eMedicine Specialties > General Surgery > Abdomen

Zenker Diverticulum: Treatment

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

Treatment

Medical Therapy

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

Surgical Therapy

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.

Preoperative Details

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.

Intraoperative Details

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

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.23

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.24

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.24

Postoperative Details

Oral intake is prohibited for 24-48 hours postoperatively.18,25 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.26 If a drain was placed, it is removed the day after oral intake resumes.

Follow-up

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

Complications

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%.27  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.27  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.

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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  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].

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  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].

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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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