Throat

Pharyngeal pouch surgery

Pharyngeal pouch surgery is required when there is a hold-up of food in the throat after swallowing due to a pouch.  The aims of surgery are

• to divide the tight and incoordinate cricopharyngeal muscle 
• to eliminate the pouch
• to restore normal swallowing 

Pharyngeal pouch surgery is done under a general anaesthetic so that the patient is asleep and unaware during the operation. Generally the operation commences by gently inserting a telescope through the mouth in order to examine the throat in general, then to inspect the pouch and to ensure that the lining is healthy i.e. no cancers. When the operation is done externally which is Dr McIvor's preferred method, the pouch is then packed with gauze to make it more obvious and a small tube is placed in the oesophagus to stretch and better define the tight cricopharyngeal muscle.

An incision is made in the lower neck on the left side as pouches tend to veer to the left. A gentle dissection is performed down to the pouch which is readily identified behind the larynx and trachea. Having gauze packing within the pouch facilitates this. The pouch is then dissected to display the underlying tight muscle which is cut without making a hole in the internal throat lining. The gauze is removed via the mouth by the anaestetist and the pouch is either inverted (usually) or excised (when large). A small drain is then inserted and the wound closed with running sutures.

The photo to the left demonstrates the small incision for this surgery. It heals as a fine and usually barely visible scar.

The procedure takes about 1 hour but can be longer depending on its complexity.

The hospital stay is usually 1 day and planned time off work should be 7-10 days.

 

Pharyngeal pouch

A pharyngeal pouch is a pocket that balloons out the back of the pharynx or throat. It collects food and the patient becomes aware of a residue of food in the throat after swallowing. As it enlarges over months/years it collects more of each swallow. This produces an unpleasant sensation of having something stuck in the throat. Often food is brought up again hours after eating it. With time more food is trapped than is swallowed and the patient can begin to lose weight. Eating out can be embarrassing. Frequently coughing occurs after eating but this generally does not deliver the food out of the pouch. In extreme cases food trapped in the pouch can spill over into the windpipe (trachea) and cause chest infections.

Pharyngeal pouches usually present in people over 50 but occasionally can occur earlier. They generally develop because of an incoordination of the swallowing mechanism.

normal swallow

Usually when we swallow food, there is an automatic process that begins at the back of the tongue and progressively travels down the throat (pharynx) and gullet (oesophagus) into the stomach. This process is a sequential wave of relaxation followed by contraction creating a travelling "squeeze" that pushes the food before it down the food passage. Relaxation of the food passage muscles before the "squeeze" wave accommodates the food bolus which essentially travels down within the travelling wave of relaxed muscles.

Why do pouches develop?

A pouch develops because there is an incoordination between the squeeze wave and the preceeding wave of relaxation. The squeeze wave ends up forcing the food bolus into an area that has not relaxed in anticipation of the food. This area is at the site of the upper oesophageal sphincter otherwise known as the cricopharyngeus muscle. Why the cricopharyngeus does not relax in time for the food bolus is not always clear but it is often associated with gastro-esophageal reflux whereby acid from the stomach comes up into the throat causing a reflex constriction of the muscle. Also, as part of the aging process there can be a generalised incoordination right down the swallowing passage but most evident in the throat.

When the food bolus comes up against the constricted cricopharyngeus there is a bulging of the pharyngeal wall at its weakest point which is the back wall just above the cricopharyngeus. This area is known as "Killian's dehiscence" after the man who described it and is relatively weaker than other areas purley because it doesn't have as many muscle layers. So the back wall gets stretched with each swallow until there is a pocket or pouch which hangs down behind the oesophagus and which collects food easily (as it doesn't have a good muscle layer unlike the main channel). The build up of food after each swallow is uncomfortable and increasingly embarrasing.

Diagnosis

A pharyngeal pouch is diagnosed from the history and a barium or videoswallow. The classic story is of food getting trapped in the throat after swallowing and of undigested food being brought up hours later. The diagnosis is clinched by a test whereby liquid barium is swallowed while video XRays are taken demonstrating the pouch ballooning out the back of the pharynx.

Pharyngeal pouch surgery

Surgery is advised when a pharyngeal pouch is diagnosed as it will increasingly become the preferred food channel and cause increasing difficulty in swallowing

When and where will the operation be done?

What must I do in the weeks before surgery? ( insurance, hospital, family, work)

What do I do on the day of surgery? and what shall I bring to hospital?

What will happen when I go to theatre?

What will happen when I get back to the ward?

Is it a safe operation and what are the side effects?

Dr McIvor has done a large number of pharyngeal pouch operations. After healing, patients are expected to swallow normally. The vast majority are able to swallow liquid on the evening of surgery and to commence a soft diet the following morning. However, as with all operations, there are some risks which Dr McIvor minimises as much as possible.The main risk (<5%) is the possibility of a small breech in the throat lining which could allow saliva, food or drink to soil the neck tissues and cause an infection or abscess. If a breech is suspected, feeding is delayed until the lining has healed. This may require a short period of antibiotics and feeding through a nasogastric tube (tube through the nose down to the stomach) to allow healing to occur. If an abscess forms then the wound will need to re-opened in the operating room under general anaesthesia, washed out, and drained. Complete healing will ensue.

A lesser risk is to the nerve (recurrent laryngeal nerve) to the larynx (voice box) on that side (<5%)This is almost certain to be temporary. It causes a weak breathy voice but as stated above it is expected to recover completely over a few weeks.

Occasionally patients become more aware of acid reflux symptoms after the procedure and require antireflux medication such as losec. This is because they already have reflux before the procedure which contributes to the tight throat cricopharyngeal muscle and pouch formation. The tight cricopharyngeus reduces the amount of acid coming up into the throat but in doing so restricts swallowing. Once the muscle is cut during the operation, in these patients the acid may be perceived coming into the throat. Typically these patients respond to medication such as losec (omeprazole) but a small number need the attention of a gastroenterologist to solve the reflux problem.

Rarely (<1%) there may be a collection of blood in the wound which may require return to theatre and drainage.

Will it affect my voice ?

Dr McIvor has done a large number of pharyngeal pouch operations.  However, as with all operations, there are some risks which Dr McIvor minimises as much as possible.

Occasionally there is bruising or stretching of the nerve (recurrent laryngeal nerve) to the larynx (voice box) on that side (

Will I have neck stiffness or pain?

You will feel some discomfort in the lower neck and throat but you will be given some medication to help ease this. Pain relief may be given in different ways, such as injections, liquid medicine or tablets. Most patients say the discomfort is not as bad as they expected, and after the first day are up and walking around.

Following discharge Dr McIvor prescribes paracetamol and an anti-inflammatory for 5 days which suffices for any discomfort.  After a few weeks you should be back to a good standard of neck and throat function

Will I have a scar?

The incision is either in a skin crease or a zig-zag vertical line which heals to leave a fine scar.

What are the costs for pharyngeal pouch surgery?

There are generally 3 costs for any procedure:  surgeon’s fee, anesthetist’s fee, hospital fee. These are given separately by the surgeon, the anaesthetist, and the hospital and are to be paid separately. 

Dr McIvor’s secretary will give or post to you an estimate for all three of these costs.  It is important that you discuss this with your insurance company prior to coming into hospital. 

The hospital account is to be paid at the time of discharge from the hospital. The anaesthetic and surgeon fees should be settled on receipt of the account through the post or at the post-operative appointment.

 

What will I look like after surgery and what will I be able to do?

1. You will have a scar in the lower left side of your neck . This will be covered by a small white dressing so that it is not visible. 
2. You will have a small drain from your wound to collect wound fluid which naturally occurs following your surgery. The drains are small plastic tubes which are inserted into the neck at the end of your operation. The long length of tubing outside the neck is attached to a plastic collection bottle into which the fluid drains. Wound drains help to speed up wound healing and reduce infection.
3. The drain is not painful can be carried around with you. It will usually be removed by a nurse the day after your operation when the drainage is minimal.   Drain removal is not painful.
4. You will feel some discomfort in your throat mainly when swallowing but you will be given some medication to help ease any pain and discomfort. Pain relief may be given in different ways such as injections, liquid medicine or tablets. Most patients say it was not as bad as they expected.
5. For your own safety it is important that you do not get out of bed on your own immediately following your operation as you may be drowsy and weak. At first when you need to use the toilet a member of staff will need to assist you with a commode or bedpan. You will soon be able to walk to the bathroom yourself.
6. You will have a nurse call bell within easy reach so that you can seek help from the ward staff as needed.
7. Following your operation you may not feel very sociable so it is wise to restrict visitors.

 

Will I have a sore neck?

When you wake from the anesthetic you will find that the skin of your neck is quite numb as the anesthetist inserts a lot of local anesthetic around the surgical area once you are asleep and prior to the operation.  This not only provides good pain relief but reduces the amount of intravenous pain relief he needs to give during the operation.  This helps to minimize the side effects of strong pain relief such as nausea and constipation.

You will be given medication to take home to relieve any discomfort.  Please take it as described on the packet and take care not to exceed the recommended dose.

Your wound area may appear swollen and hard to touch, with some numbness, which will gradually resolve as healing takes place.

When will I be able to eat and drink?

If Dr McIvor is happy with that the lining of the throat is intact then he may allow you to drink on the evening of surgery and then to commence a soft diet the following morning. This is the situation in the vast majority of cases. He will re-evaluate you in the morning and if he is happy then he will allow you to continue on the soft diet until he sees you in his clinic at one week.

Rarely(

What care do I need to take regarding my neck wound?

Keep your neck wound clean and dry.  There will be a paper tape over the wound to protect the wound.

After your skin tapes are removed at your one week appointment and the scar is healing well you can rub a small amount of unscented moisturising cream on the scar so it is less dry as it heals.  Vitamin A, Vitamin E, Bio-oil , or Aloe Vera are effective. Take care not to knock your wound and remember to keep the wound dry if it becomes wet after bathing or showering by patting it dry with a clean towel.

The pressure of rubbing the cream in will also help to soften the scar.

If the wound area becomes increasingly painful, red or swollen or you notice any discharge then please seek medical advice from Dr McIvor or your GP.

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What rest do I need and when should I return to work?

You will need to take it easy while your neck wound is healing. This means avoiding strenuous activity and heavy lifting for a couple of weeks. The wound area will gradually feel less stiff and you will soon be able to enjoy your normal activities.

You will probably need to take 7 to 10 days off work (or sometimes longer) depending on your occupation and the nature of your work.   Dr McIvor can issue you with a note for this period and then you should see your GP if more time is required.

What about my medications and tablets?

Please continue to take the medication you have been prescribed and ensure that you have a good supply. If you are unsure about any of the tablets you need to take, please check this with a nurse before you go home. Repeat prescriptions can be obtained from your GP.

 

What follow-up will there be?

Following your discharge you will need to be reviewed in the clinic to check how your wound is settling down and also your swallowing. You will usually receive the date and time for this appointment through the post or by phone from Dr McIvor’s secretary. Please contact Dr McIvor’s secretary (09 4887349)if you do not receive one shortly following discharge.

 

 

 

Endoscopy

The throat needs to be thoroughly examined and this usually requires inspection through a flexible scope in the clinic

Biopsy 
any non-healing ulcer or lump that is visible through the mouth e.g. on the tonsil, can be biopsied in the clinic under local anaesthetic.  Those further down the throat require general anaesthesia and rigid endoscopy.

CT scan 
of the throat and neck to determine the extent of tumour involvement and also whether the neck nodes are enlarged.  Often the chest will also be scanned.