You are in: eMedicine Specialties > General Surgery > Abdomen Zenker DiverticulumArticle Last Updated: Aug 20, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Todd A Nickloes, DO, Assistant Professor of Surgery, Division of Trauma/Critical Care, University of Tennessee Medical Center Todd A Nickloes 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 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 Editors: Alex Jacocks, MD, Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Amy L Friedman, MD, Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; 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 Author and Editor Disclosure Synonyms and related keywords: Zenker diverticulum, Zenker's diverticulum, Zenker diverticula, Zenker's diverticula, Zenker diverticuli, Zenker’s diverticuli, ZD, diverticula, hypopharyngeal diverticulum, pulsion diverticulum, pharyngoesophageal diverticulum, pharyngo-esophageal diverticulum, pharyngeal diverticulum, esophageal obstruction INTRODUCTIONSection 2 of 11
  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. History of the ProcedureWhile a diverticulum of the esophagus was first described in 1769 by Ludlow,1 Friedrich Albert von Zenker, professor of pathology at ProblemThe 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 FrequencyUnited States: The prevalence of Zenker diverticuli in the International: Internationally, the prevalence of Zenker diverticuli is less than that reported in the EtiologyThe 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. PathophysiologyIt 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 ClinicalPatients 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, 14 Coexistent hiatal hernia, esophageal spasm, achalasia, and esophagogastroduodenal ulceration are common.15 INDICATIONSSection 3 of 11
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.16 RELEVANT ANATOMYSection 4 of 11
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 procedure17; however, with the broad range of procedures available and the varying degrees of anesthesia required, surgery is rarely precluded in symptomatic patients. WORKUPSection 5 of 11
Lab Studies
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Diagnostic Procedures
TREATMENTSection 6 of 11
Medical therapyNo medical treatment is currently known or practiced for symptomatic Zenker diverticulum. Surgical therapySmall, 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 detailsThe 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 detailsSurgical 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.19 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.19 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.20 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.21 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 diverticuli less than 3 cm in length, owing to the fact that the stapler blade is too long for the common wall.21 Postoperative detailsOral intake is prohibited for 24-48 hours postoperatively.19, 22 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 recently demonstrated that swallow studies are no longer necessary, in the absence of esophageal symptoms.23 If a drain was placed, it is removed the day after oral intake resumes. Follow-upThe patient is followed for wound healing and relief of symptoms. Long-term follow-up care is not routinely required. COMPLICATIONSSection 7 of 11
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%.24 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.24 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. OUTCOME AND PROGNOSISSection 8 of 11
In 1984, Huang and Payne reported a series of 888 patients undergoing diverticulectomy.25 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.26 These patients experienced morbidity of less than 3% and mortality of 0%. Recurrence rates ranged from 3-10%, depending on the method of repair.26 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%27 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 CONTROVERSIESSection 9 of 11
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.15, 28, 29 Although it was first described in 1917, recent advances in endoscopic staplers have 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.30 Average operative time is 25 minutes versus 60-90 minutes for open procedures. Additionally, no neck incision or drain is required. Early reports from 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.33 MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Article Last Updated: Aug 20, 2008 | ||||||||||||
