eMedicine Specialties > General Surgery > Abdomen

Zenker Diverticulum

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

Introduction

Zenker diverticulum is rare, occurs in elderly populations, and results in a classic presentation of symptoms. Zenker diverticulum has severe complications, including aspiration and pneumonia, and is managed by both endoscopic and surgical repair. This article discusses the presentation and management of this classic disease process. (See image below and Image 1.)

Illustrated barium swallow demonstrates the pouch...

Illustrated barium swallow demonstrates the pouch retaining contrast and its connection to the esophagus immediately inferior and posterior to the larynx.

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Illustrated barium swallow demonstrates the pouch...

Illustrated barium swallow demonstrates the pouch retaining contrast and its connection to the esophagus immediately inferior and posterior to the larynx.


History of the Procedure

While a diverticulum of the esophagus was first described in 1769 by Ludlow,1 Friedrich Albert von Zenker, professor of pathology at Erlangen University in Germany, described the pulsion diverticulum that bears his name in 1877. Zenker's series included 5 personal cases and 22 cases collected from the literature.2 In the beginning of the 20th century, Killian identified the origin of the diverticulum between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles.3 Wheeler first successfully resected this pharyngoesophageal diverticulum in 1886.4

Problem

The pathological process involves herniation of the esophageal mucosa posteriorly between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles. Therefore, by strict definition, a Zenker diverticulum is a false diverticulum. A Zenker diverticulum carries with it a high frequency of retention of food elements within its pouch. These food elements and secretions frequently lead to complaints of halitosis, regurgitation, aspiration, and dysphagia.5

Frequency

United States: The prevalence of Zenker diverticula in the United States ranges from 0.01-0.11% of the population.6 This process is more common in men and in the elderly, with a peak incidence in the seventh to ninth decades.

International: Internationally, the prevalence of Zenker diverticula is less than that reported in the United States, with the European incidence being far greater than that reported in the Middle East and the Far East.7

Etiology

The etiology is incompletely understood; and, since Zenker diverticulum is unique to humans, experimental modeling is not possible. It is hypothesized that patients with Zenker diverticulum have improperly timed relaxation of the cricopharyngeus muscle during swallowing. Over time, the increased pressure causes herniation of the esophageal mucosa posteriorly, between the inferior pharyngeal constrictor and the cricopharyngeus muscle. Whether these patients have an anatomical predisposition to diverticulum formation is unknown.

Pathophysiology

It is hypothesized that abnormal muscle activity in the cricopharyngeus results in a discoordination of the swallowing mechanism,8 which, when coupled with increased intraluminal pressure on the mucosa of the pharynx, results in the slow, progressive distention of the mucosa. As the weakest portion of this area is located posteriorly, this becomes the location of the pulsion diverticulum formation.

Esophageal manometry has been used to elucidate the pathophysiology of the upper esophagus, which is responsible for the diverticular formation. However, upper esophageal manometry is technically difficult to perform. Results are confounded by the asymmetry of the upper esophageal sphincter. Pressures can be very high, but they last for only a fraction of a second, resulting in difficulty obtaining equipment sensitive enough to demonstrate these pressures accurately.

To further confound the problem, the process of obtaining measurements stimulates the swallowing reflex, resulting in the catheter being displaced and the data lost. Because of these limitations, very few studies have been performed to describe the manometric aspects of Zenker diverticulum. Manometry is certainly not useful in routine patient evaluation.

The studies that have been performed show upper esophageal sphincter pressures that can be either normal or decreased. Some patients have abnormal premature relaxation and contractions of the upper esophageal sphincter, while others have pharyngeal contractions against a closed sphincter.8,9,10,11

Presentation

Patients with Zenker diverticulum typically present with upper esophageal dysphagia, regurgitation of undigested food, aspiration, noisy deglutition, halitosis, and/or complaints of changes in their voice. Mild-to-moderate weight loss is frequent. Aspiration and pneumonia are potentially serious complications. Although the diverticulum can reach sizes of 15 cm or more, it is rarely palpable. Squamous cell carcinoma has been found in the diverticulum in less than 0.4-1.5% of specimens.12,13 Coexistent hiatal hernia, esophageal spasm, achalasia, and esophagogastroduodenal ulceration are common.14

Indications

Indications for the repair of Zenker diverticulum are broad. The diverticulum can frequently be the etiology for aspiration and pneumonia. For this reason, Zenker diverticulum should be repaired in patients capable of tolerating the operative procedure.  

Nonoperative management may be undertaken in patients with small diverticula (<1 cm) or in those patients with medical comorbidities precluding surgery.15

Relevant Anatomy

Absolute contraindications to operative management of a Zenker diverticulum do not exist.

Relative contraindications to surgery are few. In an asymptomatic patient with a small diverticulum (<1 cm) discovered incidentally, the surgeon may elect to follow the patient for the development of symptoms or enlargement of the diverticulum. The only other relative contraindication to operative treatment is the inability of the patient to tolerate the procedure16 ; however, with the broad range of procedures available and the varying degrees of anesthesia required, surgery is rarely precluded in symptomatic patients.

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

  1. Ludlow A. A case of obstructed deglutition from a preternatural dilatation of and bag formed in the pharynx. In: Medical Observations and Enquiries by a Society of Physicians in London. 3:85. 2nd ed. 1769:101.

  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.

  8. Allen MS. Pharyngoesophageal diverticulum: technique of repair. Chest Surg Clin N Am. Aug 1995;5(3):449-58. [Medline].

  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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