eMedicine Specialties > General Surgery > Abdomen

Zenker Diverticulum: Follow-up

Author: Todd A Nickloes, DO, Assistant Professor of Surgery, Division of Trauma/Critical Care, University of Tennessee Medical Center
Coauthor(s): LaMar O Mack, MD, Staff Physician, Department of Surgery, University of Tennessee Medical Center; Brian Reed, MD, Staff Physician, Department of Surgery, University of Tennessee Medical Center; Michael J Sutherland, MD, Consulting Trauma Surgeon, Department of Surgery, Santa Clara Valley Medical Center; Chief of Thoracic Surgery, Department of Surgery, David Grant USAF Medical Center, Travis Air Force Base; Brian D Peyton, MD, Chief of Vascular and General Surgery, Associate Program Director, Department of General Surgery, Keesler Medical Center; Assistant Professor, Department of Surgery, Uniformed Services University
Contributor Information and Disclosures

Updated: Oct 29, 2009

Outcome and Prognosis

In 1984, Huang and Payne reported a series of 888 patients undergoing diverticulectomy.28  They reported morbidity of 6% and mortality of 1.2%.  

In 1998, Peracchia and associates reported a series of 95 patients undergoing endoscopically stapled division of the diverticular wall.29 These patients experienced morbidity of less than 3% and mortality of 0%. Recurrence rates ranged from 3-10%, depending on the method of repair.29 Recurrence was higher in the endoscopic group.

These patients, despite their typical presentation in advanced age and multiple concomitant medical problems, did very well. Successful, uncomplicated outcomes were reported in 93-100%30 of patients, depending on the study and surgical techniques. The key to effective surgical management of Zenker diverticulum is early recognition, division of the cricopharyngeus muscle, and removal of the diverticulum as a reservoir. If these issues are addressed, any of the listed procedures can be effective.

Future and Controversies

Use of a diverticuloscope and an endoscopic stapler to divide the wall between the diverticulum and the esophagus is now the criterion standard management of Zenker’s diverticula.14,31,32 Although it was first described in 1917, subsequent advances in endoscopic stapling made this technique feasible. Endoscopic staplers accomplish the surgical requirements of eliminating the reservoir and dividing the cricopharyngeus muscle. This particular technique appears to be superior to CO2 laser with regard to efficacy and safety.33

Average operative time is 25 minutes versus 60-90 minutes for open procedures. Additionally, no neck incision or drain is required. Early reports from Europe in a series of 60 patients show no morbidity or mortality, with results equivalent to those obtained from open procedures. These patients have shorter hospital stays (24-48 h) and operative times, and they avoid the morbidity of an open incision.26 Larger series and comparative studies will bear out the long-term efficacy of this procedure, but it appears to be an excellent alternative to the well-established surgical procedures, with an equivocal safety and efficacy profile.24 In addition, it has also been proven to have greater patient satisfaction and allow for safe re-operation, if necessary.34,35

Additional methods of resection include CO2 and argon plasma coagulation. These methods have a recurrence rate of approximately 15% and require a mean of 3 repeated sessions for ablation.36

A study by Kos et al of 229 endoscopic diverticulotomies (in 189 patients) indicated that using a combination of CO2 laser and Acuspot in the endoscopic procedure provides better results than does employing endoscopic diverticultomy with electrocautery or with a carbon dioxide (CO2) laser alone.37 The investigators reported the following postsurgical results:

  • Endoscopy with CO2 laser
    • Dysphagia - Absent following 78.4% of procedures
    • Repeat surgery - Required following 19.6% of procedures
  • Endoscopy with electrocautery
    • Dysphagia - Absent following 72% of procedures
    • Repeat surgery - Required following 24.3% of procedures
  • Endoscopy with CO2 laser and Acuspot
    • Dysphagia - Absent following 84.6% of procedures
    • Repeat surgery - Required following 13% of procedures

 


More on Zenker Diverticulum

Overview: Zenker Diverticulum
Workup: Zenker Diverticulum
Treatment: Zenker Diverticulum
Follow-up: Zenker Diverticulum
Multimedia: Zenker Diverticulum
References
Further Reading
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References

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  2. Zenker FA, von Ziemssen H. Krankenheiten des oesopahgus. In: von Ziemssen H, ed. Heandbuch der Speciellen Pathologie and Therapie. Vol 7 (Suppl.). Leipzig: FCW Vogel; 1877:1-87.

  3. Killian G. Ueber den Mund der Speiseröhre. Ztschr f Ohrenh Wiesb. 1908;55:1–41.

  4. Wheeler WJ. Pharyngocele and dilation of pharynx. Dublin J Med Sci. 1886;82:349–357.

  5. Crescenzo DG, Trastek VF, Allen MS, et al. Zenker's diverticulum in the elderly: is operation justified?. Ann Thorac Surg. Aug 1998;66(2):347-50. [Medline].

  6. Watemberg S, Landau O, Avrahami R. Zenker's diverticulum: reappraisal. Am J Gastroenterol. Aug 1996;91(8):1494-8. [Medline].

  7. van Overbeek JJ, Groote AD. Zenker's diverticulum. Curr Opin Otolaryngol Head Neck Surg. 1994;2:55-8.

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  9. Fulp SR, Castell DO. Manometric aspects of Zenker's diverticulum. Hepatogastroenterology. Apr 1992;39(2):123-6. [Medline].

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

  11. Cook IJ, Blumbergs P, Cash K, et al. Structural abnormalities of the cricopharyngeus muscle in patients with pharyngeal (Zenker's) diverticulum. J Gastroenterol Hepatol. Nov-Dec 1992;7(6):556-62. [Medline].

  12. Bradley PJ, Kochaar A, Quraishi MS. Pharyngeal pouch carcinoma: real or imaginary risks?. Ann Otol Rhinol Laryngol. Nov 1999;108(11 Pt 1):1027-32. [Medline].

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

  14. Sen P, Kumar G, Bhattacharyya AK. Pharyngeal pouch: associations and complications. Eur Arch Otorhinolaryngol. May 2006;263(5):463-8. [Medline].

  15. Nemechek AJ, Amedee RG. Zenker's diverticula. J La State Med Soc. Feb 1996;148(2):49-53. [Medline].

  16. Achem SR, Devault KR. Dysphagia in aging. J Clin Gastroenterol. May-Jun 2005;39(5):357-71. [Medline].

  17. van Overbeek JJ. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol. Mar 1994;103(3):178-85. [Medline].

  18. Ferreira LE, Simmons DT, Baron TH. Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus. 2008;21(1):1-8. [Medline].

  19. Keck T, Rozsasi A, Grün PM. Surgical treatment of hypopharyngeal diverticulum (Zenker's diverticulum). Eur Arch Otorhinolaryngol. Aug 28 2009;[Medline].

  20. Sharp DB, Newman JR, Magnuson JS. Endoscopic management of Zenker's diverticulum: stapler assisted versus Harmonic Ace. Laryngoscope. Oct 2009;119(10):1906-12. [Medline].

  21. Roth JA, Sigston E, Vallance N. Endoscopic stapling of pharyngeal pouch: a 10-year review of single versus multiple staple rows. Otolaryngol Head Neck Surg. Feb 2009;140(2):245-9. [Medline].

  22. Fama AF, Moore EJ, Kasperbauer JL. Harmonic scalpel in the treatment of Zenker's diverticulum. Laryngoscope. Jul 2009;119(7):1265-9. [Medline].

  23. Mulder CJ. Zapping Zenker's diverticulum: gastroscopic treatment. Can J Gastroenterol. Jun 1999;13(5):405-7. [Medline].

  24. Bonavina L, Bona D, Abraham M, et al. Long-term results of endosurgical and open surgical approach for Zenker diverticulum. World J Gastroenterol. May 14 2007;13(18):2586-9. [Medline].

  25. Ruiz-Tovar J, Perez de Oteyza J, Collado MV, et al. 20 years experience in the management of Zenker's diverticulum in a third-level hospital. Rev Esp Enferm Dig. Jun 2006;98(6):429-35. [Medline].

  26. Narne S, Cutrone C, Bonavina L, et al. Endoscopic diverticulotomy for the treatment of Zenker's diverticulum: results in 102 patients with staple-assisted endoscopy. Ann Otol Rhinol Laryngol. Aug 1999;108(8):810-5. [Medline].

  27. Payne WS. The treatment of pharyngoesophageal diverticulum: the simple and complex. Hepatogastroenterology. Apr 1992;39(2):109-14. [Medline].

  28. Huang B, Payne WS, Cameron AJ. Surgical management for recurrent pharyngoesophageal (Zenker's) diverticulum. Ann Thorac Surg. Mar 1984;37(3):189-91. [Medline].

  29. Peracchia A, Bonavina L, Narne S, et al. Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients. Arch Surg. Jul 1998;133(7):695-700. [Medline].

  30. Aly A, Devitt PG, Jamieson GG. Evolution of surgical treatment for pharyngeal pouch. Br J Surg. Jun 2004;91(6):657-64. [Medline].

  31. Ochando Cerdan F, Moreno Gonzalez E, Hernandez Garcia D, et al. Diagnostic and treatment of Zenker's diverticulum: review of our series pharyngo-esophageal diverticula. Hepatogastroenterology. Mar-Apr 1998;45(20):447-50. [Medline].

  32. Ummels C, Konsten J, Janzing H, et al. Classical operative therapy for Zenker's diverticulum. Acta Chir Belg. Sep-Oct 2007;107(5):557-9. [Medline].

  33. Costamagna G, Iacopini F, Tringali A, et al. Flexible endoscopic Zenker's diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy. Feb 2007;39(2):146-52. [Medline].

  34. Miller FR, Bartley J, Otto RA. The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling. Laryngoscope. Sep 2006;116(9):1608-11. [Medline].

  35. Palmer AD, Herrington HC, Rad IC, et al. Dysphagia after endoscopic repair of Zenker's diverticulum. Laryngoscope. Apr 2007;117(4):617-22. [Medline].

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

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

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Further Reading

Clinical guidelines:
ACR Appropriateness Criteria® dysphagia. American College of Radiology - Medical Specialty Society. 1998 (revised 2007). 6 pages. NGC:006986

Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. American College of Chest Physicians - Medical Specialty Society. 2006 Jan. 15 pages. NGC:004829

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Keywords

Zenker diverticulum, Zenker's diverticulum, diverticulum, diverticula, cricopharyngeus, cricopharyngeal, cricopharyngeus muscle, diverticulectomy, cricopharyngeal myotomy, Zenker diverticula, Zenker's diverticula, hypopharyngeal diverticulum, pulsion diverticulum

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Contributor Information and Disclosures

Author

Todd A Nickloes, DO, Assistant Professor of Surgery, Division of Trauma/Critical Care, University of Tennessee Medical Center
Todd A Nickloes, DO is a member of the following medical societies: American College of Osteopathic Surgeons, American Medical Association, American Osteopathic Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

LaMar O Mack, MD, Staff Physician, Department of Surgery, University of Tennessee Medical Center
LaMar O Mack, MD is a member of the following medical societies: American Urological Association, National Medical Association, and Student National Medical Association
Disclosure: Nothing to disclose.

Brian Reed, MD, Staff Physician, Department of Surgery, University of Tennessee Medical Center
Brian Reed, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Michael J Sutherland, MD, Consulting Trauma Surgeon, Department of Surgery, Santa Clara Valley Medical Center; Chief of Thoracic Surgery, Department of Surgery, David Grant USAF Medical Center, Travis Air Force Base
Michael J Sutherland, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Brian D Peyton, MD, Chief of Vascular and General Surgery, Associate Program Director, Department of General Surgery, Keesler Medical Center; Assistant Professor, Department of Surgery, Uniformed Services University
Brian D Peyton, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association of Military Surgeons of the US, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Alex Jacocks, MD, Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Amy L Friedman, MD, Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse
Amy L Friedman, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, Association of Women Surgeons, International College of Surgeons, International Liver Transplantation Society, New York Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, and Transplantation Society
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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