Majumdar, Samit

Manickavasagam, Jaiganesh

Patil, Pradeep

Ravisankar, Samyukta

Shahsavari, Sommayeh

English

Siddiq MA

Sen P

Crossref

The role of upper GI flexible endoscopy in management of large pharyngeal pouches

Pharyngeal pouch operations are commonly performed in ENT. However, some pouches can be large, with poor access making surgical management more complex

University of Dundee Online Publications

                                                                    University of DundeeThe role of upper GI flexible endoscopy in management of large pharyngeal pouchesRavisankar, Samyukta; Shahsavari, Sommayeh; Manickavasagam, Jaiganesh; Majumdar,Samit; Patil, PradeepPublished in:Clinical OtolaryngologyDOI:10.1111/coa.13634Publication date:2021Licence:CC BYDocument VersionPublisher's PDF, also known as Version of recordLink to publication in Discovery Research PortalCitation for published version (APA):Ravisankar, S., Shahsavari, S., Manickavasagam, J., Majumdar, S., & Patil, P. (2021). The role of upper GIflexible endoscopy in management of large pharyngeal pouches. Clinical Otolaryngology, 46(1), 88-90.https://doi.org/10.1111/coa.13634General rightsCopyright and moral rights for the publications made accessible in Discovery Research Portal are retained by the authors and/or othercopyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated withthese rights. • Users may download and print one copy of any publication from Discovery Research Portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain. • You may freely distribute the URL identifying the publication in the public portal.Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Download date: 31. Jul. 2023Clinical Otolaryngology. 2020;00:1–3. wileyonlinelibrary.com/journal/coa  |  1 Received: 18 December 2019  |  Revised: 7 July 2020  |  Accepted: 31 July 2020DOI: 10.1111/coa.13634  C O R R E S P O N D E N C E :  O U R  E X P E R I E N C EThe role of upper GI flexible endoscopy in management of large pharyngeal pouchesSir,Pharyngeal pouch operations are commonly performed in ENT. However, some pouches can be large, with poor access mak-ing surgical management more complex. This can be worsened by long-standing pouch with associated severe dysphagia as shown in Figure 1. In this technical note, we describe the use of upper GI en-doscopy to overcome the challenges in a large pharyngeal pouch. Management of this pouch in a conventional manner with standard endoscopic approach was difficult as we tried to locate the lumen of the oesophagus and apply further staples to achieve satisfactory division of the bar.We have used this technique for 2 patients; both had a large pouch with progressive dysphagia over a few years, and associated weight loss and regurgitation of food. Fluoroscopic assessment of pharyngeal and oesophageal swallow was our first-line investigation (Figure 1A). A CT was also performed to better visualise the pouch due to its size, abnormal shape and extension into the mediastinum (Figure 2B). It also enhanced safety profile as we can identify any vascular structures adjacent to bar and tracheo-oesophageal groove.The patient was scheduled for an elective endoscopic stapling of his pharyngeal pouch, which we describe below.The procedure was performed under general anaesthetic with the patient lying in a supine position. A Weerda diverticuloscope was passed and the pouch identified.Since the patient had a large pouch, the oesophageal lumen was not easily identifiable. With the help of an upper gastrointestinal (GI) endoscopist, the oesophageal orifice was identified using a paediatric scope (Figure 3). While the upper GI endoscope was in the oesoph-agus, the diverticuloscope was inserted. The endoscopic stapling device was used to divide the bar under direct vision. The GI scope was placed intra-orally but outside of the lumen of the Weerda diver-ticuloscope (WD), hence not hindering the intra-luminal view of the WD scope. With this technique, we could see oesophageal lumen and pouch with the help of upper GI endoscope camera and rigid endo-scope, respectively.This case required two complete full-length staples (© Ethicon US. ENDOPATH® ETS; 45 mm ETS Articulating Linear Cutter), ap-plications to achieve a satisfactory division of the bar between the pouch and oesophagus. Post-operatively clear fluid was commenced after 4 hours of patient being nil by mouth. Patient was observed for signs of perforation and discharged the following day.The pharyngeal pouch or Zenker's diverticulum was first de-scribed by Ludlow in 1769. This was followed by a detailed patholog-ical description of 34 pouches by Zenker and Von Ziemssens in 1878. The pathogenesis of pharyngeal pouches is still not well understood. The most accepted explanation is that an incomplete opening of the upper oesophageal sphincter increases pressure within the pharynx, leading to a herniation through a weaker section of the mucosa.1 Patients with pouches commonly present with dysphagia, regurgita-tion and food sticking in their throats. In more severe cases, patients may also present with significant weight loss, malnutrition2 and food bolus obstruction.Several methods have been developed for the management of pouches over the years. The traditional method of treatment was open surgery—diverticulectomy, cricopharyngeal myotomy, inver-sion or diverticuloplexy.1 Over the years, other modalities of man-agement in the form of endoscopic laser treatment, coagulation and stapling have been developed.3 On the whole, while open repairs are the most successful treatment, endoscopic stapling has been associ-ated with fewer complications and quicker recovery time, especially in smaller pouches.4Generally, in endoscopic pouch operations, it is not difficult to find the oesophageal inlet, bar and pouch to perform a safe endo-scopic division of the pouch. However, in certain cases it is impossi-ble to find the oesophageal inlet even with a rigid oesophagoscopy prior to applying the Weerda diverticuloscope for full visualisation. It is possible that the Weerda scope stretches the pharynx and, in turn, the oesophageal inlet, which makes the oesophageal inlet difficult to find. In this case, the oesophageal inlet was identified with a paedi-atric upper GI endoscope.The hypothesis was that we were able to locate the lumen, pos-sibly because of the air insufflator in the non-stretch environment. Upper GI endoscopes' flexibility, air insufflator, non-stretched phar-ynx and experience of upper GI endoscopist facilitated easy iden-tification of oesophageal orifice. Once the oesophageal inlet was identified with the upper GI endoscopy, the scope was kept inside while passing the Weerda scope. The flexible GI scope was push-ing the bar down well, which enabled insertion of the endoscopic This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.© 2020 The Authors. Clinical Otolaryngology published by John Wiley & Sons Ltd2  |     CORRESPONDENCE: OUR EXPERIENCEstapler more effectively, especially for this pouch with longer length. In large pouches, lower tip of the WD scope will not reach the lower end of the pouch as it is limited by its length. This technique will increase the chances of applying the second set of staples more ef-fectively due to enhanced dual vision. A flexible endoscope was kept in the oesophagus during the entire procedure, outside the lumen of the WD scope to enhance visibility.In their review in 2004, Sen and Bhattacharya noted a 0%-30% conversion rate from endoscopic stapling procedures to open procedures reported in 29 papers from 1966 to 2003.5 The main reasons for conversion were anatomical factors in patients such as small mandibles, long necks or limited neck extension. Verdonck and Morton observed in their review that endoscopic procedures were associated with higher intraoperative failure than open pro-cedures, again due to anatomical factors.6 Overall, however, en-doscopic procedures have more favourable outcomes than open procedures when compared with post-operative1,4-6 outcomes and complications. Therefore, it is worth considering alternate ways to make endoscopic procedures possible, especially in more high-risk patients. We suggest a trial of an upper GI endoscopy to locate the oesophageal orifice in suitable situations, then reattempting a rou-tine endoscopic stapling procedure.The other options were to use a flexible endoscopic approach or an open approach to remove the pouch. However, higher rates F I G U R E  1   A, Pharyngeal pouch identified on barium swallow. B-E, Pharyngeal pouch on CT scan, marked by blue arrowsF I G U R E  2   A, Pouch visualised during the procedure; B, view after first set of staples applicationF I G U R E  3   Upper GI endoscope successfully passed in to stomach and left in place for identification of oesophageal inlet     |  3CORRESPONDENCE: OUR EXPERIENCEof post-operative bleeding and recurrence have been observed with a flexible endoscopic approach.7 The open approach would also re-quire a longer operating time and longer hospital stay along with increased risk of complications. Hence, the method used was identi-fied as the best approach for our patient.In conclusion, intraoperative input of an upper GI endoscopist could be considered in more complex and large pharyngeal pouch cases, particularly if when the oesophageal inlet proves difficult to visualise. It could potentially make the complete stapling of the pouch technically easier and safer.CONFLIC T OF INTERE S TNone to declare.DATA AVAIL ABILIT Y S TATEMENTData sharing is not applicable to this article as no new data were cre-ated or analysed in this study.Samyukta Ravisankar1Somayyeh Shahsavari2Jaiganesh Manickavasagam3Samit Majumdar2Pradeep Patil41School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK2Department of Otorhinolaryngology, Ninewells Hospital & Medical School, Dundee, UKEmail: somayyeh.shahsavari@nhs.net3Tayside academic science centre & Department of otolaryngology, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK4Department of Surgery, Ninewells Hospital & Medical School, Dundee, UKCorrespondenceSamyukta Ravisankar; Jaiganesh Manickavasagam, School of Medicine, Tayside academic science centre & Department of otolaryngology, Ninewells Hospital & Medical School, University of Dundee, Dundee DD1 9SY, UK.Email: samyukta.ravisankar@nhs.net; jaiganesh.manickavasagam@nhs.netORCIDSamyukta Ravisankar  https://orcid.org/0000-0001-8946-1345 R E FE R E N C E S 1. Stewart K, Sen P. Pharyngeal pouch management: an historical re-view. J Laryngol Otol. 2016;130(2):116-120. 2. Siddiq MA, Sood S, Strachan D, Infirmary R, Lane D, Bd B. Pharyngeal pouch (Zenker's diverticulum). Postgrad Med J. 2001;506-511. 3. Fama AF, Moore EJ, Kasperbauer JL. Harmonic scalpel in the treat-ment of Zenker’s diverticulum. Laryngoscope. 2009;119(7):1265-1269. 4. Veivers D. Pharyngeal pouch: which technique? J Laryngol Otol. 2015;129(S3):S30-S34. 5. Sen P, Bhattacharyya AK. Endoscopic stapling of pharyngeal pouch. J Laryngol Otol. 2004;118(8):601-606. 6. Verdonck J, Morton RP. Systematic review on treatment of Zenker’s di-verticulum. Eur Arch Oto-Rhino-Laryngology. 2015;272(11):3095-3107. 7. Crawley B, Dehom S, Tamares S, et al. Adverse events after rigid and flexible endoscopic repair of Zenker's diverticula: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2019;161(3):388-400.

                                                                    University of DundeeThe role of upper GI flexible endoscopy in management of large pharyngeal pouchesRavisankar, Samyukta; Shahsavari, Sommayeh; Manickavasagam, Jaiganesh; Majumdar,Samit; Patil, PradeepPublished in:Clinical OtolaryngologyDOI:10.1111/coa.13634Publication date:2021Document VersionPublisher's PDF, also known as Version of recordLink to publication in Discovery Research PortalCitation for published version (APA):Ravisankar, S., Shahsavari, S., Manickavasagam, J., Majumdar, S., & Patil, P. (2021). The role of upper GIflexible endoscopy in management of large pharyngeal pouches. Clinical Otolaryngology, 46(1), 88-90.https://doi.org/10.1111/coa.13634General rightsCopyright and moral rights for the publications made accessible in Discovery Research Portal are retained by the authors and/or othercopyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated withthese rights. • Users may download and print one copy of any publication from Discovery Research Portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain. • You may freely distribute the URL identifying the publication in the public portal.Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Download date: 29. May. 2021Clinical Otolaryngology. 2020;00:1–3. wileyonlinelibrary.com/journal/coa  |  1 Received: 18 December 2019  |  Revised: 7 July 2020  |  Accepted: 31 July 2020DOI: 10.1111/coa.13634  C O R R E S P O N D E N C E :  O U R  E X P E R I E N C EThe role of upper GI flexible endoscopy in management of large pharyngeal pouchesSir,Pharyngeal pouch operations are commonly performed in ENT. However, some pouches can be large, with poor access mak-ing surgical management more complex. This can be worsened by long-standing pouch with associated severe dysphagia as shown in Figure 1. In this technical note, we describe the use of upper GI en-doscopy to overcome the challenges in a large pharyngeal pouch. Management of this pouch in a conventional manner with standard endoscopic approach was difficult as we tried to locate the lumen of the oesophagus and apply further staples to achieve satisfactory division of the bar.We have used this technique for 2 patients; both had a large pouch with progressive dysphagia over a few years, and associated weight loss and regurgitation of food. Fluoroscopic assessment of pharyngeal and oesophageal swallow was our first-line investigation (Figure 1A). A CT was also performed to better visualise the pouch due to its size, abnormal shape and extension into the mediastinum (Figure 2B). It also enhanced safety profile as we can identify any vascular structures adjacent to bar and tracheo-oesophageal groove.The patient was scheduled for an elective endoscopic stapling of his pharyngeal pouch, which we describe below.The procedure was performed under general anaesthetic with the patient lying in a supine position. A Weerda diverticuloscope was passed and the pouch identified.Since the patient had a large pouch, the oesophageal lumen was not easily identifiable. With the help of an upper gastrointestinal (GI) endoscopist, the oesophageal orifice was identified using a paediatric scope (Figure 3). While the upper GI endoscope was in the oesoph-agus, the diverticuloscope was inserted. The endoscopic stapling device was used to divide the bar under direct vision. The GI scope was placed intra-orally but outside of the lumen of the Weerda diver-ticuloscope (WD), hence not hindering the intra-luminal view of the WD scope. With this technique, we could see oesophageal lumen and pouch with the help of upper GI endoscope camera and rigid endo-scope, respectively.This case required two complete full-length staples (© Ethicon US. ENDOPATH® ETS; 45 mm ETS Articulating Linear Cutter), ap-plications to achieve a satisfactory division of the bar between the pouch and oesophagus. Post-operatively clear fluid was commenced after 4 hours of patient being nil by mouth. Patient was observed for signs of perforation and discharged the following day.The pharyngeal pouch or Zenker's diverticulum was first de-scribed by Ludlow in 1769. This was followed by a detailed patholog-ical description of 34 pouches by Zenker and Von Ziemssens in 1878. The pathogenesis of pharyngeal pouches is still not well understood. The most accepted explanation is that an incomplete opening of the upper oesophageal sphincter increases pressure within the pharynx, leading to a herniation through a weaker section of the mucosa.1 Patients with pouches commonly present with dysphagia, regurgita-tion and food sticking in their throats. In more severe cases, patients may also present with significant weight loss, malnutrition2 and food bolus obstruction.Several methods have been developed for the management of pouches over the years. The traditional method of treatment was open surgery—diverticulectomy, cricopharyngeal myotomy, inver-sion or diverticuloplexy.1 Over the years, other modalities of man-agement in the form of endoscopic laser treatment, coagulation and stapling have been developed.3 On the whole, while open repairs are the most successful treatment, endoscopic stapling has been associ-ated with fewer complications and quicker recovery time, especially in smaller pouches.4Generally, in endoscopic pouch operations, it is not difficult to find the oesophageal inlet, bar and pouch to perform a safe endo-scopic division of the pouch. However, in certain cases it is impossi-ble to find the oesophageal inlet even with a rigid oesophagoscopy prior to applying the Weerda diverticuloscope for full visualisation. It is possible that the Weerda scope stretches the pharynx and, in turn, the oesophageal inlet, which makes the oesophageal inlet difficult to find. In this case, the oesophageal inlet was identified with a paedi-atric upper GI endoscope.The hypothesis was that we were able to locate the lumen, pos-sibly because of the air insufflator in the non-stretch environment. Upper GI endoscopes' flexibility, air insufflator, non-stretched phar-ynx and experience of upper GI endoscopist facilitated easy iden-tification of oesophageal orifice. Once the oesophageal inlet was identified with the upper GI endoscopy, the scope was kept inside while passing the Weerda scope. The flexible GI scope was push-ing the bar down well, which enabled insertion of the endoscopic This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.© 2020 The Authors. Clinical Otolaryngology published by John Wiley & Sons Ltd2  |     CORRESPONDENCE: OUR EXPERIENCEstapler more effectively, especially for this pouch with longer length. In large pouches, lower tip of the WD scope will not reach the lower end of the pouch as it is limited by its length. This technique will increase the chances of applying the second set of staples more ef-fectively due to enhanced dual vision. A flexible endoscope was kept in the oesophagus during the entire procedure, outside the lumen of the WD scope to enhance visibility.In their review in 2004, Sen and Bhattacharya noted a 0%-30% conversion rate from endoscopic stapling procedures to open procedures reported in 29 papers from 1966 to 2003.5 The main reasons for conversion were anatomical factors in patients such as small mandibles, long necks or limited neck extension. Verdonck and Morton observed in their review that endoscopic procedures were associated with higher intraoperative failure than open pro-cedures, again due to anatomical factors.6 Overall, however, en-doscopic procedures have more favourable outcomes than open procedures when compared with post-operative1,4-6 outcomes and complications. Therefore, it is worth considering alternate ways to make endoscopic procedures possible, especially in more high-risk patients. We suggest a trial of an upper GI endoscopy to locate the oesophageal orifice in suitable situations, then reattempting a rou-tine endoscopic stapling procedure.The other options were to use a flexible endoscopic approach or an open approach to remove the pouch. However, higher rates F I G U R E  1   A, Pharyngeal pouch identified on barium swallow. B-E, Pharyngeal pouch on CT scan, marked by blue arrowsF I G U R E  2   A, Pouch visualised during the procedure; B, view after first set of staples applicationF I G U R E  3   Upper GI endoscope successfully passed in to stomach and left in place for identification of oesophageal inlet     |  3CORRESPONDENCE: OUR EXPERIENCEof post-operative bleeding and recurrence have been observed with a flexible endoscopic approach.7 The open approach would also re-quire a longer operating time and longer hospital stay along with increased risk of complications. Hence, the method used was identi-fied as the best approach for our patient.In conclusion, intraoperative input of an upper GI endoscopist could be considered in more complex and large pharyngeal pouch cases, particularly if when the oesophageal inlet proves difficult to visualise. It could potentially make the complete stapling of the pouch technically easier and safer.CONFLIC T OF INTERE S TNone to declare.DATA AVAIL ABILIT Y S TATEMENTData sharing is not applicable to this article as no new data were cre-ated or analysed in this study.Samyukta Ravisankar1Somayyeh Shahsavari2Jaiganesh Manickavasagam3Samit Majumdar2Pradeep Patil41School of Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK2Department of Otorhinolaryngology, Ninewells Hospital & Medical School, Dundee, UKEmail: somayyeh.shahsavari@nhs.net3Tayside academic science centre & Department of otolaryngology, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK4Department of Surgery, Ninewells Hospital & Medical School, Dundee, UKCorrespondenceSamyukta Ravisankar; Jaiganesh Manickavasagam, School of Medicine, Tayside academic science centre & Department of otolaryngology, Ninewells Hospital & Medical School, University of Dundee, Dundee DD1 9SY, UK.Email: samyukta.ravisankar@nhs.net; jaiganesh.manickavasagam@nhs.netORCIDSamyukta Ravisankar  https://orcid.org/0000-0001-8946-1345 R E FE R E N C E S 1. Stewart K, Sen P. Pharyngeal pouch management: an historical re-view. J Laryngol Otol. 2016;130(2):116-120. 2. Siddiq MA, Sood S, Strachan D, Infirmary R, Lane D, Bd B. Pharyngeal pouch (Zenker's diverticulum). Postgrad Med J. 2001;506-511. 3. Fama AF, Moore EJ, Kasperbauer JL. Harmonic scalpel in the treat-ment of Zenker’s diverticulum. Laryngoscope. 2009;119(7):1265-1269. 4. Veivers D. Pharyngeal pouch: which technique? J Laryngol Otol. 2015;129(S3):S30-S34. 5. Sen P, Bhattacharyya AK. Endoscopic stapling of pharyngeal pouch. J Laryngol Otol. 2004;118(8):601-606. 6. Verdonck J, Morton RP. Systematic review on treatment of Zenker’s di-verticulum. Eur Arch Oto-Rhino-Laryngology. 2015;272(11):3095-3107. 7. Crawley B, Dehom S, Tamares S, et al. Adverse events after rigid and flexible endoscopic repair of Zenker's diverticula: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2019;161(3):388-400.

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The role of upper GI flexible endoscopy in management of large pharyngeal pouches

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