1. The Management of Zenker's Diverticulum
JHSGR 21/07/2012
Anson Fung
Queen Elizabeth Hospital

2. 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.

3. 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 p.1.

4. 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:

5. 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.

6. 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

7. Diagnosis Usually diagnosed with Barium studies
Diverticulum arising from the posterior wall of the esophagus
Extrinsic compression of the esophagus from behind

8. Diagnosis Can present as an incidental finding in endoscopy
Tight opening of the cricopharyngeus
Lumen opening into the diverticulum

9. 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

10. 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.

11. 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.

12. 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

13. Treatment
Case reports began to emerge throughout the s 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

14. 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

15. 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

16. 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: /mmcts

17. 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

18. 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:

19. 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

20. 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:
Hashiba K, de Paula AL, da Silva JG, et al. Endoscopic treatment of Zenker’s diverticulum. Gastrointest Endosc 1999; 49:93-97

21. 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

22. 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:

23. Thank You!