Zenker’s and Epiphrenic Diverticula

David W Rattner, MD

Massachusetts General Hospital

Pharyngoesophageal diverticula

Pathogenesis of Zenker’s Diverticulum

• Cricopharyngeus spasm caused by GER– unclear role, but several studies have described a normal or low pressure at

the cricopharyngeus.

• “Achalasia” of the cricopharyngeus– UES does relax during swallow in Zenker’s patients

• Dyscoordination of cricopharyngeal function

Clinical Presentation

Most patients develop symptoms due to obstruction and retention

• Upper esophageal dysphagia• Regurgitation• Aspiration• Halitosis• Voice change• Weight loss

Diagnosis of Zenker’s Diverticulum

• Barium swallow

• Manometry if symptoms of reflux

• Endoscopy

Small diverticula

Large diverticula

Giant Zenker’s Diverticulum

Diagnosis of Zenker’s Diverticulum• Endoscopy

– laryngoscopy– short rigid esophagoscopy– flexible endoscopy

• High aspiration risk– Keep patients sitting up– Rapid sequence intubations– Rigid suction at hand– Refractory to Selleck’s maneuver

Treatment options: open procedures

• Diverticulectomy with myotomy– best for the large diverticulum– carries risks associated with esophageal repair

• Diverticulopexy with myotomy– may be suitable for smaller (<2cm) diverticula

• Myotomy alone– may prevent progression of mild symptoms associated with a small

diverticulum

Treatment options: open procedures

• Diverticulectomy or diverticulopexy without myotomy– not recommended– fails to address the basic functional abnormality

Diverticulectomy

Mayo Clinic Series (n=888)• Morbidity=3% Mortality=1.2%

• Recurrence=3.6%

• Good or Excellent relief of dysphagia=93%

Diverticulopexy

• May be useful if healing of a suture or staple line is a concern

• Diverticulum is sutured to the prevertebral facia allowing dependent drainage

• Sutures through the diverticulum (5-0 wire) can obliterate the lumen

Treatment options: endoscopic diverticulectomy

• Described by Dohlman (1964)

• Septum between the diverticulum and the esophagus is divided

• 92-98% success rate at palliating dysphagia

– 3% conversion rate to open procedure

– 30% of cases endoscopic repair not attempted

Endoscopic Options

• Moscher 1917– Divided septum with a knife (punch biopsy)– 7 patients- – Abandoned following postoperative death

• Dohlman and Mattsson 1960– 100 patients/fixed laryngoscope (better visualization)– Endoscopic division of the common wall using a diathermy knife – Symptom recurrence rate 7%, no significant complications were observed

Mosher HP. Webs and pouches of the esophagus: their diagnosis and treatment. Surg Gynecol Obstet 25: 1917. 175–187

Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticula. Arch Otolaryngol 71: 1960. 744–752

Endoscopic Options• Van Overbeek 1982

– 12 patients (as compared to electrocoagulation)– Septum divided with CO2 laser– Several sessions with larger diverticula– Operating microscope

• Collard 1993– 30mm Endo-GIA stapler/eventually modified stapler tip– Video assistance– 6 patients- dysphagia relieved in 5 and improved in 1

van Overbeek JJ, Hoeksema PE, Edens ET.Microendoscopic surgery of the hypopharyngeal diverticulum using electrocoagulation or carbon dioxide laser. Ann Otol Rhinol Laryngol. 1984 Jan-Feb;93(1 Pt 1):34-6

Collard JM, Otte JB, Kestens PJ.Endoscopic stapling technique of esophagodiverticulostomy for Zenker's diverticulum. Ann Thorac Surg. 1993 Sep;56(3):573-6

OperativeConsiderations

• Diverticulum >3 cm in size

• Limitations to mouth opening

• Prominent overbite

• Cervical osteoarthritis/poor neck flexion

Transoral Stapling (TOS)- Technique

• Supine• General anesthesia

Transoral Stapling - Technique

• EGD with placement of guidewire

Transoral Stapling - Technique

• Weerda diverticuloscope/laryngoscope (Karl Storz)

Transoral Stapling - Technique

• Stapler: Endo-GIA 30 (modified)

Transoral Stapling - Technique

• 5mm 30 degree thoracoscope

Transoral Stapling - Technique

• Autosuture Endostitch

Transoral Stapling - Technique

• Autosuture Endostitch

Transoral Stapling - Technique

Transoral Stapling - Technique

Transoral Stapling - Technique

Comparative Studies

• UPMC 2007– Dysphagia scores comparable preoperatively (2.78 OS / 2.79

TOS )

– Improved significantly in both groups (1.1 TOS / 1.0 OS)

– Follow up 17 months

Transoral Stapling of Zenker’s Diverticulum

• Transoral treatment employed from beginning of century• Relative advantages

– No incision/OR time/No pain/Short LOS/Earlier POs/

• Procedure of choice for recurrent Zenker’s diverticulum?• Procedure of choice with previous neck surgery?

• Requires general anesthesia• Small diverticulum – contraindication• Introduction of scope/stapler limited in some patients• Residual spur• Individualized approach

Transoral Stapling of Zenker’s Diverticulum

Transoral Stapling of Zenker’s Diverticulum

Conclusions• The presence of a Zenker’s diverticulum is an indication

for surgery– Symptoms frequently progress

• Routine use of myotomy favored

• Management of diverticulum after myotomy depends on size of residual pouch and patients condition– Rare contraindications to surgery

Epiphrenic diverticulum

FEATURES• Least common esophageal diverticulum• Occurs within 10cm from the EG jxn and almost

always of pulsion type• Acquired diverticulum later in adult life • Prevalence difficult to quantitate

– Asymptomatic patients not discovered

• Majority of patients have some form of esophageal dysmotility with functional esophageal obstruction

PATHOPHYSIOLOGY• Increase intraluminal pressure against a

relative obstruction causes mucosal herniation false diverticulum

• Altorki, Orringer, DeMeester suggest all patients have esophageal dysmotility

• Some association with:– Achalasia– Diffuse esohageal spasm– Connective tissue diseases– Hypertensive LES– Reflux strictures

ASSOCIATED ESOPHAGEAL DISORDERS

Nehra 2002Castrucci 1998 51 27 5 6 12 26 6 4

SIGNS AND SYMPTOMS

• Dysphagia

• Regurgitation

• Halitosis

• Chest, epigastric pain

• Cough, hoarseness

• Aspiration pneumonia

• No correlation between size and severity of symptoms

PREOPERATIVE EVALUATION

• Barium esophagram

• Esophagoscopy to rule out achalasia or neoplasm

• Esophageal manometry – Endoscopic placement

– *24hr ambulatory study increased diagnostic yield

• 24hr pH probe if GERD suspected

*Nehra D, DeMeester TR et al., Ann Surg, 2002.

CONTROVERSYShould asymptomatic patients undergo

repair?

Does diverticulum size matter?

Length of esophagomyotomy

? Anti-reflux procedure

TREATMENT• Symptom severity

– Minimal conservative management– Altorki recommends Rx in all patients– Moderate to Severe surgical repair

• Left transpleural approach most common– Diverticulectomy– Long myotomy over 50-54 bougie– Antireflux procedure controversial

• Minimally invasive approach– Thoracoscopy– Laparoscopy found similar to open

TRANSPLEURAL APPROACH Left thoracotomy Diverticulectomy Long myotomy

– Opposite the diverticulum – Including the length of the motor

abnormality

± Anti-reflux procedure– Incomplete Fundoplication– Dor, anterior 180°– Toupet, posterior 270°– Belsy thoracic, posterior 240°

Rotation and isolation of diverticulum

DIVERTICULECTOMY

MYOTOMY

Closure of muscularis propria over diverticulectomy

Myotomy carried onto the stomach 1-2 cm

Antireflux procedure?

LONG MYOTOMY

Including the length of the motor abnormality

TREATMENTMayo Clinic Series16yr Retrospective study - 112 Patients • 71 pts. no symptoms

• 35 followed long term with no sequelae @ 7yrs

• 41 pts. symptomatic• 33 underwent repair • 90% dysphagia, 82% regurg, 30% aspiration• 50% hiatal hernia

• 9% mortality• 33% major complication (18% leak rate)• Fair or poor long term function in 24%

Benacci JC et al., Ann Thor Surg, 1993.

CORNELL EXPERIENCENEW YORK HOSPITAL

• 21 Patients– Size 3-10cm– 17/21 (81%) Transthoracic diverticulectomy with esophageal

myotomy and anti-reflux procedure– 24% pulmonary symptoms– 52% dysphagia and regurgitation– 43% achalasia – All had abnormal esophageal motility– 26% pulmonary complications

Altorki NK, Skinner DB, J Thorac Cardiovasc Surg, 1993.

REVIEW OF SURGICAL SERIES

Series N D M DM DMA Other Morbidity Mortality

Outcome Excellent

Fekete 1992 27 10 0 1 10 6 9 (2 leak) 11% (3) 77%

Streitz 1992 16 3 13 0 0 0 1 leak 0% 62%

Altorki 1993 17 0 0 0 15 2 NA 6% (1) 88%

Benacci 1993 33 7 1 16 6 3 11 (6 leak) 9% (3) 82%

Nehra

2002

18 0 0 0 13 5 2(bleeding,leak)

5.5% (1) 88%

Varhgese 2007

35 0 0 1 33 1 1 leak 2.8% (1) 76%

Reznik 2007 44 3 0 0 32 9 22 (1 leak) 0% 68%

D = diverticulectomy, M = myotomy, A = antireflux, DMA = combined treatment

MINIMALLY INVASIVE APPROACH• Many small series ( leak rate)

• Found feasible and safe*– Laparoscopic transhiatal approach and

thoracoscopic approach– Diverticulum divided with linear stapler– Myotomy on opposite esophageal side– Anti-reflux procedure

• Potential difficulty with a long myotomy via laparoscopic approach

*Rosati R, et al. Laparoscopic treatment of epiphrenic diverticula. J Laparoendosc Adv Surg Tech A. 2001 Dec;11(6):371-5

ASYMPTOMATIC PATIENTS

• Over a 12 yr period, enlargement was noted in 16%, significance unclear*

• High risk of aspiration found in 46%#

• Overall < 10% will develop sx’s

• Regular clinical and radiologic review once identified

*Bruggeman LL, Seaman WB. Epiphrenic diverticula. An analysis of 80 cases. Am J Roentgenol Radium Ther Nucl Med, 1973; 119:266-276.

#Altorki NK, Skinner DB, J Thorac Cardiovasc Surg, 1993.

CONCLUSIONS• Epiphrenic diverticulae are always associated with esophageal

motor disorders• Symptomatic diverticulae should be repaired• Operative repair in asymptomatic patients controversial

– Food or contrast retention potential indication Castrucci– Series complications occur in 45% pts. Altorki, DeMeester

• Diverticulectomy, diverticulopexy, long myotomy yield a good result in 90% of pts.

• Anti-reflux repair as part of management prevails in more recent series (partial fundoplication, loose Nissen)