Guidance
3 The procedure
3 The procedure
3.1 Endoscopic carbon dioxide laser cricopharyngeal myotomy for relief of oropharyngeal dysphagia divides the cricopharyngeal muscle via an endoscope using a carbon dioxide laser, as an alternative to open surgery.
3.2 The procedure is done with the patient in the supine position, usually under general anaesthesia. A rigid endoscope is introduced through the mouth, to visualise the cricopharyngeal muscle, which forms the upper oesophageal sphincter. The posterior wall of the junction between the pharynx and oesophagus, at the level of cricopharyngeal muscle, is visualised. A carbon dioxide laser (set in continuous wave mode), connected to a microscope and targeted with a micromanipulator, is used to transect the mucosa and then the deeper muscle layers, in the midline, down to the prevertebral fascia. If there is a tight stenosis, due to contracture or fibrosis of the cricopharyngeal muscle, then dilatation may be needed before myotomy to allow adequate access for the laser. Some authors recommend sealing the surgical site with fibrin glue or closure of the mucosal edges with sutures. After the procedure the patient does not eat or drink for at least 24 hours. Antibiotics are given and postoperative swallow studies are performed on day 1. If no leaks are observed, patients are allowed to drink clear fluids initially, progressing to unrestricted liquids or soft diet for a few days, and then a normal diet.
3.3 This procedure has been used for patients with oropharyngeal dysphagia with a number of underlying causes. This guidance addresses the use of this procedure for patients with cricopharyngeal muscle dysfunction and not for those with Zenker's diverticulum.