HYPOPHARYNGEAL (PHARYNGOESOPHAGEAL) AZENKER=S@ PSUEDO PULSION DIVERTICULUM FIRST DESCRIBED BY LUDLOW 1769, CLARIFIED BY ZENKER 1874 JUST SUP TO TRANSVERSE FIBERS OF THE CRICOPHARYNGEUS (CP)—IN INF ASPECT OF KILLIAN=S DEHISSANCE (DEHISSANCE IN INF CONSTRICTORS)—DESCRIBED BY BELL OFTEN COINCIDE WITH REFLUX—-HIATAL HERNIA—LEADS TO CP SPASM AND PULSION DIVERTICULUM USUALLY LEFT OF MIDLINE ON POST HYPOPHARYNGEAL WALL –LESS FASCIAL SUPPORT AND MORE ROOM TO THE CAROTID SHEATH A PULSION DIVERTICULUM A PSEUDO DIVERTICULUM—-ONLY THE MUCOSA VS A TRUE (ALL LAYERS) DIVERTICULUM —TRACTIONS ARE TRUE ( VS LATERAL HYPOPHARYNGEAL DIVERTICULUM [CAN BE B], EPIPHRENIC PULSION DIVERTICULUM USUALLY RIGHT OF MIDLINE JUST OVER LES, MIDTHORACIC ATRACTION@ DIVERTICULUM IS USUALLY LEFT OF MIDLINE AND ASSOC. WITH HILAR ADENOPATHY[BRONCHOGENIC CA, SARCOID, TB]) 60% PTS > 60 HAVE SOME DEGREE OF IT GRADUAL ONSET OF ATRANSFER@ DYSPHAGIA—-MAY BE YEARS GLOBUS SENSATION AT SUPRASTERNAL NOTCH REGURGITATION AFTER MEALS—RUMINATION ASPIRATION—POST PRANDIAL COUGH, PNEUMONIA HALITOSIS Dx: MOD BARIUM SWALLOW, FLEX FIBEROPTIC NASOPHARYNGOSCOPY WITH REVERSE MUELLER MANUEVER Rx: OBSERVATION, DIETARY MODIFICATION, EXTERNAL APPROACH: EXCISION, PEXY, CP MYOTOMY (HIGH RISK TO RLN), ENDOSCOPIC CP MYOTOMY ADOHLMAN PROCEDURE@ WITH KTP LASER OR ENDOSCOPIC STAPLING WITH US SURGICAL ENDOSCOPIC IGA STAPLER—MAY HAVE TO DEAL WITH APEX OF WOUND WITH SUTURES COMPLICATIONS INCLUDE—RLN PARALYSIS, DENTAL, PERF—MEDIASTINITIS DOHLMAN

PROCEDURE—GUSTA DOHLMAN (1960)
 HAVE PRE-OP CXR AND EKG KEFZOL OCOR? LASER WRAP TUBE—-EYEWEAR GET KTP LASER UP—–CONTINUOUS MODE AT 6 WATTS START WITH DL—-WEERDA OR DIVERTICULOSCOPE STEROIDS AND ABX MAY MASK AN EARLY MEDIASTINITIS—–PROBABLY AVOID HAVE KTP OR CO2 LASER UP CONSIDER ENDO GIA 30 –3.5 STAPLER—-WORKS WELL, CAN MODIFY HAVE PT IN CLINIC OPEN MOUTH AND EXTEND THEIR NECK PUT IN NG TUBE INTRA-OP—MAY DO INITIALLY OR CONFIRM WITH ESOPHAGOSCOPE—CONSIDER LUMEN FINDERS KEEP NPO OVER NIGHT DON’T FORGET TEETH GUARD–MOST STURDY VARIETY PUT IN DIVERTICULOSCOPE, MOST DIFFICULT PART OF THE CASE, LIFT UP CRICOID, FIND ESOPHAGUS WITH LUMEN FINDER GET POST OP CXR (NEED NOT BE ACUTE)—LOOKING FOR PNEUMOMEDIASTINIM ECT..STAPLE OR LASER OR BOTH, ALSO FIND USEFUL BIPOLAR LAP CAUTERY. INJECT 30 UNITS BOTOX WITH SMALL BUTTERFLY ON A MICROLARYNGEAL FORCEPS FOR ADDITIONAL BENEFIT WATCH POST OP VS CAREFULLY (TEMP, HR, RR)

PLEURODYNIA, ECT….CONSIDER GASTROGRAFFIN SWALLOW.
CPT 43130 OR UNLISTED 43499