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.


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 E The role of upper GI flexible endoscopy in management of large pharyngeal pouches
Sir, Pharyngeal pouch operations are commonly performed in ENT. However, some pouches can be large, with poor access making 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 endoscopy 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 oesophagus, 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- Generally, in endoscopic pouch operations, it is not difficult to find the oesophageal inlet, bar and pouch to perform a safe endoscopic division of the pouch. However, in certain cases it is impossible 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 paediatric upper GI endoscope.
The hypothesis was that we were able to locate the lumen, possibly because of the air insufflator in the non-stretch environment.  7 The open approach would also require a longer operating time and longer hospital stay along with increased risk of complications. Hence, the method used was identified 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.

CO N FLI C T O F I NTE R E S T
None to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were created or analysed in this study.