Endoscopic stapling of pharyngeal pouch

# Guidance
Current evidence on the safety and efficacy of endoscopic stapling of pharyngeal pouch appears adequate to support the use of the procedure, provided that normal arrangements are in place for consent, audit and clinical governance.# The procedure

# Indications
Pharyngeal pouch, which is also known as Zenker's diverticulum, occurs when a piece of the pharyngeal lining herniates through the muscles of the pharyngeal wall. It occurs mainly in older people, with an estimated overall incidence of about 1 per 100,000 people per year.
Pharyngeal pouch may cause difficulty in swallowing or a cough, and sometimes causes respiratory problems because of aspiration of the pouch contents into the lungs.
The standard treatment for pharyngeal pouch is open surgery to the neck. Endoscopic techniques are less invasive than open surgery. The standard endoscopic technique, known as Dohlman's procedure, uses diathermy or lasers to divide the wall between the pouch and the oesophagus. Endoscopic stapling of pharyngeal pouch is an alternative to the standard endoscopic technique.

# Outline of the procedure
Endoscopic stapling of pharyngeal pouch involves stapling the bar of tissue that divides the pouch from the oesophagus. A specially designed endoscope is used to gain access to the bar and the openings of both the pouch and the oesophagus. The procedure is performed under general anaesthetic.

# Efficacy
The evidence suggested that endoscopic stapling allows a more rapid recovery, and requires a shorter stay in hospital (12 days) than open surgery. Patients returned to normal swallowing promptly. For more details refer to the sources of evidence section.
The Specialist Advisors considered endoscopic stapling to be an established procedure, now widely practiced in specialist centres by specifically trained otorhinolaryngologists. They considered it effective in terms of reducing operating time and the duration of hospital stay.
The Specialist Advisors noted that the problem can recur but that the procedure can be repeated if this happens.

# Safety
Few complications were reported in the studies reviewed. Mild bleeding, perforation of the pharynx and a need for nasogastric feeding were reported, but these were uncommon. For more details refer to the sources of evidence section.
The Specialist Advisors concurred that perforation and leakage from the pharynx were no more common with endoscopic stapling than with alternative procedures.

# Other comments
Training and post-operative care are of great importance. The 1996/97 'Annual Report of the National Confidential Enquiry into Peri-operative Deaths' recommended that sub-specialisation within otorhinolaryngology departments should occur for this procedure.
Andrew Dillon Chief Executive November 2003# Further information

# Sources of evidence
The evidence considered by the Interventional Procedures Advisory Committee is described in the following document.
'Interventional procedure overview of endoscopic stapling of pharyngeal pouch', November 2002.

# Information for patients
NICE has produced information on this procedure for patients and carers ('Understanding NICE guidance'). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Changes since publication
January 2012: minor maintenance.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2003. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
Contact NICE
National Institute for Health and Clinical ExcellenceLevel 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT
www.nice.org.uk
    nice@nice.org.uk