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Esophageal Diverticula Treatment & Management

  • Author: Jack Bragg, DO; Chief Editor: Julian Katz, MD  more...
 
Updated: Jun 18, 2014
 

Medical Care

Asymptomatic and minimally symptomatic esophageal body diverticula do not require treatment.

In many patients with mid esophageal and epiphrenic diverticula, dysphagia is related to underlying dysmotility; thus, treatment should be directed to the motility disorder when feasible. For instance, achalasia can be treated with pneumatic dilation, botulinum toxin injection into the lower esophageal sphincter, or surgical Heller esophagomyotomy.

Treatment of esophageal intramural pseudodiverticulosis is directed toward underlying strictures or dysmotility.

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Surgical Care

Treatment of Zenker diverticulum traditionally has been surgical, although the specific operation used still is controversial. Surgical options include diverticulectomy with cricopharyngeal myotomy, diverticular suspension (diverticulopexy) with cricopharyngeal myotomy, and cricopharyngeal myotomy alone.

Diverticulectomy

Consider diverticulectomy when esophageal body diverticula are believed to be the cause of aspiration. An abdominal laparoscopic approach may be feasible for some patients with epiphrenic diverticula. Case reports of endoscopic treatment of giant midesophageal diverticula have been reported. However, patients who are being considered for diverticulectomy should first undergo careful study with barium swallow, flexible endoscopy, and esophageal manometry. Treatment directed at an underlying esophageal motility disorder, such as achalasia, cannot be ignored.

Diverticulectomy usually is not performed by itself, because it does not correct the defect in cricopharyngeal function that usually contributes to the formation of a Zenker diverticulum. While the transcervical approach has been used traditionally, the transoral route using a rigid esophagoscope also may be used.

Good results have been obtained by performing a diverticulotomy using a flexible endoscope and needle-knife papillotome to cut the common wall between the diverticulum and the oropharynx as well as the cricopharyngeus while the patient is consciously sedated. Data suggest that this technique offers good results with a relatively high success rate, but it should be performed in large centers with surgeons who are experienced with this technique. In some variations of this technique, the diverticulum is stapled.[12]

Other procedures

Other novel techniques are being developed. Flexible endoscopic diverticulotomy approaches have been explored using various techniques, including argon plasma coagulation, monopolar coagulation forceps, and needle-knife incision.[9, 10, 13, 14] These techniques typically use a cap or hood attached to the endoscope. The goal of these techniques is the division of the septum between the diverticulum and the esophagus, thus performing a cricopharyngeal myotomy.

Increased efforts to a laparoscopic approach to repair both epiphrenic diverticula and Zenker diverticula have been explored. The literature supports open surgery and a laparoscopic approach as appropriate methods of repair.[15] The laparoscopic technique uses stapler closure, and multiple case reports cite wound leakage from stapler failure as a complication. With complication rates as high as 20%, a skilled surgeon with experience in this procedure is beneficial. Benefits of the laparoscopic approach include decreased morbidity because of no thoracotomy wounds and chest tubes and a less invasive approach.

A study of 229 endoscopic diverticulotomies (in 189 patients), conducted by Kos et al, indicated that better results can be achieved using a combination of CO2 laser and Acuspot in the endoscopic procedure than by employing endoscopic diverticulotomy with electrocautery or with a carbon dioxide (CO2) laser alone.[9] The investigators reported the following postsurgical results:

  • Endoscopy with CO 2 laser: Dysphagia was absent following 78.4% of procedures; repeat surgery was required following 19.6% of procedures
  • Endoscopy with electrocautery: Dysphagia was absent bsent following 72% of procedures; repeat surgery was required following 24.3% of procedures
  • Endoscopy with CO 2 laser and Acuspot: Dysphagia was absent following 84.6% of procedures; repeat surgery was required following 13% of procedures

Several reports in the literature lately describe surgical treatment of esophageal diverticula. One recent publication analyzed a single surgeon’s experience with endoscopic CO2 laser and stapler repair of Zenker diverticulum by comparing dysphagia and regurgitation outcomes in 148 patients. This report concluded that endoscopic CO2 laser and staple methods are effective in treating Zenker diverticulum. The laser can have greater efficacy and result in lower recurrence rates.[16]

Most of the reports involve treatment of Zenker diverticula and discuss open versus endoscopic methods.[17, 18, 19, 20] None was a controlled study. They were series reports or retrospective reviews. There is no consensus of which method is the best.

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Consultations

Consult a gastroenterologist for patients who have symptoms associated with esophageal diverticula or who have esophageal motility disorders, such as achalasia.

Consult a general or thoracic surgeon (with experience) after gastroenterological evaluation for patients who have significant symptoms associated with Zenker diverticulum, achalasia, or diverticula.

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Contributor Information and Disclosures
Author

Jack Bragg, DO Associate Professor, Department of Clinical Medicine, University of Missouri School of Medicine

Jack Bragg, DO is a member of the following medical societies: American College of Osteopathic Internists, American Osteopathic Association

Disclosure: Nothing to disclose.

Coauthor(s)

John B Marshall, MD Professor, Department of Internal Medicine, Division of Gastroenterology, University of Missouri School of Medicine

John B Marshall, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF Associate Professor of Clinical Medicine, Albert Einstein College of Medicine of Yeshiva University; Associate Professor of Clinical Medicine, Hofstra Medical School

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, New York Society for Gastrointestinal Endoscopy, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Simmy Bank, MD Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Christopher (Kit) Bartalos, DO Fellow, Department of Gastroenterology, University of Missouri at Columbia

Disclosure: Nothing to disclose.

Rodney A Perez, MD Medical Director, The Endoscopy Center, Asheville Gastroenterology Associates; Consulting Staff, Department of Gastroenterology, Mission St Joseph's Hospital

Rodney A Perez, MD is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

References
  1. Herbella FA, Patti MG. Modern pathophysiology and treatment of esophageal diverticula. Langenbecks Arch Surg. 2012 Jan. 397(1):29-35. [Medline].

  2. D'Journo XB, Ferraro P, Martin J, Chen LQ, Duranceau A. Lower oesophageal sphincter dysfunction is part of the functional abnormality in epiphrenic diverticulum. Br J Surg. 2009 Aug. 96(8):892-900. [Medline].

  3. Ekberg O, Nylander G. Lateral diverticula from the pharyngo-esophageal junction area. Radiology. 1983 Jan. 146(1):117-22. [Medline].

  4. Kim HK, Lee JI, Jang HW, Bae SY, Lee JH, Kim YS, et al. Characteristics of Killian-Jamieson diverticula mimicking a thyroid nodule. Head Neck. 2012 Apr. 34(4):599-603. [Medline].

  5. Pang JC, Chong S, Na HI, Kim YS, Park SJ, Kwon GY. Killian-Jamieson diverticulum mimicking a suspicious thyroid nodule: sonographic diagnosis. J Clin Ultrasound. 2009 Nov-Dec. 37(9):528-30. [Medline].

  6. Lixin J, Bing H, Zhigang W, Binghui Z. Sonographic diagnosis features of Zenker diverticulum. Eur J Radiol. 2011 Nov. 80(2):e13-9. [Medline].

  7. Vicentine FP, Herbella FA, Silva LC, Patti MG. High resolution manometry findings in patients with esophageal epiphrenic diverticula. Am Surg. 2011 Dec. 77(12):1661-4. [Medline].

  8. Christiaens P, De Roock W, Van Olmen A, et al. Treatment of Zenker's diverticulum through a flexible endoscope with a transparent oblique-end hood attached to the tip and a monopolar forceps. Endoscopy. 2007 Feb. 39(2):137-40. [Medline].

  9. Kos MP, David EF, Mahieu HF. Endoscopic carbon dioxide laser Zenker's diverticulotomy revisited. Ann Otol Rhinol Laryngol. 2009 Jul. 118(7):512-8. [Medline].

  10. Helmstaedter V, Engel A, Huttenbrink KB, Guntinas-Lichius O. Carbon dioxide laser endoscopic diverticulotomy for Zenker's diverticulum: results and complications in a consecutive series of 40 patients. ORL J Otorhinolaryngol Relat Spec. 2009. 71(1):40-4. [Medline].

  11. Visosky AM, Parke RB, Donovan DT. Endoscopic management of Zenker's diverticulum: factors predictive of success or failure. Ann Otol Rhinol Laryngol. 2008 Jul. 117(7):531-7. [Medline].

  12. Wasserzug O, Zikk D, Raziel A, Cavel O, Fleece D, Szold A. Endoscopically stapled diverticulostomy for Zenker's diverticulum: results of a multidisciplinary team approach. Surg Endosc. 2009 Aug 18. [Medline].

  13. Rabenstein T, May A, Michel J, et al. Argon plasma coagulation for flexible endoscopic Zenker's diverticulotomy. Endoscopy. 2007 Feb. 39(2):141-5. [Medline].

  14. Vogelsang A, Preiss C, Neuhaus H, et al. Endotherapy of Zenker's diverticulum using the needle-knife technique: long-term follow-up. Endoscopy. 2007 Feb. 39(2):131-6. [Medline].

  15. Koch M, Mantsopoulos K, Velegrakis S, Iro H, Zenk J. Endoscopic laser-assisted diverticulotomy versus open surgical approach in the treatment of Zenker's diverticulum. Laryngoscope. 2011 Oct. 121(10):2090-4. [Medline].

  16. Adam SI, Paskhover B, Sasaki CT. Laser versus stapler: outcomes in endoscopic repair of Zenker diverticulum. Laryngoscope. 2012 Sep. 122(9):1961-6. [Medline].

  17. Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker's diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital. 2013 Aug. 33(4):219-29. [Medline]. [Full Text].

  18. Huberty V, El Bacha S, Blero D, Le Moine O, Hassid S, Devière J. Endoscopic treatment for Zenker's diverticulum: long-term results (with video). Gastrointest Endosc. 2013 May. 77(5):701-7. [Medline].

  19. Undavia S, Anand SM, Jacobson AS. Killian-Jamieson diverticulum: a case for open transcervical excision. Laryngoscope. 2013 Feb. 123(2):414-7. [Medline].

  20. Seth R, Rajasekaran K, Lee WT, Lorenz RR, Wood BG, Kominsky A, et al. Patient reported outcomes in endoscopic and open transcervical treatment for Zenker's diverticulum. Laryngoscope. 2014 Jan. 124(1):119-25. [Medline].

  21. American Society for Gastrointestinal Endoscopy. Technology Assessment Status Evaluation: botulinum toxin therapy in gastrointestinal endoscopy. November, 1996. ASGE. American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 1998 Jun. 47(6):569-72. [Medline].

  22. Bak YT, Kim HJ, Jo NY, et al. Endoscopic "clip and cut" diverticulotomy for a giant midesophageal diverticulum. Gastrointest Endosc. 2003 May. 57(6):777-9. [Medline].

  23. Bassotti G, Annese V. Review article: pharmacological options in achalasia. Aliment Pharmacol Ther. 1999 Nov. 13(11):1391-6. [Medline].

  24. Bowdler DA, Stell PM. Carcinoma arising in posterior pharyngeal pulsion diverticulum (Zenker's diverticulum). Br J Surg. 1987 Jul. 74(7):561-3. [Medline].

  25. Boyce HW Jr, Boyce G. Esophagus: anatomy and structural anomalies. Yamada T, ed. Textbook of Gastroenterology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003. 1148-65.

  26. Bremner CG, DeMeester TR. Endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc. 1999 Jan. 49(1):126-8. [Medline].

  27. Cassivi SD, Deschamps C, Nichols FC 3rd, et al. Diverticula of the esophagus. Surg Clin North Am. 2005 Jun. 85(3):495-503, ix. [Medline].

  28. Cook IJ, Gabb M, Panagopoulos V, et al. Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology. 1992 Oct. 103(4):1229-35. [Medline].

  29. Del Genio A, Rossetti G, Maffetton V, et al. Laparoscopic approach in the treatment of epiphrenic diverticula: long-term results. Surg Endosc. 2004 May. 18(5):741-5. [Medline].

  30. Fernando HC, Luketich JD, Samphire J, et al. Minimally invasive operation for esophageal diverticula. Ann Thorac Surg. 2005 Dec. 80(6):2076-80. [Medline].

  31. Fraiji E Jr, Bloomston M, Carey L, et al. Laparoscopic management of symptomatic achalasia associated with epiphrenic diverticulum. Surg Endosc. 2003 Oct. 17(10):1600-3. [Medline].

  32. Hashiba K, de Paula AL, da Silva JG, et al. Endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc. 1999 Jan. 49(1):93-7. [Medline].

  33. Heinen FL, Vallone P, Elmo G. Esophageal diverticulum in an infant with Down's syndrome and type III esophageal atresia. J Pediatr Surg. 2003 Apr. 38(4):E9. [Medline].

  34. Herman TE, McAlister WH. Esophageal diverticula in childhood associated with strictures from unsuspected foreign bodies of the esophagus. Pediatr Radiol. 1991. 21(6):410-2. [Medline].

  35. Herter B, Dittler HJ, Wuttge-Hannig A, et al. Intramural pseudodiverticulosis of the esophagus: a case series. Endoscopy. 1997 Feb. 29(2):109-13. [Medline].

  36. Huang BS, Unni KK, Payne WS. Long-term survival following diverticulectomy for cancer in pharyngoesophageal (Zenker's) diverticulum. Ann Thorac Surg. 1984 Sep. 38(3):207-10. [Medline].

  37. Jeyarajah R, Harford W. Diverticula of the hypopharynx, esophagus, stomach, jejunum, and ileum. Feldman M, Friedman LS, Sleisenger MH, eds. Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. Philadelphia, Pa: Saunders; 2002. 359-68.

  38. Kimura H, Konishi K, Tsukioka Y, et al. Superficial esophageal carcinoma arising from the diverticulum of the esophagus. Endoscopy. 1997 Nov. 29(9):S53-4. [Medline].

  39. Knapp AB, Ladetsky L. Endoscopic retrieval of a small bowel enteroscopy capsule lodged in a Zenker's diverticulum. Clin Gastroenterol Hepatol. 2005 May. 3(5):xxxiv. [Medline].

  40. Kochhar R, Mehta SK, Nagi B, et al. Corrosive acid-induced esophageal intramural pseudodiverticulosis. A study of 14 patients. J Clin Gastroenterol. 1991 Aug. 13(4):371-5. [Medline].

  41. Long JD, Orlando RC. Esophageal submucosal glands: structure and function. Am J Gastroenterol. 1999 Oct. 94(10):2818-24. [Medline].

  42. Mahajan RJ, Marshall JB. Severe dysphagia, dysmotility, and unusual saccular dilation (diverticulum) of the esophagus following excision of an asymptomatic congenital cyst. Am J Gastroenterol. 1996 Jun. 91(6):1254-8. [Medline].

  43. Mahajan SK, Warshauer DM, Bozymski EM. Esophageal intramural pseudo-diverticulosis: endoscopic and radiologic correlation. Gastrointest Endosc. 1993 Jul-Aug. 39(4):565-7. [Medline].

  44. Medeiros LJ, Doos WG, Balogh K. Esophageal intramural pseudodiverticulosis: a report of two cases with analysis of similar, less extensive changes in "normal" autopsy esophagi. Hum Pathol. 1988 Aug. 19(8):928-31. [Medline].

  45. Motoyama S, Maruyama K, Okuyama M, et al. Laparoscopic long esophagomyotomy with Dor's fundoplication using a transhiatal approach for an epiphrenic esophageal diverticulum. Surg Today. 2006. 36(8):758-60. [Medline].

  46. Sam AD Jr, Chaer RA, Cintron J, et al. Upper gastrointestinal bleeding caused by a "hypophrenic" diverticulum of the distal esophagus. Am Surg. 2005 Apr. 71(4):333-5. [Medline].

  47. Tedesco P, Fisichella PM, Way LW, et al. Cause and treatment of epiphrenic diverticula. Am J Surg. 2005 Dec. 190(6):891-4. [Medline].

  48. Tobin RW. Esophageal rings, webs, and diverticula. J Clin Gastroenterol. 1998 Dec. 27(4):285-95. [Medline].

  49. Toyohara T, Kaneko T, Araki H, et al. Giant epiphrenic diverticulum in a boy with Ehlers-Danlos syndrome. Pediatr Radiol. 1989. 19(6-7):437. [Medline].

 
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Barium esophagram, anteroposterior view, demonstrating a bilobed Zenker diverticulum.
Zenker diverticulum, lateral view.
Esophagram demonstrating a dilated tortuous esophagus and a large midesophageal diverticulum.
Barium esophagram demonstrating an epiphrenic diverticulum.
Multiple, small, flask-shaped outpouchings characteristic of esophageal intramural pseudodiverticulosis.
Esophageal intramural pseudodiverticulosis involving the entire length of the esophagus.
 
 
 
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