The Management of Zenker's Diverticulum

JHSGR 21/07/2012

Anson Fung

Queen Elizabeth Hospital

Introduction

Zenker's diverticulum is an out- pouching of the mucosa through the Killian's triangle

It is an area of muscular weakness between the inferior aspect of the inferior pharyngeal constrictor muscle and the cricopharyngeus muscle

The condition was first described by Ludlow in 1767 in a post- mortem examination

Ludlow A. A case of obstructed deglutition from a preternatural dilatation of a bagformed in pharynx. Med Observations Inquiries 1767; 3:85.

Introduction

In 1877, Zenker and von Ziemssen reviewed the world literature, and since then this kind of diverticulum has been called Zenker's diverticulum

Zenker FA, von Ziemssen H. Krankheiten des Oesophagus. In: Handbuch der specielen Pathologie und Therapie, Von Ziemssen H (Ed), FC Vogel, Leipzig 1877. p.1.

Etiology

Secondary to the generation of high pharyngeal pressures during swallowing

Due to poor compliance of the cricopharyngeus muscle, creating a relative obstruction to the free passage of food bolus

Postulated that it involves the loss of coordination between pharyngeal contraction and the opening of the cricopharyngeus muscle

Cook IJ, GabbM, Jamieson G et al. Pharyngeal diverticulum is a disorder of upper oesophageal sphincter opening. Gastroenterology 1992; 103: 1229-35

Clinical Presentation

Usually presents over the age of 60

Majority of them being males

Asymptomatic or transient dysphagia in the early stages of the disease

Mulder CJ, Costamagna G, Sakai P. Zenker's diverticulum: treatment using a flexible endoscope. Endoscopy 2001; 33:991.

Clinical Presentation

The sac will gradually grow, until it is large enough to retain mucous, food and sputum

Patient may complain of gurgling in the throat, halitosis, regurgitation, aspiration or a neck mass

Severe cachexia may present in patients with a large sac with significant esophageal obstruction and long- standing dysphagia

Diagnosis

Usually diagnosed with Barium studies

Diverticulum arising from the posterior wall of the esophagus

Extrinsic compression of the esophagus from behind

Diagnosis

Can present as an incidental finding in endoscopy

Tight opening of the cricopharyngeus

Lumen opening into the diverticulum

Treatment

The mainstay of treatment of symptomatic ZD has been surgery

The traditional management consisted of an open approach

Diverticular sac is amputated and myotomy of the cricopharyngeal muscle is performed

Treatment

The efficacy of myotomy is supported by a number of surgical series in which excellent responses have been observed in 80 to 100 percent of patients

A major concern related to diverticulectomy is the potential for causing mediastinitis

Shaw DW, Cook IJ, Jamieson GG, et al. Influence of surgery on deglutitive upper oesophageal sphincter mechanics in Zenker's diverticulum. Gut 1996; 38:806.

Treatment

Other complications include vocal cord paralysis, pharyngocutaneous fistula, esophageal stenosis, and a recurrent or persistent Zenker’s diverticulum

The overall complication rate in one series of 900 patients treated with diverticulectomy was less than 10%

Payne WS. The treatment of pharyngoesophageal diverticulum: the simple and complex. Hepatogastroenterology 1992; 39:109.

Treatment

Are there any minimal invasive approachs?

The concept of treating a Zenker’s diverticulum with an endoscopic approach has already been described by Mosher in 1917

The theory is to create a common channel between the diverticulum and the esophageal lumen

This is to facilitate drainage and at the same time dividing the cricopharyngeus muscle

Van Overbeek JM, Hoeksemma PE. Endoscopic treatment of the hypopharyngeal diverticulum. Laryngoscope 1982:92:88-91

Treatment

Case reports began to emerge throughout the 1930-1950s with division of the cricopharyngeal bar with electrocautery, CO2 laser etc.

Unfortunately, many patients died of mediastinitis and a number of case series published a morbidity rate of ˜10%

Not until 1993, Collard et al. described the use of an endoscopic stapling device with a proposed advantage of shorter operative time, hospital stay and less morbidity

Ishioka S, Sakai P, Maluf- Filho F et al. Endoscopic incision of Zenker's diverticula. Endoscopy 1995; 27: 433-7

Treatment

The procedure is performed under general anesthesia with the neck hyperextended

A bi- valved rigid diverticuloscope is introduced into the hypopharynx with one blade is placed in the esophagus and the other in the diverticulum

Treatment

An endoscopic linear stapler is introduced under endoscopic control, with the longer jaw containing the staples and the cutting blade inserted into the esophageal introitus, then fired

Treatment

For anatomical reasons, trans- oral stapling is not possible in ˜3%

Patients with prominent front teeth, micrognathia, or limited neck extension will cause difficulty in placing the endoscope

Trans- oral stapling will not be possible on diverticula <2 cm in length due to inadequate access of the stapler cartridge

B. Weksler et al. Multimedia Manual of Cardiothoracic Surgery. doi:10.1510/mmcts.2007.002923

Treatment

There has been many successful series on endoscopic stapling and the 2 largest series comes from Italy

Endoscopic stapling was successfully completed in >95% percent of patients

Both claimed to have a response rate ˜97%

The incidence of major complications is ˜3%

Narne S, Cutrone C, Bonavina L, Chella B, Peracchia A. Endoscopic diverticulotomy for the treatment of Zenker's diverticulum: results in 102 patients with staple-assisted endoscopy. Ann Otol Rhinol Laryngol 1999; 108: 810–815. Peracchia A, Bonavina L, Narne S, Segalin A, Antoniazzi L, Marotta G. Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients. Arch Surg 1998; 133: 695–700

Treatment

What about those patients who are too frail to undergo general anesthesia?

What can we offer to the small number of patients who cannot be offered endoscopic stapling because of anatomical variations?

In 1995, Ishioka in Brazil reported his first experience with endoscopic incision of Zenker’s diverticulum using an electrosurgical system with flexible endoscopy

Ishioka S. Endoscopic incision of Zenker's diverticula. Endoscopy 1995; 27:433-437

Treatment

The technique involves coagulation/cutting of the cricopharyngeal bar with needle knifes/ mono- polar forceps/ argon plasma coagulation

The procedure is done under sedation

A naso- gastric tube is inserted to protect the contralateral esophageal wall from thermal injury

Treatment

There have been 8 series published since 1995 on flexible endoscopic Zenker’s diverticulectomy using the needle knife

The 2 largest case series reported a response rate of ˜96%

Complication rate 5-14%

Ishioka S. Endoscopic incision of Zenker's diverticula. Endoscopy 1995;27:433-437. Hashiba K, de Paula AL, da Silva JG, et al. Endoscopic treatment of Zenker’s diverticulum. Gastrointest Endosc 1999; 49:93-97

Conclusion

Zenker’s Diverticulum is a rare disease with various treatment options available

Treatment of patients with Zenker's diverticula should consider the availability of local expertise and tailor made to each patient

The advantages of endoscopic treatment are shorter operative time, hospital stay, less morbidity and easy access in case of recurrence

Conclusion

The main advantage of the flexible endoscopic approach is that it does not require general anesthesia and extension of the neck

Endoscopic treatment is not possible in diverticula <2 cm and a myotomy is all that is needed

An open surgical approach is recommended for extremely large sacs (>7cm)

Cassivi SD, Deschamps C, Nichols FC, et al. Diverticula of the esophagus. Surg Clin North Am 2005; 85:495-503

Thank You!