1. Zenker’s and Epiphrenic Diverticula
David W Rattner, MD
Massachusetts General Hospital

2. Pharyngoesophageal diverticula

3. 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

4. Clinical Presentation
Most patients develop symptoms due to obstruction and retention
Upper esophageal dysphagia
Regurgitation
Aspiration
Halitosis
Voice change
Weight loss

5. Diagnosis of Zenker’s Diverticulum
Barium swallow
Manometry if symptoms of reflux
Endoscopy

6. Small diverticula

7. Large diverticula

8. Giant Zenker’s Diverticulum

9. 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

10. 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

11. Treatment options: open procedures
Diverticulectomy or diverticulopexy without myotomy
not recommended
fails to address the basic functional abnormality

12. Diverticulectomy Mayo Clinic Series (n=888)
Morbidity=3% Mortality=1.2%
Recurrence=3.6%
Good or Excellent relief of dysphagia=93%

13. 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

14. 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

15. Endoscopic Options Moscher 1917 Dohlman and Mattsson 1960
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: –187
Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticula. Arch Otolaryngol 71: –752 15

16. Endoscopic Options Van Overbeek 1982 Collard 1993
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 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 Sep;56(3):573-6 16

17. Operative Considerations
Diverticulum >3 cm in size
Limitations to mouth opening
Prominent overbite
Cervical osteoarthritis/poor neck flexion 17

18. Transoral Stapling (TOS)- Technique
Supine
General anesthesia 18

19. Transoral Stapling - Technique
EGD with placement of guidewire 19

20. Transoral Stapling - Technique
Weerda diverticuloscope/laryngoscope (Karl Storz) 20

21. Transoral Stapling - Technique
Stapler: Endo-GIA 30 (modified) 21

22. Transoral Stapling - Technique
5mm 30 degree thoracoscope 22

23. Transoral Stapling - Technique
Autosuture Endostitch 23

24. Transoral Stapling - Technique
Autosuture Endostitch 24

25. Transoral Stapling - Technique25

26. Transoral Stapling - Technique26

27. Transoral Stapling - Technique

28. 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 28

29. 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?

30. Transoral Stapling of Zenker’s Diverticulum
Requires general anesthesia
Small diverticulum – contraindication
Introduction of scope/stapler limited in some patients
Residual spur
Individualized approach

31. 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

32. Epiphrenic diverticulum

33. 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
Occurs within 10cm from the GE jxn, commonly associated with esophageal dysmotility or relative obstruction. These types of diverticula ("pulsion") occur in areas of prolonged increased intraluminal pressure usually near a physiologic sphincter (upper esophageal sphincter/ lower esophageal sphincter). Physiologic conditions associated with pulsion diverticula include achalasia, hypertensive lower esophageal sphincter, nutcracker esophagus, and diffuse esophageal spasm About 450 cases in the literature. Wheeler calculated prevalence to be 0.015% reviewing 20,000 esophagrams. Japanese prevalence higher due to screening found to be %. Usually occurs in the 6th to 7th decade with a male preponderance. 33

34. 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
Most occur on the right. Mediastinal structures may limit the appearance of left sided pulsion diverticula 34

35. ASSOCIATED ESOPHAGEAL DISORDERS
Nehra/ Demeester’g group have the largest series of operative intervention on 51 pts.
Nehra 2002
Castrucci 35

36. SIGNS AND SYMPTOMS Dysphagia Regurgitation Halitosis
Chest, epigastric pain
Cough, hoarseness
Aspiration pneumonia
No correlation between size and severity of symptoms
Many are asymptomatic. 36

37. 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
24 hour ambulatory study allowed analysis of > 1000 swallows during and between meals, awake and alseep. Picked up more dysmotility than the stationary study which looks at 10 swallows. The main finding was an increase in the % of simultaneous contractions. Hiatal hernia coexists in 33-75% of pts. with esophageal diverticula. Castrucci found 18% to have GERD. Esophagoscopy to rule out malignancy which is rare. No conclusive relationship between malignant risk and size or chronicity of diverticulum.
*Nehra D, DeMeester TR et al., Ann Surg, 2002. 37

38. CONTROVERSY Should asymptomatic patients undergo repair?
Does diverticulum size matter?
Length of esophagomyotomy
? Anti-reflux procedure

39. TREATMENT Symptom severity Left transpleural approach most common
Minimal  conservative management
Altorki recommends Rx in all patients
Moderate to Severe  surgical repair
Left transpleural approach most common
Diverticulectomy
Long myotomy over bougie
Antireflux procedure controversial
Minimally invasive approach
Thoracoscopy
Laparoscopy found similar to open
Diverticulectomy without myotomy has been associated with a higher incidence of tic recurrence and suture line leak of 10-20%. Laparoscopic diverticulectomy combined with myotomy and fundoplication has been shown to be feasible for the Rx of diverticula, it may be difficult to reach the superior aspect of the diverticular neck and difficult to perform a long myotomy. 39

40. 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°
Routine diverticulectomy adds little morbidity to the repair, and addresses the development of long term complications including the risk of malignancy. Those without myotomy may recur. Suture line leaks are associated with high morbidity (27%). Strong suspicion that insufficient myotomies may contribute to diverticulectomy site leaks and therefore many authors extend myotomy across the LES for 2 cm. 40

41. DIVERTICULECTOMY
Rotation and isolation of diverticulum

42. Closure of muscularis propria over diverticulectomy
MYOTOMY
Closure of muscularis propria over diverticulectomy

43. Myotomy carried onto the stomach 1-2 cm
Antireflux procedure?

44. Including the length of the motor abnormality
LONG MYOTOMY
Including the length of the motor abnormality

45. TREATMENT Mayo Clinic Series 16yr Retrospective study - 112 Patients
71 pts. no symptoms
35 followed long term with no 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%
Manometric probe only passed into the stomach in 20/33 patients. Abnl motility in 19/33 patients. Longterm follow-up up to 15 years
Benacci JC et al., Ann Thor Surg, 1993. 45

46. CORNELL EXPERIENCE NEW 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.

47. REVIEW OF SURGICAL SERIESN D M DM
DMA
Other
Morbidity
Mortality
Outcome Excellent
Fekete 1992 27 10 1 6
9 (2 leak)
11% (3)
77%
Streitz 1992 16 3 13
1 leak 0%
62%
Altorki 1993 17 15 2 NA
6% (1)
88%
Benacci 1993 33 7
11 (6 leak)
9% (3)
82%
Nehra
2002 18 5
2(bleeding,leak)
5.5% (1)
Varhgese 2007 35
2.8% (1)
76%
Reznik 2007 44 32 9
22 (1 leak)
68%
D = diverticulectomy, M = myotomy, A = antireflux, DMA = combined treatment

48. 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
Laparoscopic diverticulectomy combined with myotomy and fundoplication has been shown to be feasible for the Rx of diverticula, it may be difficult to reach the superior aspect of the diverticular neck and difficult to perform a long myotomy.
*Rosati R, et al. Laparoscopic treatment of epiphrenic diverticula. J Laparoendosc Adv Surg Tech A Dec;11(6):371-5 48

49. 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:
#Altorki NK, Skinner DB, J Thorac Cardiovasc Surg, 1993.

50. 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 Nissan)