J. R. Coll. Surg. Edinb., 43, February 1998, 31—32

Stapler failure in pharyngeal diverticulectomy: a suggested modification in surgical technique

H. KUBBA AND S. S. MUSHEERHUSSAIN
Department of Otolaryngology and Head and Neck Surgery, Freeman Hospital, Newcastle upon Tyne, England

The use of a mechanical stapling device during excision of a pharyngeal pouch is now becoming more common, and has many adyantages including less contamination of the wound by pharyngeal contents and a shorter operating time. The manufacturers recommend dividing the neck of the pouch flush with the stapler before removing the stapler. We report a case where the stapler failed, leaving a large defect in the pharyngeal wall necessitating a hand sutured closure. We recommend a change in practice: an artery forcep is applied across the pouch distal to the stapler, the stapler is then removed and the staple line inspected before dividing the pouch.

Keywords: pharyngeal pouch/diverticulum, stapler, surgical technique

Pharyngeal pouch (Zenker’s diverticulum) is a pulsion diverticulum which originates from Killian’s dehiscence between the cricopharyngeus and thyropharyngeus muscles. The incidence rises with age and it is twice as common in men. The cardinal symptoms being dysphagia and regurgitation.1

Options for treatment include diverticulopexy with cricopharyngeal myotomy2 and endoscopic diverticulotomy3 which is most easily accomplished with a stapling device.4 For the majority of patients, however, excision of the pouch through an incision in the neck is the treatment of choice, usually combined with a cricopharyngeal myotomy.5 The use of a mechanical stapling device to close the neck of the diverticulum was suggested more than 25 years ago5 to protect the wound from contamination by pharyngeal contents, and also to shorten the operating time for patients who are often old and frail. Mechanical staplers are now commonly used in diverticulectomy, and a number of authors have reported good results.6-12

Staplers are widely used in many surgical specialities and are reliable and accurate. True technical failures of the instrument have been encountered only rarely, and problems with staplers are usually attributed to improper use of the instrument.13 There have been reports, however, of devices failing to staple the pulmonary artery completely during thoracoscopic pulmonary lobectomy, leading to life-threatening haemorrhage.14,15 Also reported are cases where an instrument stapled but failed to cut during gastro-intestinal anastomosis.16,17

We report here a case where the mechanical failure of the stapler occurred during excision of a pharyngeal pouch, leading to a change of method in use of the instrument.

CASE REPORT

The patient, a 66-year-old gentleman, first presented to our Otolaryngology department in April 1996 with a 6-month history of dysphagia for solids and heartburn associated with regurgitation of food. Flexible endoscopy had been arranged prior to referral, and this showed a large pharyngeal pouch at 20 cm. It had not been possible to pass the endoscope distal to this. The pouch was confirmed by a barium swallow, which also showed a tight cricopharyngeus. In August 1996 he underwent excision of the pouch with cricopharyngeal myotomy.

At operation an Ethicon Proximate TL3O linear stapler was placed across the neck of the diverticulum and fired in the usual manner. The pouch was transacted flush with the stapler according to the manufacturers’ instructions (Operation of the Proximate Reloadable Linear Stapler, Ethicon Ltd.) and the stapler removed. It then became apparent that the stapler had not functioned, leaving a large defect in the pharyngeal wall with no staples visible. The defect was closed in layers with absorbable sutures, and the patient made an uneventful recovery. He was swallowing normally when discharged 8 days post-operatively, and also when reviewed in clinic a month later. At this time a barium swallow was performed and this showed no evidence of metallic staples in the patient. A Shatzki ring was noted in the lower oesophagus. There were also no staples in the excised pouch on histological examination.

The stapler was returned to the manufacturer (Ethicon Quality Control, Cincinnati, USA) who reported the incident to the Food and Drug Administration. The stapler was tested and found to function normally. There was no comment in the report on the presence or absence of staples in the cartridge.

DISCUSSION

Staplers have been widely used in many surgical situations and found to be safe and reliable. Any mechanical device, however, will have a failure rate. Ethicon test fire every Proximate TL3O stapler after manufacture, and then insert a new cartridge of staples prior to packaging. It is possible that an instrument could be despatched empty if the cartridge were accidentally not replaced. It is not possible to check that the device has stapled correctly prior to its removal.

In the situation described here, we followed the manufacturers’ recommended practice of transacting the pouch flush with the stapler prior to its removal, a practice which has been followed by other authors.11 This runs the risk of leaving a large defect should the stapler fail to operate. Closure with sutures is difficult and time consuming, and the potential exists for contamination of the wound with pharyngeal contents, leading to an increased risk of infection and fistula formation.

We have changed our practice and now apply a straight artery forceps across the neck for the pouch, distal to the stapler, and then remove the stapler to inspect the staple line. The neck of the pouch may then be easily divided, using the artery forceps as a guide. We advocate that others adopt this safer method in pouch excision surgery.

REFERENCES

  1. Maran AGD, Wilson JA, Al Muhanna AH. Pharyngeal diverticula. Clin Otolaryngol 1986; 11: 219—25.
  2. Konowirz, PM and Butler HF. Diverticulopexy and cricopharyngeal myotomy: treatment for the high risk patient with a pharyngoesophageal (Zenker’s) diverticulum. Otolaryngol Head Neck Surg 1989; 100:146—53.
  3. Mosher HP. Webs and pouches of the oesophagus: their diagnosis and treatment. Surg Gynaecol Obstet 1917; 25: 175—87.
  4. Bates GJ and Koay CB. Endoscopic stapling diverticulectomy of pharyngeal pouch. Ann Roy Coll Surg Eng 1996; 78(2): 151—3.
  5. Hoehn JG and Payne WS Resection of pharyngoesophageal diverticulum using stapling device. Mayo Clinic Proc 1969; 44(10): 738—41.
  6. Vered IY, Rosen G, Resnick S. Excision of Zenker’s diverticulum using autosuture technique Larygoscope 1982 92{9): 1081—2.
  7. George CD and Pollock D, Excision of pharyngoesophageal diverticula using surgical stapling device. BJSurg 1984; 71: 422.
  8. Pagliero KM. Use of autosuture during oesophageal and pharyngeal diverticulectomy Clin Otolaryngol11985 10(5): 263—4.
  9. Talmi VP, Finkelstein Y, Sadov RY, Zohar Y. Use of a linear stapler in excision of Zenker’s diverticulum. Head Neck 1989; 11(2): 150—2.
  10. Westmore GA. Staple gun in the surgery of hypopharyngeal diverticula. J Laryngol Otol 1990; 104(7):553-6.
  11. Fatsis ME, Hatzinis AC, Arstypas GD. Automatic stapling devices in the surgical treatment of esophageal diverticula. Scandi Thoracic Cardiovas Surg 1991; 25(3): 195—7.
  12. Chaplin JM and Stewart IA. Use of surgical stapling device in excision of pharyngeal divertieulum. Aust NZJ Surg 1994; 64(7): 501—2.
  13. Bard V, Cohen Z, Ross T. An unusual intra-operative complication of stapled colorectal anastomosis: report of a case and review of the literature. Canadian J Surg 1993; 36(2): 165—8.
  14. Craig SR and Walker WS. Potential complications of vascular stapling in thoracoscopic pulmonary resection. Ann Thoracic Surg 1995; 59(3): 736—7.
  15. Yim AP and Ho JK. Video assisted thoracoscopic lobectomy: a word of caution. Aust NZJ Surg 1995; 65(6): 438—41.
  16. Blamey SL and Lee PW. A comparison of circular stapling devices in colorectal anastomosis. Bri Surg 1982; 69(1): 19—22.
  17. Fabri B and Donnelly RJ. Oesophagogastrectomy using the end to end anastomosing stapler. Thorax 1982; 37(4): 296-9.

Paper accepted 7May 1997

Correspondence: Dr S.S. Musheer Hussain, Associate Professor & Chief ENT. Head & Neck Surgery, The Aga Khan University Hospital, Stadium Road, P.O. Box 3500 Karachi 74800, Pakistan.

© 1998 The Royal College of Surgeons of Edinburgh, J. R. Coll. Surg. Edinb., 43, February, 31-32.