Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients.

Much discussion in the literature concerning Zenker's diverticulum is related to etiology. Various theories have been propounded, but no single conclusion is generally accepted. We believe that an anatomic predisposition plays a prominent role. Considerations for this conclusion will be discussed. In the otorhinolaryngology departments of University Hospital and Martini Hospital (Groningen, the Netherlands) 545 patients with a diverticulum were treated endoscopically since 1964. Initially we used the procedure described by Dohlman. With the increase in the number of patients, the technique and instruments used have improved. In 1981 we started to apply a microendoscopic procedure with a special double-lipped scope and the carbon dioxide laser. The rate of complications was very low, and 91% of the patients are highly satisfied. In view of our results, we feel justified in maintaining that endoscopic treatment is a relatively safe and effective method.

Endoscopic treatment of the hypopharyngeal (Zenker's) diverticulum.

Over the years the techniques for endoscopic treatment of Zenker's diverticulum have been improved. Initially, in 1964, we used the electrocoagulation technique as described by Dohlman, but currently we prefer to sever the tissue bridge between the diverticulum and esophagus with the CO2 laser under microscopic control. The results of endoscopic treatment in 507 patients with a diverticulum are discussed. It is concluded that endoscopic treatment can readily be performed with good results, especially in the case of elderly patients in a poor general condition.

Upper esophageal sphincterotomy in dysphagic patients with and without a diverticulum.

Symptoms of high dysphagia are sometimes too readily interpreted as symptoms of globus. When patients have unmistakable difficulties during meals, focused diagnostic procedures are indicated. The upper esophageal sphincter (UES) is the key structure at the transition from hypopharynx to esophagus. In many disorders presenting with dysphagia, the UES mechanism remains intact and can cause the symptoms. Especially in patients with a hypopharyngeal (Zenker's) diverticulum and in patients with a hypopharyngeal paralysis due to a neurologic disorder, sphincterotomy may be indicated. In the microendoscopic treatment of Zenker's diverticulum, a transmucosal sphincterotomy is created and at the same time a more ample overflow from diverticulum to esophagus is effected. In view of our results in 507 patients we are justified in maintaining that this procedure can be regarded as a safe and effective treatment. In patients with neurologic dysphagia, sphincterotomy by an external approach can ensure adequate passage of food from the hypopharynx to the esophagus, resulting in marked improvement of the dysphagic symptoms. Our technique and results of external approach sphincterotomy are described here.

Pathogenesis and endoscopic treatment of the hypopharyngeal (Zenker's) diverticulum.

The authors review the literature about the pathogenesis -still unknown- of Zenker's diverticulum as well as their experience of endoscopic treatment of this disease. From 1964 till 1988, they have treated endoscopically 507 patients, 323 by electrocoagulation, 184 by CO2-laser. The endoscopic procedure is described, consisting in precise division of the tissue bridge between the oesophagus and the diverticulum by micro-endoscopic surgery under general anesthesia. In recent years, the CO2-laser was found preferable, since it may cause less tissue necrosis and consequently less fibrous scar tissue. The results were very favourable, with more than 99% of the patients satisfied. Although many patients were old and in poor condition, only one patient died two days after operation because of cardiac failure. Complications such as bleeding, emphysema, mediastinitis and stenosis were seen in 5% of the patients, but in most cases there complications were mild and conservative therapy was sufficient. Stenosis occurred in 8 patients treated by electrocoagulation and in none of the patients treated by laser. Microendoscopic surgery is a safe and efficient method of therapy for the hypopharyngeal diverticulum.

Laser surgery in lingual tonsil hyperplasia.

Modern techniques have reduced the long existing reluctance to perform lingual tonsillectomy. The results of treatment of hyperplasia of the lingual tonsil with the carbon dioxide laser in 32 patients are presented. After exposure with a special endoscope the lingual tonsil can be vaporized or excised under microscopic control with promising results, far superior to the results obtained with other surgical techniques. Since the success rate of the surgery depends on the diagnostic criteria for applying this therapy, a careful selection of patients is essential.

Benign endobronchial tumours treated by neodymium-YAG laser.

We present two patients with benign endobronchial tumours: polypi and a chondroma. Both were treated by Neodymium-YAG laser photoresection. There have been no signs of recurrence in the four years since treatment. Endobronchial resection by Neodymium-YAG laser is an effective treatment for benign endobronchial tumours.

Endoscopic treatment of a whistling middle-lobe bronchus.

A 32-year old man presented with dyspnea and a loud inspiratory wheeze. Examination revealed a nonfibrous, fissure-shaped entrance to the middle-lobe bronchus. The cause of this stenosis was unclear. Endoscopic treatment consisted of splitting the spur and resulted in complete disappearance of the wheeze.

Three years' anaesthetic experience with the Groningen Nd YAG laser coagulation technique.

The use of the Neodymium YAG Laser technique in the palliative treatment of tracheo-bronchial tumors in 47 patients is described and the merits of the coagulation and anaesthetic techniques are discussed.

Simultaneous manometry and electromyography in the pharyngoesophageal segment.

Whether the occlusion between hypopharynx and esophagus is established by anatomical relations and tissue elasticity or by a functional resting tone of the muscle fibers is not quite clear. This study describes simultaneous electromyography (EMG) and electromanometry in the pharyngoesophageal segment to solve this problem and investigate the complex mechanism of deglutition. To register the EMG from the hypopharyngeal constrictor muscle and the upper esophageal sphincter (UES), two copper wire electrode pairs with hooked bare ends were used. These electrodes were introduced into the muscles through a rigid esophagoscope. It is demonstrated that at rest muscle activity is present in the UES. This activity disappears during the relaxation period. Simultaneous manometry and EMG is a valuable supplement to diagnostic procedures in dysphagia patients.

Microendoscopic surgery of the hypopharyngeal pouch with the CO2 laser.

In 1964 we started to treat hypopharyngeal (Zenker's) diverticula endoscopically, using the procedure described by Dohlman. With the increase in the number of patients (350), the technique and the instruments used have improved. This paper describes the technique, which involves exposure of the tissue bridge between esophagus and diverticulum with the aid of a specially designed scope and subsequent severance with the CO2 laser of this bridge under microscopic control. The use of an operating microscope and the laser is a great improvement in endoscopic treatment of hypopharyngeal diverticula.

CO2 laser in malignant lesions of the larynx.

The CO2 laser is being used in several otolaryngology departments around the world. Clinical experience has shown that it is a unique surgical tool in the management of benign and in some malignant lesions of the larynx. Until now, little has been written about its indications in patients with carcinomas of the larynx. The purpose of this paper is to present our experience with 58 patients with various premalignant and malignant lesions of the larynx in which the CO2 laser was employed as a curative or palliative debulking procedure.

Microendoscopic surgery of the hypopharyngeal diverticulum using electrocoagulation or carbon dioxide laser.

In 1964 we started to treat hypopharyngeal (Zenker's) diverticular endoscopically, using the procedure described by Dohlman. With the increase in the number of patients (274 patients up until 1982), the technique and the instruments used have improved. This paper describes the technique we have used since 1981, which involves exposure of the tissue bridge between esophagus and diverticulum with the aid of a specially designed scope and subsequent severance of this bridge under microscopic control. In 12 cases the bridge was severed by electrocoagulation, while the CO2 laser was used for this purpose in another 12 cases. Both techniques have given good results. Essential advantages or disadvantages of either of these methods could not be elicited. We regard the use of an operating microscope as a great improvement.

Continuous intravenous anesthesia with etomidate for carbon dioxide laser surgery of the larynx.

Twenty-five adult patients undergoing carbon dioxide laser surgery for benign and malignant disease of the larynx were given continuous infusion of etomidate at 60 micrograms . kg-1 . min-1 for induction of anesthesia. Maintenance anesthesia was continued using one of three infusion rates: 20 micrograms . kg-1 . min-1 (n = 5), 30 micrograms . kg-1 . min-1 (n = 10), and 40 micrograms . kg-1 . min-1 (n = 10) of etomidate in air-oxygen mixture. Muscular relaxation was achieved by continuous infusion of succinylcholine, and fentanyl was used for analgesia. Continuous etomidate infusion for induction of anesthesia resulted in a significant decrease in the incidence of pain along the injection site to 8% and involuntary muscular movements to 12% compared with 35% and 44%, respectively, in a group of 25 adult patients undergoing endoscopic procedure who received intravenously a single volus injection of etomidate (0.3 mg .g kg-1). However, a prolonged recovery time was observed after 30 minutes of continuous etomidate infusion.

A simple endoscopic intubation technique in esophageal obstruction.

Endoscopic intubation was effected in 42 cases of malignant esophageal stenosis during the period 1979-1981. The stenosis was dilated with the aid of thermoplastic probes passed through a rigid esophagoscope of sufficient length, whereupon a tube was introduced under endoscopic control and left in situ in the malignant stricture. This "rigid" technique is suitable for process confined to the esophagus. Introduction of the tube requires adequate endoscopic skill and is not devoid of risk. Perforation, the gravest risk, occurred in two cases. Proximal tube migration was observed in five patients.

Renal involvement in Wegener's granulomatosis. Report of three unusual cases.

Three patients with rapidly progressive glomerulonephritis due to Wegener's granulomatosis are described. In one patient, acute renal failure was initially the sole manifestation of the disease. Treatment of the two other patients with prednisone and cyclophosphamide resulted in a remarkable recovery of renal function even after a prolonged period of hemodialysis. These cases illustrate that early and sustained treatment with prednisone and cyclophosphamide can restore an adequate renal function in patients with anuria or severe glomerulonephritis due to Wegener's disease.