the throat."
From The Royal College of Surgeons of Edinburgh
http://www.edu.rcsed.ac.uk/photoalbum/ph130.htm
==
"The most common symptom is difficulty in swallowing food/solids with
a feeling of a lump in the throat....Although the pouch may present
with a palpable lump in the neck, this is very rare. Pouches are
typically painless and pain may signify ulceration of the mucosa or
carcinoma within the pouch."
From "Pharyngeal Pouches." ENT Nursing
http://www.entnursing.com/pharyngealpouch.htm
*********************
I wish your mother-in-law the best of health and hope that she can
find relief from her discomfort!
Sincerely,
umiat
Google Search Strategy
pharyngeal pouch
pharyngeal pouch +operation
"pharyngeal pouch" need for surgery
+removal of "pharyngeal pouch"
surgical dilation throat muscles
"cricopharyngeal myotomy" AND "pharyngeal pouch"
Pub Med Search for "pharyngeal pouch"
http://www.ncbi.nih.gov/entrez/query.fcgi |
