Postoperative Dysphagia Scores Research Articles

Lateral Deviation of the Hyoid Bone and Thyroid Cartilage Influences Prevertebral Soft-Tissue Swelling and Dysphagia After Anterior Cervical Diskectomy and Fusion.

Prevertebral soft-tissue swelling (PSTS) after anterior cervical diskectomy and fusion (ACDF) is known to be influenced by several factors. We considered the effect of lateral deviation on the traction force and attempted to find a relationship with the PSTS. This study was designed to evaluate the preoperative lateral deviation of the hyoid bone and thyroid cartilage and its effect on PSTS, airway collapse, and clinical outcomes after ACDF. Preoperative lateral deviations of the hyoid bone and thyroid cartilage at the superior cornu and inferior cornu were measured. To assess the effect of lateral deviation, patients who underwent 1 or 2 level ACDF with the left-sided approach were divided into a deviation group (left-sided deviation >5 mm or >10 mm) and a nondeviation group (left-sided deviation <5 mm or <10 mm). Difference of preoperative and postoperative PSTS (dPSTS), airway collapse, dysphagia score, and Neck Disability Index were compared between the 2 groups. Lateral deviation was measured in 290 patients, and 145 were enrolled to assess the effect of lateral deviation. Left-sided deviation was more common than right-sided deviation in all 3 structures (the hyoid bone, superior cornu, and inferior cornu of the thyroid cartilage). The deviation group demonstrated a significantly larger dPSTS at the C3 and C4 levels, more airway collapse at the C4 level, and a higher dysphagia score. There was no significant difference in the Neck Disability Index between the 2 groups. Lateral deviation significantly correlated with dPSTS (C3, C4, C5, and C6 levels) and airway collapse (C3 and C4 levels). A left-sided deviation of more than 5 mm of the hyoid bone or thyroid cartilage discouraged the left-sided approach for ACDF because of the aggravation of dPSTS, airway collapse, and dysphagia postoperatively.

Severe Dysphagia is Rare After Magnetic Sphincter Augmentation

BackgroundDysphagia remains the most significant concern after anti-reflux surgery, including magnetic sphincter augmentation (MSA). The aim of this study was to evaluate postoperative dysphagia rates, its risk factors, and management after MSA.MethodsFrom a prospectively collected database of all 357 patients that underwent MSA at our institution, a total of 268 patients were included in our retrospective study. Postoperative dysphagia score, gastrointestinal symptoms, proton pump inhibitor intake, GERD-HRQL, Alimentary Satisfaction, and serial contrast swallow imaging were evaluated within standardized follow-up appointments. To determine patients’ characteristics and surgical factors associated with postoperative dysphagia, a multivariable logistic regression analysis was performed.ResultsAt a median follow-up of 23 months, none of the patients presented with severe dysphagia, defined as the inability to swallow solids or/and liquids. 1% of the patients underwent endoscopic dilatation, and 1% had been treated conservatively for dysphagia. 2% of the patients needed re-operation, most commonly due to recurrent hiatal hernia. Two patients underwent device removal due to unspecific discomfort and pain. No migration of the device or erosion by the device was seen. The LINX® device size ≤ 13 was found to be the only factor associated with postoperative dysphagia (OR 5.90 (95% CI 1.4–24.8)). The postoperative total GERD-HRQL score was significantly lower than preoperative total score (2 vs. 19; p = 0.001), and daily heartburn, regurgitations, and respiratory complains improved in 228/241 (95%), 131/138 (95%) and 92/97 (95%) of patients, respectively.ConclusionsDysphagia requiring endoscopic or surgical intervention was rare after MSA in a large case series. LINX® devices with a size < 13 were shown to be an independent risk factor for developing postoperative dysphagia.

The Effect of Esophageal Temperature Probes on Postoperative Dysphagia Following Primary Anterior Cervical Discectomy and Fusion: A Randomized Prospective Study.

The anterior approach to the cervical spine is associated with postoperative dysphagia. It is difficult to predict which patients are most at risk for dysphagia. The objective of this study was to determine if placing an esophageal temperature probe preoperatively would affect the severity and length of postoperative dysphagia. We hypothesize that use of an esophageal temperature probe would result in worse postoperative dysphagia at all measured time points as measured by the Swallowing-Quality of Life (SQAL-QOL) survey after anterior cervical discectomy and fusion (ACDF). A total of 44 patients were enrolled in a prospective, randomized controlled trial and randomized into groups: 1 with an esophageal temperature probe placed at the time of surgery and 2 without. A total of 39 patients filled out postoperative SWAL-QOL questionnaires at their preoperatives. Using the survey results, the data were analyzed between groups and subanalyzed based on number of operative levels and sex. SWAL-QOL scores for patients undergoing 2-level ACDF with an esophageal temperature probe were significantly better compared with those without a probe at 2 weeks and 6 months postoperatively. These results were not significant at other time points in in the overall analysis, but a trend toward improved dysphagia scores at each time point postoperatively was seen with the probe group. No differences were found between the 2 groups with respect to age at the time of surgery, sex, and preoperative SWAL-QOL score. Placement of an esophageal temperature probe at the time of surgery significantly improved postoperative dysphagia scores in patients undergoing 2-level ACDF at 2 weeks and 6 months postoperatively. 2 CLINICAL RELEVANCE: Placement of a temperature probe is a safe and effective technique that is readily available and easily applicable to the practice of spine surgery and may improve postoperative dysphagia after ACDF.

The relationship between the interruption of the lower esophageal sphincter and relief of dysphagia after per-oral endoscopic myotomy for achalasia.

Background and Objectives:We investigated the relationship between the interruption of the muscularis propria of the lower esophageal sphincter (LES) measured by EUS and the relief of dysphagia in patients with esophageal achalasia treated by per-oral endoscopic myotomy (POEM).Patients and Methods:Patients with achalasia treated by POEM at our endoscopy center between January 2015 and August 2016 were included in the study. Preoperative clinical characteristics and dysphagia and Eckardt scores, operative and postoperative complications, dysphagia and Eckardt scores at 3- and 7-months postoperatively, and the incidence of postoperative gastroesophageal reflux disease (GERD) were recorded. Patients were divided into two groups according to the degree of separation of the muscularis propria at the LES, as measured by EUS: Group A, separation distance 2–5 mm and Group B, separation distance 5–9 mm, for comparison.Results:Preoperative clinical characteristics, Eckardt scores, and dysphagia scores were similar in the two groups. Patients in both groups had significant symptom relief postoperatively, with significant decreases in Eckardt scores and dysphagia scores. On the comparison between the groups, there was no significant difference in postoperative Eckardt score, but the dysphagia score was statistically significantly lower in Group B as compared to Group A (P < 0.05). There was no significant difference between the groups in the incidence of gas-related complications or in the incidence of postoperative GERD.Conclusions:POEM was largely effective in the treatment of esophageal achalasia in this study. Patients with larger defects of the muscularis propria at the LES after myotomy had greater relief of dysphagia without an increased incidence of postoperative complications.

The Presence of Thyroid Cartilage at the Surgical Level Reduces Early Dysphagia after Single-Level Anterior Cervical Surgery: A Retrospective Study

Background: Early dysphagia is a frequent complication of anterior cervical (AC) spine surgery. However, there are no reports that have discussed the correlation between early dysphagia and the positional relationship between thyroid cartilage and the surgical level.Methods: We retrospectively enrolled 82 patients in our hospital who underwent single-level AC discectomy performed by the same surgeon using the same internal fixation apparatus from 2015 to 2017. Swallowing difficulty was rated during the first five postoperative days using a 10-point scoring system. The positional relationship between the thyroid cartilage and the surgical level was defined as discectomy within the thyroid cartilage (IN group) or outside the thyroid cartilage (OUT group) using preoperative computed tomography (CT) images. The confounding factors such as gender, age, body mass index (BMI), hypertension, diabetes mellitus, drinking, smoking, operative level, operative time, and blood loss were analyzed by a binomial logistic regression.Results: The thyroid cartilage was most commonly located above the C5 level (65.1%). Early dysphagia developed in 47.6% of the patients during the first five postoperative days. The IN and OUT groups each contained 41 cases. The difference in the cumulative postoperative early dysphagia score between the IN and OUT groups was statistically significant (p < .05). The factors of gender, age, BMI, hypertension, diabetes mellitus, drinking, smoking, operative level, operative time, blood loss did not significantly influence the incidence of postoperative early dysphagia.Conclusions: We found that early dysphagia, which is a self-limiting complication, was correlated with surgery performed at levels outside the thyroid cartilage region. Preoperative review of the positional relationship between the thyroid cartilage and the surgical level can predict the incidence of postoperative transient dysphagia.

VS02.01: FLEXIBLE ENDOSCOPIC CRICOPHARYNGEAL MYOTOMY WITH THULIUM LASER

Abstract Description Flexible endoscopic treatment of Zenker's diverticulum is feasible, but electrocautery and CO2 laser technology carry the risk of collateral thermal injury. Thulium laser septum incision may overcome this limitation. We describe for the first time the use of thulium laser through flexible endoscopy in a small cohort of patients with Zenker diverticulum. Methods Thulium laser septum division was performed via flexible endoscopy under general anesthesia in 11 consecutive symptomatic patients with primary or recurrent Zenker diverticulum. Primary study aims were feasibility and safety of the procedure. To improve exposure and stabilize the septum during the procedure, either a transparent cap or a bivalve soft overtube were used. The laser system used was Opera® (Quanta System SpA, Varese, Italy), emitting a 1.9 μm Thulium wavelength radiation. A continuous laser configuration and an emission power of 5 to 16 W were chosen to allow incision of the mucosa and cricopharyngeal myotomy. Using 272 and 365 μm optical fibres in a non-contact mode, laser incision was performed in the midline of the septum until cricopharyngeal muscle fibers were encountered and a V-shaped myotomy was completed under visual control. Results Between May and January 2018, 11 consecutive patients were treated. Four patients presented with recurrent symptomatic diverticulum after previous transoral septum stapling or endoscopic myotomy. Median dysphagia and regurgitation scores were 4.1 ± 0.7 and 3.3 ± 0.8 respectively. Complete division of the septum was achieved in all patients. There was no bleeding nor need of adjunctive electrocautery devices to complete the procedure. The post-operative course was uneventful in all patients; the chest film and gastrographin swallow study on post-operative day one were negative for pneumomediastinum or leaks. All patients were discharged within 48 hours on a soft diet. At the 2-month follow-up visit, all patients were satisfied with the procedure with a post-operative dysphagia score of 2.0 ± 0.6 and a regurgitation score of 1.5 ± 0.4. Conclusions Division of Zenker's septum with Thulium laser is feasible and safe through flexible endoscopy. Longer term follow-up is required to establish effectiveness and reproducibility of this novel procedure. Disclosure All authors have declared no conflicts of interest.

A study of dysphagia symptoms and esophageal body function in children undergoing anti-reflux surgery.

The role of high-resolution esophageal impedance manometry (HRIM) for establishing risk for dysphagia after anti-reflux surgery is unclear. We conducted a prospective study of children with primary gastroesophageal reflux (GER) disease, for whom symptoms of dysphagia were determined pre-operatively and then post-operatively and we examined for features that may predict post-operative dysphagia. Thirteen children (aged 6.8-15.5 years) undergoing work-up prior to 360o Nissen fundoplication were included in the study. A dysphagia score assessed symptoms at pre-operative study and post-operatively (mean 1.4 years). A HRIM procedure recorded 5-ml liquid, 5-ml viscous and 2-cm solid boluses. We assessed esophageal motility, esophago-gastric junction (EGJ) morphology, EGJ contractility and pressure-flow variables indicative of bolus distension pressures and bolus clearance pressures. A composite pressure-flow index score was also derived. Pre-operative pressure-flow index was positively correlated with post-operative dysphagia score (viscous bolus r = 0.771, p < 0.005). Of three variables that comprise the pressure-flow index, the ramp pressure measured during bolus clearance was the main driver of the effect seen (viscous bolus r = 0.819, p < 0.005). In order to mitigate symptoms in relation to anti-reflux surgery, dysphagia symptoms and esophageal function need to be pre-operatively assessed. In patients with normal motility, an elevated pressure-flow index may predict post-operative dysphagia.

Long-term outcomes of laparoscopic large hiatus hernia repair with nonabsorbable mesh.

The use of mesh to augment suture repair of large hiatus hernias remains controversial. Repair with mesh may help reduce the recurrence rate of primary repair, but concerns about the potential for serious complications, such as mesh erosion or stricturing, continue to limit its use. We aim to evaluate the long-term outcome of primary hiatus hernia repair with lightweight polypropylene mesh (TiMesh) specifically looking at rates of clinical recurrence, dysphagia, and mesh-related complications. From a prospectively maintained database, 50 consecutive patients who underwent elective primary laparoscopic hiatal hernia repair with TiMesh between January 2005 and December 2007 were identified. Case notes and postoperative endoscopy reports were reviewed. Clinical outcomes were evaluated using a structured questionnaire, including a validated dysphagia score. Of the 50 patients identified, 36 (72%) were contactable for follow-up. At a median follow-up of 9 years, the majority of patients (97%) regarded their surgery as successful. Twelve patients (33%) reported a recurrence of their symptoms, but only 4 (11%) reported that their symptoms were as severe as prior to the surgery. There was no significant difference between pre- and postoperative dysphagia scores. Postoperative endoscopy reports were available for 32 patients at a median time point of 4 years postoperatively, none of which revealed any mesh-related complications. One patient had undergone a revision procedure for a recurrent hernia at another institution. In this series, primary repair of large hiatus hernia with nonabsorbable mesh was not associated with any adverse effects over time. Patient satisfaction with symptomatic outcome remained high in the long term.

Randomized clinical trial of 270° posterior versus 180° anterior partial laparoscopic fundoplication for gastro-oesophageal reflux disease.

Partial fundoplications provide similar reflux control with fewer post-fundoplication symptoms compared with Nissen fundoplication for gastro-oesophageal reflux disease (GORD). The best choice of procedure for partial fundoplication remains unclear. The aim of this study was to compare the outcome of two different types of partial fundoplication for GORD. A double-blind RCT was conducted between 2012 and 2015 in two hospitals specializing in antireflux surgery. Patients were randomized to undergo either a laparoscopic 270° posterior fundoplication (Toupet) or a laparoscopic 180° anterior fundoplication. The primary outcome was postoperative dysphagia at 12 months, measured by the Dakkak score. Subjective outcome was analysed at 1, 3, 6 and 12 months after surgery. Objective reflux control was assessed before and 6 months after surgery. Ninety-four patients were randomized to laparoscopic Toupet or laparoscopic 180° anterior fundoplication (47 in each group). At 12 months, 85 patients (90 per cent) were available for follow-up. Objective scores were available for 76 (81 per cent). Postoperative Dakkak dysphagia score at 12 months was similar in the two groups (mean 5·9 for Toupet versus 6·4 for anterior fundoplication; P = 0·773). Subjective outcome at 12 months demonstrated no significant differences in control of reflux or post-fundoplication symptoms. Overall satisfaction and willingness to undergo surgery did not differ between the groups. Postoperative endoscopy and 24-h pH monitoring showed no significant differences in mean oesophageal acid exposure time or recurrent pathological oesophageal acid exposure. Both types of partial fundoplication provided similar control of GORD at 12 months, with no difference in post-fundoplication symptoms. Registration number: NTR5702 (www.trialregister.nl).

Risk Factors for Dysphagia After Single-Level Anterior Cervical Decompression with Arthroplasty or Fusion: A Prospective Study Comparing 2 Zero-Profile Implants

To determine any differences in self-reported dysphagia in patients treated with single-level anterior cervical decompression with different zero-profile implants (arthroplasty vs. arthrodesis) and identify risk factors for postoperative dysphagia. A total of 112 patients with 1-level cervical degenerative disc disease were included in the prospective study. The dysphagia conditions and radiologic results were assessed using Bazar dysphagia scoring system, the Swallowing Quality of Life scores, cervical alignment (CA), segmental angle, and prevertebral soft tissues swelling (PSTS). All these parameters were compared before and after surgery in the respective group, which were also compared between the 2 groups. Correlations between the confounding factors and postoperative dysphagia were analyzed. No significant differences existed in preoperative or initially postoperative dysphagia rate and scores between the 2 groups (P > 0.05). However, the dysphagia rate and scores of cervical disc arthroplasty was better than those of fusion at postoperative day 7. Heavy smoker, PSTS change (≥5 mm), or CA change (≥5 degrees) was prone to have postoperative dysphagia. Postoperative dysphagia remains a common incidence, despite advances in instrumentation technologies. However, cervical disc arthroplasty is superior to anterior cervical discectomy and fusion in ameliorating the symptom of dysphagia in the early postoperative term. Heavy smoker, PSTS change (≥5 mm), and CA change (≥5 degrees) were important predictors of postoperative dysphagia.

Retropharyngeal Steroids and Dysphagia Following Multilevel Anterior Cervical Surgery.

A retrospective case-control study. The aim of this study was to determine the effect of retropharyngeal steroids on postoperative dysphagia scores and clinical outcomes following multilevel anterior cervical discectomy and fusion (ACDF). Dysphagia is a well-known complication following ACDF surgery and increased rates of dysphagia are seen with increased levels of surgery. Retropharyngeal steroids have been shown to decrease painful swallowing and prevertebral soft tissue (PSTS) swelling in 1- and 2-level anterior cervical surgery. A retrospective review of 44 patients undergoing multilevel (2-, 3-, 4-level) ACDF. Twenty-two patients who received retropharyngeal steroids (methylprednisone) placed on a collagen sponge at the time of surgery were compared with a matched cohort of controls who did not receive local steroids. Postoperative day 1 and 6-week radiographs were analyzed for differences in PSTS. Clinical outcomes were measured pre-operatively, 6 weeks, and 3 months postoperatively utilizing the Neck Disability Index (NDI), the Bazaz-Yoo Dysphagia Scoring System, and Eat Assessment Tool (EAT-10). Significant improvement in dysphagia scores were seen utilizing both outcome measures. Bazaz-Yoo scores were significantly better at both 6 weeks and 3 months in patients receiving local steroids compared with controls (P = 0.008 and P = 0.022, respectively). EAT-10 showed similar improvement of the steroid group versus control at 6 weeks and 3 months (P = 0.067 and P = 0.012, respectively). A trend toward decreased PSTS was found with locally delivered steroids on initial postoperative radiographs (P = 0.07), but was no longer evident at 6 weeks. NDI, although improved from pre-operative scores, failed to demonstrate significant differences between groups. No differences in length of stay or complications were observed between the groups. The use of retropharyngeal steroids resulted in decreased rates of dysphagia following multilevel ACDF. Locally delivered methylprednisone did not result in increased rates of short-term postoperative complications. 4.

Su1756 The Role of Syptom Index (SI) and Symptom Associated Probability (SAP) in the Surgical Treatment of Atypical GERD Symptoms

S A T A b st ra ct s performed or reduce postoperative dysphagia. Methods and Procedures: We performed a retrospective review of all patients undergoing PEH repair between January 2011 and July 2014. Demographic, preoperative, operative, and outcome data were collected prospectively and maintained in an IRB approved database. The primary outcome measures included the type of fundoplication performed and post-operative dysphagia scores. Secondary outcomes included disease specific quality of life scores (GERD-HRQL) and patient satisfaction. Data were analyzed using Stata 12 software (Stata Corporation, College Station, TX) with significance set at p < 0.05. Results: One hundred twenty-five patients underwent laparoscopic PEH repair during the study period. Forty-seven (37%) patients underwent preoperative manometry, and 78 (62%) did not. The mean age was 65.6±14.3 years and 87 (70%) were female with a mean body mass index (BMI) of 29.9±5.8 kg/m2. Patients who did not undergo manometry were older (67.9 vs. 61.7, p=0.02), but the groups did not differ in terms of BMI, gender, Proton Pump Inhibitor (PPI) use, baseline dysphagia score, baseline GERDHRQL score or type of fundoplication performed. At a median follow-up of 16 months (range 4 44 months), the median dysphagia score was 0 for both groups (p=0.41). Five (14%) patients in the no manometry group required endoscopic dilation compared to 3 (17%) in the manometry group (p=0.76). Median GERD-HRQL score improved significantly in both the no manometry and manometry groups (7 vs. 2, p<0.01 and 16 vs. 2, p<0.01 respectively). Overall 96% of patients were satisfied with their operation and 96% would choose to have surgery again given the benefit of hindsight. Conclusions: Laparoscopic paraesophageal hernia repair with complete fundoplication is a safe and effective treatment that improves disease specific quality of life with a low rate of post-operative dysphagia. The use of preoperative manometry does not impact the choice of fundoplication and its omission does not increase the rate of post-operative dysphagia or the need for postoperative dilation. Hence, the routine use of preoperative manometry for patients undergoing paraesophageal hernia repair is not necessary. Further study is needed to define which patients may benefit from selective preoperative manometry.

Surgical Techniques for Zenker's Diverticulum: A Comparative Analysis

To compare the different modalities for treatment of Zenker's diverticulum and the associated clinical outcomes. Case series with chart review. Tertiary care hospital. Between 1995 and 2011, 164 patients underwent surgery for Zenker's diverticulum (stapler, n = 69; laser, n = 68; open, n = 27). Patient sociodemographics, medical comorbidities, pre- and postoperative subjective dysphagia and regurgitation score, complications, length of stay, time to oral intake, and recurrence were reviewed for each surgical modality. No statistically significant difference in diverticulum prevalence was associated with age, gender, or treatment group. Mean length of hospital stay was not significantly different between the 3 groups (P = .14). A significant difference in time to oral intake was observed in the laser group compared with the other 2 groups (P = .012). No significant difference in recurrence (P = .21) or complication (P = .12) rates was identified between the 3 groups. Although all 3 groups demonstrated a significant decrease between preoperative and postoperative dysphagia and regurgitation scores, the degree of improvement was not significant when the 3 groups were compared. There is no single "best" approach to Zenker's diverticulum. The open, laser, and stapler methods are equally effective and have similar complication rates.

Carbon Dioxide Laser Versus Stapler‐Assisted Endoscopic Zenker's Diverticulotomy: A Systematic Review and Meta‐Analysis

To evaluate outcomes following endoscopic management of Zenker's diverticula using a carbon dioxide laser (CO2) or stapler-assisted technique, a systematic review and meta-analysis were conducted. Seven retrospective, uncontrolled case series including 391 procedures met selection criteria. No higher quality studies were identified. Outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status (2 studies), length of hospitalization (LOH, 2 studies), and fewer postoperative fevers and abnormal chest x-rays (1 study). Outcomes favoring the CO2 technique included greater improvement in postoperative dysphagia and regurgitation scores (2 studies) and a lower revision rate (1 study). Meta-analysis demonstrated increased nondental complications in the CO2 group (odds ratio 3.81; 95% confidence interval, 1.37-10.59; P = .01) but no difference in duration of NPO (P = .06), LOH (P = .07), overall complications (P = .08), dental complications (P = .57), major complications (P = .38), or revision surgery (P = .82). Implications are limited by the quality of studies identified.

Peroral endoscopic myotomy: A short-term comparison with the standard laparoscopic approach

We report our short-term experience with peroral endoscopic myotomy (POEM) and compare perioperative outcomes with laparoscopic Heller myotomy (LHM) for achalasia. Patients from an institutional review board-approved protocol underwent POEM and were followed prospectively. Comparisons were made, in a prospective esophageal database, with patients who underwent LHM over the same period. We studied 18 patients who underwent POEM and compared them to 21 who underwent LHM. Demographics, preoperative Eckardt scores, motility data, and prior intervention history were comparable. Operative time, myotomy length, and complication rates (1 perforation in each group) were equal. Postoperative pain was significantly different by visual analogue score (POEM 3.9 ± 0.6 versus LHM 5.7 ± 0.4, P = .02) and analgesic use (POEM 26.0 ± 13.7 versus LHM 90.0 ± 48.5 mg morphine, P = .02). Return to activities of daily living was significantly faster in the POEM group (2.2± 0.6 vs 6.4 ± 1.0 days, P = .03). Postoperative dysphagia and Eckardt scores were equally successful in both groups. POEM results in similar relief of dysphagia with less postoperative pain and quicker return to normal activities.

CO2 Laser versus Stapler‐Assisted Endoscopic Zenker's Diverticulotomy: A Systematic Review

Objectives: To evaluate outcomes following endoscopic Zenker’s diverticulotomy using a carbon dioxide (CO2) laser or stapler-assisted technique. Methods: Systematic review and meta-analysis of retrospective studies comparing CO2 laser and stapler-assisted endoscopic Zenker’s diverticulotomy were performed. PubMed, Scopus (Embase), and United States and United Kingdom clinical trial registries were searched. References were cross-checked. Results: No randomized controlled trials were identified. Six studies were included: 2 retrospective reviews of consecutive patients, 3 retrospective reviews with unknown consecutive status, and 1 case series totaling 379 procedures (219 laser, 160 stapler). Individual study outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status and hospital stay (4 studies), as well as fewer postoperative fevers and abnormal chest x-rays (1 study). Individual study outcomes favoring the laser technique included greater improvement in postoperative dysphagia and regurgitation scores and a lower revision rate (1 study). Random effects meta-analysis of 2 appropriate studies demonstrated a greater duration of NPO status (weighted mean difference (WMD): 1.14, 95% confidence interval [0.46-1.81]) and hospital stay (WMD: 2.84 [2.10-3.58]) for the laser technique. Mantel-Haenzel fixed effects meta-analysis of all studies suggested a greater rate of non-dental complications (odds ratio (OR): 2.32 [0.87-6.20]) and revision surgery (OR: 1.27 [0.68-2.36]) for the laser technique, but differences were not statistically significant. Conclusions: The stapler-assisted technique may shorten duration of NPO status and hospital stay, while decreasing complication and revision rates compared to the laser technique for endoscopic Zenker’s diverticulotomy; however, the best available evidence is Level 4.

Surgical effect of dysphagia in patients with bulbar myasthenia gravis

To retrospectively analyze the clinical data of 42 patients at our department with bulbar myasthenia gravis. They underwent video-assisted thoracoscopic extended thymectomy (VATET) from May 2003 to August 2010. Another 42 patients treated with medications alone were selected as controls. Compared with the control group(4.32±0.23), postoperative dysphagia scores improved significantly in patients undergoing VATET(9.21±0.41). And so did the dysphagia assessment classification (P<0.05). Thus VATET could effectively and definitely relieve dysphagia in patients with bulbar myasthenia gravis. Key words: Myasthenia gravis; Deglutition disorders

The preliminary evaluation of peroral endoscopic myotomy via posterior wall of esophagus for cardiaachalasia

Objective To explore the clinical efficacy and safety of peroral endoscopic myotomy （POEM） via posterior wall of esophagus for eardia achalasia （AC）. Methods The patients who were diagnosed with AC by esophageal barium meal and pull-through esophageal manometry were enrolled in this study. Pre-and postoperative dysphagia score and lower esophageal sphincter relaxation pressure （LESRP） were employed to evaluate short-term efficacy of POEM for achalasia. Operation related complications were observed to assess safety of POEM via posterior wall. Results A total of 28 patients were enrolled, of whom, 26 were treated successfully by POEM via posterior wall of esophagus, with a mean operation time of 68.8 min. The procedure was discontinued in other two patients due to severe submucosal scar at cardia. No fatal intraor postoperative complications occurred during POEM. The mean LESRP decreased by 16. 37 mm Hg after POEM. One month after POEM, the mean Eckardt dysphagia symptom score was reduced by 6.69, with a total efficiency rate of 96. 1% （25/26）. Reflux symptoms developed in 1 patient after POEM. Conclusion POEM via posterior esophageal wall could efficiently improve the clinical symptoms of dysphagia and decrease LESRP in achalasia patients, which is also safe with lower rate of postoperative complication. Key words: Cardia achalasia; Peroral endoscopic myotomy （POEM） ; Short term efficacy; Safety

Hypopharyngeal diverticulum after cervical spine surgery; The role of endoscopic management

PurposeThe purpose of this study was to assess the role of minimally invasive endoscopic diverticulostomy in patients who develop hypopharyngeal diverticulum after cervical spine surgery/fixation. Materials and methodsThis is a retrospective case series of seven patients who underwent endoscopic management of a symptomatic hypopharyngeal diverticulum. The patients were analyzed for diverticulum size, pre-operative and post-operative dysphagia and regurgitation scores, and complications. The overall success with the endoscopic approach was compared to the prior experience with traditional Zenker's diverticulum. ResultsOf the seven patients with hypopharyngeal diverticulum, four were successfully managed with minimally invasive endoscopic diverticulostomy (57%). These four patients all demonstrated clinically significant improvement in both dysphagia and regurgitation scores at a minimum of 6months postoperatively. Complications were minimal and consisted of one case with postoperative subcutaneous air. There were no cases of fistula, mediastinitis, or nerve injury. ConclusionsMinimally invasive endoscopic diverticulotomy can be successfully applied to patients who develop hypopharyngeal diverticulum after cervical spine surgery/fixation.

The effect of narrowed segment length on the degree of early postoperative dysphagia in laparoscopic Nissen fundoplication

Although laparoscopic Nissen fundoplication is the gold standard in the surgical treatment of gastroesophageal reflux disease, it may cause troublesome complications like dysphagia. In this study, we demonstrated the effect of narrowed segment length on early dysphagia in patients. Forty-one patients who underwent laparoscopic Nissen fundoplication by a single surgeon between January 2007 and November 2008 were reviewed. Dysphagia scores were assessed by a question in the Gastrointestinal Quality of Life Index questionnaire and recorded preoperatively and at 1 month and 6 months. Barium esophagogram was performed for all patients at 1 month. Narrowed segment length was measured on esophagogram. Patients were divided into two groups (Group 1, ≤30 mm; Group 2, >30 mm). Dysphagia scores preoperatively and at 1 month and 6 months were compared between the two groups. The two groups were homogeneous in age, gender, body mass index, and preoperative dysphagia score. We were unable to demonstrate any difference in preoperative and postoperative dysphagia scores between the two groups. In this study, we used subjective data for grade of dysphagia and esophagogram for wrap length instead of manometric data. In our opinion, there is no effect of narrowed segment length on the degree of early postoperative dysphagia in patients undergoing laparoscopic Nissen fundoplication.