Diseases of the Esophagus (199b) 9, 22-32 © 1996 International Society for Diseases of the Esophagus / Pearson Professional Ltd TOPIC FORUM THE PHARYNGOESOPHAGEAL SEGMENT: Cervical myotomy as therapeutic principle for pharyngoesophageal disorders T. Lerut, W. Coosemans, Ph. Cuypers, P. De Leyn, G. Deneffe, M. Migliore, D. Van Raemdonck Department of Thoracic Surgery, University Hospitals at Leuven, Leuven, Belgium INTRODUCTION Pharyngoesophageal disorders (PEDs) represent a complex and interesting chapter in human pathology. Zenker's diverticulum is the most frequent of pharyngoe- sophageal disorders, while other disorders are rare but associated with a wide range of etiologic conditions such as: neurogenic and myogenic disorders, idiopathic dys- function, iatrogenic causes, distal esophageal dysfunction, and disorders with a mechanical or psychogenic origin. Surgery has a predominant role in the treatment of a number of PEDs and the main goal is to restore normal deglutition while avoiding aspiration. In 1932, Sieffert was probably the first surgeon to perform a cricopharyngeal myotomy for a Zenker's diverticulum (ZD).' The first description of cricopha- ryngeal myotomy for a neurologic condition was the operation of Kaplan in 1951 ? Later, Belsey drew atten- tion to the importance of cricopharyngeal myotomy to correct the underlying functional disorder in pharyngo- esophageal dysphagia. 3 In subsequent years, for a num- ber of surgeons considering the cricopharyngeal muscle to be the number one cause of ZD and the diverticulum to be the complication rather than the cause of the dys- function, myotomy has been the key to the successful treatment of this disease. Nevertheless, indication for cervical myotomy in pharyngoesophageal disorders are not well clarified either in patients with ZD or in patients with other types of PED. For definition, cervical myotomy is not restricted to the cricopharyngeal muscle but it includes, at least to a certain extent, other muscles participating in the pha- ryngeal (inferior constrictor) and esophageal (proximal Correspondence to: T. Lerut, Department of Thoracic Surgery, University Hospitals of Leuven, U.Z. Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium. cervical muscle) phase of swallowing. Such a long myotomy is believed to coincide with the upper eso- phageal sphincter (UES) zone. Myotomy, however, is not to be considered as a minor operation because severe postoperative complications can develop (medi- astinitis, pneumonia, esophageal fistula) if not per- formed properly. To discuss the rationale for myotomy, we will review indications and results from the most recent and perti- nent literature and report our own experience and research, in particular with Zenker's diverticulum. ZENKER'S DIVERTICULUM Abraham Ludlow in 1767 4 was the first surgeon to describe pharyngoesophageal diverticulum, but it was Zenker who, in 1877, published a complete clinical and pathological description, giving his name to the disease." Zenker's diverticulum (ZD) arises in the Killian's tri- angle, which is the area between the oblique fibers of thyropharyngeus and the horizontal fibers of cricopha- ryngeus. But it must be remembered that because differ- ent anatomical arrangements exist between thryopharyn- geus and cricopharyngeus, different sites of origin of pharyngoesophageal diverticula have been demon- strated. 5 ' 6 Several techniques have been performed in the last century for treatment of ZD: drainage of the divertic- ulum by establishing a fistula, invagination of the diver- ticulum by creating a pursestring suture around its neck, diverticulectomy as a two-stage, or one-stage approach, cricopharyngeal myotomy, whether or not associated with diverticulopexy or diverticulectomy, the Dohlman endoscopic procedure and, most recently, video- endoscopic esophagodiverticulostomy. 7- ' ° This existing variety of approaches emphasizes the lack of unanimity regarding the optimal therapy, 22 Downloaded from https://academic.oup.com/dote/article/9/1/22/4210300 by guest on 26 September 2023