Zenker Diverticulum Surgery Treatment & Management

No medical treatment is currently known or practiced for symptomatic Zenker diverticulum.

Small, asymptomatic diverticula require no specific therapy. For other diverticula, surgical treatment is the preferred therapy.

The two key elements of the successful surgical management of Zenker diverticulum are division of the cricopharyngeus muscle to eliminate the potentially elevated pressure zone and elimination of the diverticular pouch as a reservoir of food and secretions.

The patient should receive routine preoperative evaluation for general anesthesia as guided by a thorough history and physical examination. No preoperative preparation is specific to addressing the Zenker diverticulum.

Surgical approaches include the following: (1) stapled or hand-sewn diverticulectomy with cricopharyngeal myotomy, (2) stapled or hand-sewn diverticulopexy with cricopharyngeal myotomy, and (3) endoscopic division of the diverticular wall with an endoscopic stapler.^{[18, 19, 20, 21, 22, 23, 24, 25, 26]}

Historically, myotomy alone was performed, with a lower rate of relief of symptoms and more frequent complications. Myotomy alone is associated with persistent symptoms in up to 30% of patients.^[18] Recurrence requiring repeat surgery is necessary more frequently than with other procedures.

Presently, the goal of myotomy is to reduce the septum to less than 1 cm in length.^[27]

Diverticulectomy with cricopharyngeal myotomy

With a stapled or hand-sewn diverticulectomy and cricopharyngeal myotomy, the pouch neck is either oversewn or stapled, and the pouch is excised. The cricopharyngeus muscle is divided longitudinally no less than 5 cm. This is typically performed through a left neck incision and is primarily closed with a closed suction drain in place.

Diverticulopexy with cricopharyngeal myotomy

In the diverticulopexy with cricopharyngeal myotomy, the diverticulum is inverted and sutured to the prevertebral fascia, and the cricopharyngeus muscle is divided as above. The difference in this procedure is that the pouch is not excised. This procedure is more commonly advocated in the severely debilitated patient because there is no division of the esophagus, pharynx, or diverticulum, and there is no suture line.^[28]

Endoscopic myotomy

In the endoscopic myotomy, a double-bladed rigid endoscope is placed into the pharynx with one blade positioned in the esophagus and the other in the diverticulum. A reticulating endoscopic linear stapler is introduced into the pharynx with one jaw of the stapler in the pouch and one jaw in the esophagus. The stapler is locked across the common septum of the two and is fired. If necessary, this is repeated until the bottom of the pouch is reached. This results in an opening of the pouch and a division of the cricopharyngeus muscle. The pouch wall becomes incorporated as a wall of the esophagus. This technique should not be used for diverticula less than 3 cm in length, owing to the fact that the stapler blade is too long for the common wall.^[28]

Oral intake is prohibited for 24-48 hours postoperatively.^{[18, 29]} A Gastrografin swallow study is performed to exclude extravasation of contrast. If no leak is present, the diet is advanced as tolerated, and the patient is discharged. It has been demonstrated that swallow studies are no longer necessary, in the absence of esophageal symptoms.^[30] If a drain was placed, it is removed the day after oral intake resumes.

The patient is followed for wound healing and relief of symptoms. Long-term follow-up care is not routinely required.

In a review of over 900 patients with Zenker diverticulum who underwent diverticulectomy and cricopharyngeus myotomy from 1944-1978 at the Mayo Clinic, the overall uncomplicated success rate was 93%.^[31] Mortality in this series was 1.2%, and morbidity was similarly low, including vocal cord paralysis (3.0%), wound infection (1.2%), and wound infection with fistula (1.8%). Recurrence was listed as a delayed complication and occurred in 3.6% of the patients.

In the Mayo Clinic report, complications were predicted by the patients' underlying medical problems or specific attributes of the diverticulum.^[31] Factors relating to the diverticulum that predicted complications included large size, perforation, recurrence, cancer (in the sac), and respiratory or nutritional complications related to the sac.

In 1984, Huang and Payne reported a series of 888 patients undergoing diverticulectomy.^[32] 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.^[33] These patients experienced morbidity of less than 3% and mortality of 0%. Recurrence rates ranged from 3-10%, depending on the method of repair.^[33] 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%^[34] 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.

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, 35, 36]} 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.^[37]

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.^[30] 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.^[28] In addition, it has also been proven to have greater patient satisfaction and allow for safe re-operation, if necessary.^{[38, 39]}

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.^[40]

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.^[41] The investigators reported the following postsurgical results:

Endoscopy with CO₂ laser, as follows:

• Dysphagia - Absent following 78.4% of procedures
• Repeat surgery - Required following 19.6% of procedures

Endoscopy with electrocautery, as follows:

• Dysphagia - Absent following 72% of procedures
• Repeat surgery - Required following 24.3% of procedures

Endoscopy with CO₂ laser and Acuspot, as follows:

• Dysphagia - Absent following 84.6% of procedures
• Repeat surgery - Required following 13% of procedures