Question

What is the treatment of choice for an old man who has reflux of foul smelling food?

• A. Cricopharyngeal myotomy
• B. Sac removal
• C. Laser evaporation
• D. Myotomy with sac excision

Hint:

Foul smelling food regurgitation in an elderly man points to a pharyngeal pouch, treated by myotomy with sac excision.

Answer 1

The Correct Option is D

Step 1: Recognise the clinical picture.
An elderly man with regurgitation of undigested, foul smelling food, sometimes hours after eating, along with a gurgling noise in the neck, bad breath, and occasional aspiration, is a classic description of a pharyngeal pouch, also called Zenker's diverticulum.

Step 2: Recall why the pouch forms.
The pouch is a pulsion diverticulum that bulges out through a weak spot in the pharyngeal wall, called Killian's dehiscence, between the oblique fibres of the inferior constrictor and the transverse fibres of the cricopharyngeus. The underlying problem is poor relaxation or spasm of the cricopharyngeus muscle, which raises pressure in the pharynx during swallowing and pushes mucosa out through the weak area.

Step 3: Understand why myotomy alone is not enough.
A cricopharyngeal myotomy alone, option A, treats the underlying high pressure problem and can help small pouches, but once a pouch has already formed and become symptomatic, as here with foul smelling reflux, the sac itself keeps trapping food and causing symptoms unless it is removed or fixed.

Step 4: Understand why sac removal alone is not enough.
Removing the sac alone, option B, without dividing the tight cricopharyngeus muscle leaves the high pressure problem in place, raising the risk of recurrence or of a leak at the repair site.

Step 5: Consider laser evaporation.
Endoscopic laser or stapling techniques, option C, are used in some centers, mainly for smaller pouches or frail patients where open surgery carries more risk, but they are not the standard treatment of choice answer in this classic teaching format.

Step 6: State the correct combined approach.
The accepted treatment of choice combines both steps, a cricopharyngeal myotomy to release the abnormal pressure that caused the pouch, plus excision of the sac to remove the diverticulum, done together in the same operation.

Step 7: Final answer.
\[ \boxed{\text{Myotomy with sac excision}} \]