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.
Speech and language therapists (SLT's) can be helpful in patients who are awaiting surgery, aren't surgical candidates, or refuse surgery but need to lower the risk of aspiration. [17] In a study of 23 patients who were identified with a pharyngoesophageal diverticulum on a swallow study and who were symptomatic with respiratory difficulties or voice changes were seen and evaluated by SLT's. Using a combination of fluid and food modification and swallow strategies, a reduced risk of aspiration was confirmed by video swallow studies in most patients. [17]
Treatment of esophageal intramural pseudodiverticulosis is directed toward underlying strictures or dysmotility.
Surgical Care
Treatment of Zenker diverticulum traditionally has been surgical, along with endoscopically assisted techniques, [18, 19] 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. No consensus exists for the surgical treatment of non-Zenker diverticula; however, staple line leakage occurs frequently and can be significantly reduced by myotomy. [20]
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. [1]
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. [21]
A German group reported endoscopic therapy of a Zenker diverticulum with a Clutch Cutter device. The Clutch Cutter was originally designed for endoscopic submucosal dissection. [22]
Other procedures
Other novel techniques are being developed. [19] Flexible endoscopic diverticulotomy approaches have been explored using various techniques, including argon plasma coagulation, monopolar coagulation forceps, and needle-knife incision. [14, 15, 23, 24] 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.
Minimally invasive endoscopic treatment is increasingly favored; it is typically performed for symptomatic relief. The peroral endoscopic myotomy technique (POEM) is among many modalities used, but iatrogenic esophageal diverticula may develop. [25]
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. [26] 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 2018 retrospective, single institution review of prospectively collected data (1997-2018) of surgical outcomes for symptomatic epiphrenic diverticulum in 27 patients found laparascopic diverticulectomy to be safe and effective for long-term symptomatic resolution with low complication rates. [27] Sixteen patients (59.2%) of the 27 patients had abnormal esophageal motility (mostly achalasia [29.6%]). All 27 underwent minimally invasive diverticulectomy (26 laparoscopic, one thoracoscopic), without any conversions to open surgery; 88.9% had concurrent myotomy and 85.2% had antireflux procedures. Nearly 90% of patients (89.9%) achieved overall symptomatic resolution, with 11.1% having persistent dysphagia. At 35.8 months of follow-up, there were no reports of esophageal leaks, recurrent diverticula, or deaths. [27]
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. [14] The investigators reported the following postsurgical results:
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Endoscopy with CO2 laser: Dysphagia was absent following 78.4% of procedures; repeat surgery was required following 19.6% of procedures
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Endoscopy with electrocautery: Dysphagia was absent bsent following 72% of procedures; repeat surgery was required following 24.3% of procedures
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Endoscopy with CO2 laser and Acuspot: Dysphagia was absent following 84.6% of procedures; repeat surgery was required following 13% of procedures
Several reports in the literature describe surgical treatment of esophageal diverticula. One study analyzed a single institution’s experience with endoscopic CO2 laser and stapler repair of Zenker diverticulum by comparing dysphagia and regurgitation outcomes in 148 patients. [28] 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. Another study included 91 patients treated with CO2 laser: 1 year after surgery, almost 87% of patients were symptom free. [29]
Most of the reports involve treatment of Zenker diverticula and discuss open versus endoscopic methods. [30, 31, 32, 33] None was a controlled study. They were series reports or retrospective reviews. There is no consensus of which method is the best.
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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Esophageal Diverticula. Barium esophagram, anteroposterior view, demonstrating a bilobed Zenker diverticulum.
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Esophageal Diverticula. Zenker diverticulum, lateral view.
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Esophageal Diverticula. Esophagram demonstrating a dilated tortuous esophagus and a large midesophageal diverticulum.
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Esophageal Diverticula. Barium esophagram demonstrating an epiphrenic diverticulum.
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Esophageal Diverticula. Multiple, small, flask-shaped outpouchings characteristic of esophageal intramural pseudodiverticulosis.
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Esophageal Diverticula. Esophageal intramural pseudodiverticulosis involving the entire length of the esophagus.
