Biomedical subjects
William J Richtsmeier
Publications and source records attributed to William J Richtsmeier.
Myotomy length determinants in endoscopic staple-assisted esophagodiverticulostomy for small Zenker's diverticula.
A small Zenker's pouch is a major challenge for endoscopic staple-assisted esophagodiverticulostomy (ESED). This study tested the stapler dimensions so as to identify limitations they impose on ESED. Combining ESED with additional endoscopic suturing could extend the incision and consequently the myotomy. Zenker's diverticulum residual pouch measurements were performed with a previously reported latex glove model and in patients undergoing surgery. Two stapler designs were compared by measuring the residual pouch length for both the stock and modified staplers. One other stapler model cannot be modified without damaging the mechanism. The Endostitch was used to place an additional suture at the apex of the staple line, allowing cutting between the staples while leaving a closed distal incision. All three staplers suitable for ESED leave a residual pouch of 1.5 cm when unmodified. The modified anvil staplers gave a smaller residual pouch by 4 to 5 mm. An additional septal reduction can be accomplished by suturing the area distal to the staple line and incising the party wall beyond the stapler cut. The absolute amount of residual pouch with an additional myotomy is 3 mm. The combined staple-suture technique has proven relatively safe thus far. To provide a maximally efficient myotomy in a patient with a short pouch, the surgeon needs to be aware of the stapler differences. Modifications of the staplers may decrease the depth of the residual pouch, but may carry an added liability. A minimum residual pouch can be achieved with a combination of stapler and suture techniques, but is more technically demanding than the original ESED description.
Endoscopic management of Zenker diverticulum: the staple-assisted approach.
Hypopharyngeal (Zenker) diverticulum is a physiologic obstruction of the esophageal entroitus due, at least in part, to reflux irritation. Endoscopic techniques have largely replaced the traditional treatment, comprising external excision and myotomy. In this article, the classic Dohlman technique is compared with the newer endoscopic staple-assisted esophagodiverticulostomy, which provides an endoscopic approach to Zenker diverticulum-associated dysphasia. This technique can be practiced with a simulator, requires little experience, has a good safety record, and has acceptable results.
Dissecting the "endoscopic neck".
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Postendoscopic sinus surgery debridement.
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Postendoscopic Zenker esophagodiverticulostomy leaks associated with a specific stapler cartridge.
OBJECTIVE: To determine the cause of postoperative leaks in 2 patients with Zenker diverticula treated with endoscopic staple-assisted esophagodiverticulostomy. DESIGN: Medical chart review and simulated surgery. SETTING: Teaching hospital. PATIENTS AND METHODS: Two case reports of postoperative leaks in patients treated with endoscopic staple-assisted esophagodiverticulostomy and experimental simulated surgery to investigate the possible cause of this complication. Use of a TR45B, 3.5-mm cartridge for an Endopath ETS Flex45 Endoscopic Articulation Linear Cutter stapler was associated with complications, whereas use of a TR45W, 2.5-mm cartridge in the same stapler was not. RESULTS: In a simulated surgery model, the 3.5-mm cartridge staple line leaked from the incision apex with pressure of less than 20 cm H(2)O, whereas the apex remained dry when using the 2.5-mm cartridge. When pressure was increased to 30 cm H(2)O, the staple line of the 2.5-mm cartridge had diffuse weeping of fluid but no focal, apical leak. CONCLUSIONS: Endoscopic staple-assisted esophagodiverticulostomy continues to be a relatively safe procedure; however, to provide maximum safety at the apex, the surgeon needs to be aware of stapler cartridge differences.
Simulated Zenker's endoscopic staple-assisted esophagodiverticulostomy (ESED) surgery.
PURPOSE: The process of learning new surgical procedures remains a challenge in otolaryngology-head and neck (OHN) surgery. Endoscopic surgery for Zenker's diverticulum presents a dilemma mandating simulated surgery because there is no animal model or cadaver situation resembling the pathologic condition. STUDY DESIGN: The author has developed an inexpensive model for ESED using a utility latex glove to provide a simulated pharynx with a Zenker's diverticula. METHODS: First, the thumb and index finger are isolated with a staple line and a rubber band is placed around the long and ring fingers to simulate the cricopharyngeus muscle. The long finger, which will act as the larynx, is cannulated with a noncompressible endotracheal tube. The ring finger then simulates the esophagus and the little finger, the Zenker's diverticular pouch. The glove and the endotracheal tube are positioned inside a 1-ft length of 3-in polyvinyl chloride (PVC) pipe. A bivalving laryngoscope is suspended to visualize the "postcricoid area" and the parting wall. The rubber band pulls the inferior aspect of the "esophagus" up against the "larynx," simulating the tight cricopharyngeal segment. Using video-telescopic control, the endoscopic stapler is used in the standard fashion as described for ESED. RESULTS: This model provides an opportunity for OHN surgeons to become familiar with endoscopic stapling and suturing devices, and experience the difficulty of using long telescopes, suspension laryngoscopes, and staplers in a confined area. CONCLUSION: Part of the experience of endoscopic surgery of the pharynx can be gained through an inexpensive simulation of a Zenker's diverticulum.