Presentation on theme: "The Management of Zenker's Diverticulum"— Presentation transcript:
1The Management of Zenker's Diverticulum JHSGR 21/07/2012Anson FungQueen Elizabeth Hospital
2IntroductionZenker's diverticulum is an out- pouching of the mucosa through the Killian's triangleIt is an area of muscular weakness between the inferior aspect of the inferior pharyngeal constrictor muscle and the cricopharyngeus muscleThe condition was first described by Ludlow in 1767 in a post- mortem examinationLudlow A. A case of obstructed deglutition from a preternatural dilatation of a bagformed in pharynx. Med Observations Inquiries 1767; 3:85.
3IntroductionIn 1877, Zenker and von Ziemssen reviewed the world literature, and since then this kind of diverticulum has been called Zenker's diverticulumZenker FA, von Ziemssen H. Krankheiten des Oesophagus. In: Handbuch der specielen Pathologie und Therapie, Von Ziemssen H (Ed), FC Vogel, Leipzig p.1.
4EtiologySecondary to the generation of high pharyngeal pressures during swallowingDue to poor compliance of the cricopharyngeus muscle, creating a relative obstruction to the free passage of food bolusPostulated that it involves the loss of coordination between pharyngeal contraction and the opening of the cricopharyngeus muscleCook IJ, GabbM, Jamieson G et al. Pharyngeal diverticulum is a disorder of upper oesophageal sphincter opening. Gastroenterology 1992; 103:
5Clinical Presentation Usually presents over the age of 60Majority of them being malesAsymptomatic or transient dysphagia in the early stages of the diseaseMulder CJ, Costamagna G, Sakai P. Zenker's diverticulum: treatment using a flexible endoscope. Endoscopy 2001; 33:991.
6Clinical Presentation The sac will gradually grow, until it is large enough to retain mucous, food and sputumPatient may complain of gurgling in the throat, halitosis, regurgitation, aspiration or a neck massSevere cachexia may present in patients with a large sac with significant esophageal obstruction and long- standing dysphagia
7Diagnosis Usually diagnosed with Barium studies Diverticulum arising from the posterior wall of the esophagusExtrinsic compression of the esophagus from behind
8Diagnosis Can present as an incidental finding in endoscopy Tight opening of the cricopharyngeusLumen opening into the diverticulum
9Treatment The mainstay of treatment of symptomatic ZD has been surgery The traditional management consisted of an open approachDiverticular sac is amputated and myotomy of the cricopharyngeal muscle is performed
10TreatmentThe efficacy of myotomy is supported by a number of surgical series in which excellent responses have been observed in 80 to 100 percent of patientsA major concern related to diverticulectomy is the potential for causing mediastinitisShaw DW, Cook IJ, Jamieson GG, et al. Influence of surgery on deglutitive upper oesophageal sphincter mechanics in Zenker's diverticulum. Gut 1996; 38:806.
11TreatmentOther complications include vocal cord paralysis, pharyngocutaneous fistula, esophageal stenosis, and a recurrent or persistent Zenker’s diverticulumThe 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.
12Treatment 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 1917The theory is to create a common channel between the diverticulum and the esophageal lumenThis is to facilitate drainage and at the same time dividing the cricopharyngeus muscleVan Overbeek JM, Hoeksemma PE. Endoscopic treatment of the hypopharyngeal diverticulum. Laryngoscope 1982:92:88-91
13TreatmentCase 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 morbidityIshioka S, Sakai P, Maluf- Filho F et al. Endoscopic incision of Zenker's diverticula. Endoscopy 1995; 27: 433-7
14TreatmentThe procedure is performed under general anesthesia with the neck hyperextendedA bi- valved rigid diverticuloscope is introduced into the hypopharynx with one blade is placed in the esophagus and the other in the diverticulum
15TreatmentAn 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
16TreatmentFor 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 endoscopeTrans- oral stapling will not be possible on diverticula <2 cm in length due to inadequate access of the stapler cartridgeB. Weksler et al. Multimedia Manual of Cardiothoracic Surgery. doi: /mmcts
17TreatmentThere has been many successful series on endoscopic stapling and the 2 largest series comes from ItalyEndoscopic stapling was successfully completed in >95% percent of patientsBoth 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
18TreatmentWhat 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 endoscopyIshioka S. Endoscopic incision of Zenker's diverticula. Endoscopy 1995; 27:
19TreatmentThe technique involves coagulation/cutting of the cricopharyngeal bar with needle knifes/ mono- polar forceps/ argon plasma coagulationThe procedure is done under sedationA naso- gastric tube is inserted to protect the contralateral esophageal wall from thermal injury
20TreatmentThere have been 8 series published since 1995 on flexible endoscopic Zenker’s diverticulectomy using the needle knifeThe 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
21ConclusionZenker’s Diverticulum is a rare disease with various treatment options availableTreatment of patients with Zenker's diverticula should consider the availability of local expertise and tailor made to each patientThe advantages of endoscopic treatment are shorter operative time, hospital stay, less morbidity and easy access in case of recurrence
22ConclusionThe main advantage of the flexible endoscopic approach is that it does not require general anesthesia and extension of the neckEndoscopic treatment is not possible in diverticula <2 cm and a myotomy is all that is neededAn 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: