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Zenker's diverticulum (ZD) results from a posterior mucosal herniation through Killian’s triangle, an area situated above the cricopharyngeus (CP) muscle and below the inferior pharyngeal constrictor muscle. ZD is likely caused by incomplete relaxation of the upper esophageal sphincter as well as increased intraluminal pressure. ZD can be asymptomatic, and the most common symptom associated with symptomatic ZD is dysphagia. The definitive treatment for symptomatic Zenker’s diverticulum is a surgical correction, either by an open transcervical or an endoscopic approach. The open surgical approach involves a transcervical incision usually involving concurrent cricopharyngeal (CP) myotomy, whereas the endoscopic utilizes an endoscope to visualize and divide the diverticulum from the inside. Endoscopic approaches have gained widespread acceptance due to shorter hospital stays, lower rates of complications, ease of access in case of recurrence, and shorter operation times. Thus, endoscopic access is often considered the first-line choice for the treatment of ZD. We present a case of a patient with a symptomatic ZD that is treated with an endoscopic staple-assisted diverticulotomy. The clinical presentation, diagnostic criteria, surgical procedure, and postoperative care are highlighted.
Zenker’s diverticulum (ZD) is the most common type of esophageal diverticula, typically presents in patients older than 70 years of age,1 and is slightly more common in males.2 ZD protrudes through Killian’s triangle, which is an area of least resistance between the oblique fibers of the inferior pharyngeal constrictors and the cricopharyngeus (CP) muscle. The overall prevalence of ZD is believed to be between 0.01–0.11%.3 ZD has a higher prevalence in the USA, Canada, and Australia compared with Japan and Indonesia. The pathophysiology of ZD is unclear; however, certain risk factors such as abnormal esophageal motility, altered upper esophageal sphincter function, and aging predispose patients to its development.4, 5
ZD can be asymptomatic. For patients who develop symptoms, the most common presenting symptom of ZD is dysphagia. Other associated symptoms can include retrosternal pressure sensation, halitosis, and regurgitation of undigested food. Weight loss can be reported due to the distress caused by eating. Swallowed contents can become lodged within the diverticulum and cause halitosis and further outpouching, possibly leading to the appearance of a neck mass on physical examination. However, physical exam findings are often unremarkable. The most serious consequence of ZD is the pulmonary aspiration, and patients may present with a history and typical signs of aspiration pneumonia. ZD can be found incidentally in patients who undergo upper endoscopy for other reasons, but surgical intervention should be reserved for symptomatic patients.
Diagnosis is made by correlating the patient’s history and clinical findings with imaging studies, such as a barium or gastrografin esophagram. A definitive diagnosis requires visualization of the diverticulum by showing a contrast-filled pouch that is best detected using lateral projection.5 Additionally, upper endoscopy is recommended to confirm the diagnosis and rule out possible malignancy.
The goal of surgical treatment is to restore the continuity from the hypopharynx to the esophageal lumen without obstruction or retention of swallowed contents. There are two ways to accomplish this, either with elimination or circumvention of the reservoir that traps debris, and release of the upper esophageal sphincter by a cricopharyngeal myotomy.
There are two main surgical approaches: open transcervical and endoscopic.6
Diverticulectomy with CP myotomy: division of the pouch tissue.
Diverticulopexy with CP myotomy: suspension of the pouch preventing flow into it.
Diverticulotomy with CP myotomy: cleavage of the septum between esophageal lumen and diverticulum.
In this case, the Weerda laryngoscope is introduced into the esophageal inlet and placed in suspension. A rigid endoscope is used to visualize and identify the ZD (posteriorly) and esophagus (anteriorly) along with the common wall between them. The diverticulum is then cleared of debris using suction before placement of two lateral retraction sutures (using a 2-0 silk on an Endostitch suturing device) that assist in providing increased control of the common wall during staple placement. As demonstrated in the video, these are placed starting with the needle within the diverticulum and moving through the common wall. An endoscopic linear stapler (Endo-GIA 30 stapler (US Surgical Corp., Norwalk, CT)) is introduced and placed with the cartridge blade in the esophagus and anvil blade in the diverticulum to divide and seal the diverticulum against the esophageal inlet. The careful and simultaneous action of division and sealing during stapling reduces the risk of perforation, infection, and bleeding. Upon assessment, there is a restoration of continuity between the hypopharynx and the esophageal lumen. It is important to recheck that the staple line is snug against the esophageal inlet as any gap can leave a residual ZD. Once retraction sutures are removed and hemostasis is controlled, the Weerda laryngoscope can be removed.
Overall, the complications involved in both open and endoscopic approaches to a ZD are similar and include recurrent nerve injury, leak or perforation, cervical infection, hematoma, respiratory infection, stenosis, and mediastinitis.7 However, there are some complications that are specific to endoscopic approaches such as dental injury and cervical or mediastinal emphysema, which is the most common endoscopic complication.7 Further complications arise from the necessity of rigid endoscopy and surgical measures requiring general anesthesia, whereas flexible endoscopy has the benefit of being able to be performed under deep sedation. The difference in anesthesia management is just one difference that changes postoperative care between approaches. Open surgical procedures may require a longer recovery period that may require additional office visits due to wound care or removal of drains. Overall, postoperative management includes recommending that patients sleep at an incline of 30 degrees and refrain from any straining or heavy lifting that involves the upper body for two weeks.8 There are a number of individualizations that need to be made in regard to pain and diet. With the endoscopic approach, patients have a Dobhoff tube placed at the time of surgery. A gastrografin swallow study is performed the morning after surgery to assess for potential leak. If the patient ‘passes,’ then he/she may start a clear liquid diet for 48 hours, followed by a full liquid diet advanced to a soft diet for 1–2 weeks; however, some patients may benefit shortly from enteral nutrition through a nasogastric tube. It is important to normalize that patients may experience voice changes such as hoarseness for a few days after surgery. Persistent voice changes suggest injury to the recurrent laryngeal nerve, and flexible laryngoscopy should be performed. There are a number of postoperative red flags that patients should look out for such as fever; neck swelling; pain with breathing, swallowing, or speaking; difficulty breathing; and increased severity or frequency of concerning symptoms. 8
The endoscopic staple-assisted diverticulotomy is a commonly used approach for the management of ZD. Historically, the open surgical approach has been the gold standard of ZD management; however, over the last two decades, the trend has shifted towards the minimally invasive endoscopic repair. This change is prompted by the success rates of therapy using endoscopic repair when compared with open surgical approaches (rigid endoscopy: 90–100%, flexible endoscopy: 43–100%, open surgical approach 80–100%). Furthermore, rigid endoscopy has the lowest rate of recurrence of symptoms at 12.8%, whereas flexible endoscopy is at 20%,9, 10 and open surgery can be as high as 19%.11 In the presented case, rigid endoscopic stapling was performed, which provides an effective resolution of the diverticulum as well as low rates of associated complications with a rate of 7.1% (vs 10.5% for surgical repair and 15% for flexible endoscopy).7 Rigid endoscopy generally has the same indications and contraindications as open surgical approaches; however, flexible endoscopy has the benefit of being able to be performed under deep sedation or on those with limited cervical mobility.12 Additionally, endoscopic repair offers a variety of tools that allow adaptability in approach, including endoscopic stapling, needle knife, CO2 laser, argon plasma coagulation, hook knife, harmonic scalpel, and clutch cutter. Given this large array of treatment modalities, there has been little consensus on the technical aspects of how the operation should be carried out.
However, the CO2 laser and the stapler are two endoscopic tools that appear to have similar outcomes.13
Given the relative infrequency of Zenker’s diverticulum, it remains challenging to establish clear clinical and endoscopic guidelines that improve patient outcomes. Nonetheless, the case above showcases an example of rigid endoscopic staple-assisted diverticulotomy for the treatment of a ZD.
Author C. Scott Brown also works as editor of the Otolaryngology section of the Journal of Medical Insight.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenker's diverticulum). Postgrad Med J. 2001;77(910):506-511. https://doi.org/10.1136/pmj.77.910.506
- Watemberg S, Landau O, Avrahami R. Zenker's diverticulum: reappraisal. Am J Gastroenterol. 1996;91(8):1494-1498. PMID: 8759648
- Verhaegen VJ, Feuth T, van den Hoogen FJ, Marres HA, Takes RP. Endoscopic carbon dioxide laser diverticulostomy versus endoscopic staple-assisted diverticulostomy to treat Zenker's diverticulum. Head Neck. 2011;33(2):154-159. https://doi.org/10.1002/hed.21413
- Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker's diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital.
- Law R, Katzka DA, Baron TH. Zenker's Diverticulum. Clin Gastroenterol Hepatol. 2014;12(11):1773-e112. https://doi.org/10.1016/j.cgh.2013.09.016
- Bizzotto, A., Iacopini, F., Landi, R., & Costamagna, G. (2013). Zenker's diverticulum: exploring treatment options. Acta otorhinolaryngologica Italica: organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale, 33(4), 219–229.
- Yuan Y, Zhao YF, Hu Y, Chen LQ. Surgical treatment of Zenker's diverticulum. Dig Surg. 2013;30(3):207-218. https://doi.org/10.1159/000351433
- Courey M, Mori M. Zenker’s Diverticulectomy/Cricopharyngeal Myotomy Postoperative Care Instructions. Published 2020. Access: https://www.mountsinai.org/locations/grabscheid-voice-swallowing-center/postop-instructions/zenkers-diverticulectomy.
- Mantsopoulos K, Psychogios G, Künzel J, Zenk J, Iro H, Koch M. Evaluation of the different transcervical approaches for Zenker diverticulum. Otolaryngol Head Neck Surg. 2012;146(5):725-729. https://doi.org/10.1177/0194599811435304
- Leong SC, Wilkie MD, Webb CJ. Endoscopic stapling of Zenker's diverticulum: establishing national baselines for auditing clinical outcomes in the United Kingdom. Eur Arch Otorhinolaryngol. 2012;269(8):1877-1884. https://doi.org/10.1007/s00405-012-1945-3
- Ferreira LE, Simmons DT, Baron TH. Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus. 2008;21(1):1-8. https://doi.org/10.1111/j.1442-2050.2007.00795.x
- Ishaq S, Sultan H, Siau K, Kuwai T, Mulder CJ, Neumann H. New and emerging techniques for endoscopic treatment of Zenker's diverticulum: State-of-the-art review. Dig Endosc. 2018;30(4):449-460. https://doi.org/10.1111/den.1303
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Table of Contents
All right, so we're going to try and get exposure over our esophageal inlet and the Zenker's opening using the large Weerda scope. So we're working our way down towards the esophageal inlet, posterior to the larynx. Once you're there, then open up and see if we can advance in to get a good view. What - you want to open it up some more? Not yet? We want to open that as wide as we can so we can get our instruments inside. You'll have to do both. That's the nice thing about the Weerda too, you have your 2 points of opening. Yes. You still have a good view? Yeah, want to take a look? Yeah, but let's make sure we're good and open. You've got that scope, Dave, if you want to show through on the screen. To your left there. Get that out of the way. Do you have maybe the open tip? That's a lot of debris. Clean up the debris, and then we can get a better visualization of our common wall, esophagus, and pouch. She does have a wide opening on the barium swallow. I'm surprised she doesn't have a pneumonia. All right, so that looks like you are in the pouch. And the esophageal lumen is likely up there. So what we need to - you can try, by opening this up some more. It's possible you may have to slightly adjust it a little bit more, you can try with a - spatula, just to see if you can feel into the esophagus, but that looks like you are - it's a wide-mouth diverticulum. What do you feel up there? That still feel like wall? It does still feel like wall. Okay, so we might have to back up. Back it up and then... Yeah. Okay, that's - there you go. Okay. There we go. That's better, yeah. So that's our common wall. There's our esophagus anteriorly. That's the pouch that you just cleaned. So, feel with your spatula up there, just to confirm that - you can pass easily into the esophagus. No obstruction at all. No, no obstruction. Good. You can go ahead and open up the suture. So what we want to do now is, we're going to want to get a stay suture.
And let's make sure we're as wide as we can be here. We're going to want your one suture over here, one suture on this side of the common wall, so we can have some retraction as we put in our staple. We'll take a picture of this for the family. Have you put in staples before? No. All right, well let me show you one. Of course. So I've just adjusted this a little bit more. Tell me when. All right, that's good. I just moved the scope back just a little bit so we have more room to manipulate that common wall to get our sutures in place. Okay, so the way the sutures work. This switches - you have to squeeze that, but this switches where the - the needle goes, with this little device here. And so it's always best to - come in from the pouch side with the needle, and up, and then once you're there, then you switch it, and you often have to kind of twist - this - so that the suture is going posteriorly to twist to get it out. And you put these out as laterally as you can. As lateral as we can go, so that we have room in between to get our staple in. So there's my suture. So I'm going to try and slide as laterally as I can in here and engage, then flip the suture. And then we have to do kind of a little twist to get that suture out. And then what we'll do is we'll cut this end here. And then a hemostat, please? And so there is one of our sutures. And so - we now want to get one kind of in this area over here and then we should have ample room to go in between to put our staple. So, suture coming in from the pouch, and see if you can slide in as much as you can, and sometimes - we'll see - it's possible I didn't engage the muscle enough, I might redo my suture, but let's - you have enough traction there to go ahead and get yours in. We don't want to pull through the mucosa. So I'll take a feel of that. Mine looks - maybe it's not quite as deep as I thought I was. So you have to… Yep, so you want to go in like that, so you have to close it a little bit. And then you'll slide in, and then switch it. Okay. Cool. Okay? So go as laterally as you can. So close it a little bit so you can get in there. That looks good. It looks better than mine. Good, so close. Okay, I'll switch it for you. Thanks. Okay. And then come out, and then take that top tine - yep. A little twist - okay, good. Good. Scissors, please. And then a hemostat. Now, your suture - looks better positioned than mine. Mine looks a little too superficial. So we're going to take out this suture and redo it. One more suture, please. One more suture coming in. See how mine was a little superficial? And yours is - you've got good engagement of the muscle. So yours will have better retraction than what we had at first, so - it's all about the set-up. So take the time to make sure you have what you want. If we're pulling and we shred and have a little hole, or a tear, we don't want that. So we're going to redo that. So, close the instrument a little bit to get down where you need to be. We're going to try and slide out laterally. As lateral as you can. Yep. And then swing that inferior tine - that looks better. Okay, close. Are you closed? Yep, closed. I'll switch the needle for you. Okay. Good. Yep, nice, gentle twists, and it will come. You're good. It's coming. Yep. Keep twisting. There you go. There you go, good. Maybe a touch better, but not too much. I think it's better. Take it out. Scissors? Okay, and we're going to take a staple. So now we have good retraction and better positioning of your - that left lateral suture. Now we're going to get our staple device.
And the staple device is going to go right in between these two. So these sutures allow us to have a good purchase so that as we push the staple in, we can retract the common wall towards us proximally, and that will allow us to engage the common wall. Because the key is to have a complete division of the upper esophageal sphincter. And so, the way this works - This allows you to twist the orientation here and we always have the staple, the blue part, in the lumen. Okay. This closes. Okay. And then this one fires. Okay. But we don't do this until we are 100% positioned and certain of where we want to be. Okay. So we go in like this. The assistant will hold some gentle traction on the sutures. You'll have to close it a little bit to engage. Okay. And then you just want to advance it as far as you can. And sometimes you need more than one staple line, which we'll find out once we're done, but most likely we'll need at least two, looking at this Zenker's here. Is it a ratcheted firing, or is it just a single application? A single application. So you have to close that a little bit to get it in there. Good. And then as you get close - perfect. So we're going to engage. So now you can open up all the way. You want to just gently slide that in a little bit more if you can. I'm holding good traction here. And then as far as it can go, then we'll stop then we'll fire this one. Can you get it any further in, do you think, or - does it feel about as...? I was hoping to be able to get a little bit more, but… Okay, well we can start here. So go ahead and close. Now, yep, pull the blue all the way down. Good. Now before you fire - we're good on that side, look at the other side. That looks perfect. Okay. Okay, so we'll get your camera back so we can see. Okay, and then it's a nice - you want to squeeze that all the way in. Keep going, all the way. All the way. You all the way squeezed? Yep. Okay, then you can let go of that one. And then you're going to release the top blue. All the way up. Good, and then you should be able to slide out. Good. And so there's our first division. So that's good, but we're going to take one more staple line. Looks good. Just so we can get a little deeper, go ahead into the pouch there. So we can see lumen. Yeah. But if we can get this division to be a little bit more towards that base, we're going to see if we can slide in more with a little bit more retraction of our common wall. This is why the staple's nice. We've divided it and we've sealed as well. Okay. So one more good placement of that staple cartridge and that should be complete. You're going to need to retrieve past some of those loose staples. Yeah, so go ahead and - you can see a loose staple right there, go ahead and take that out. It's a nice division though. Good. So again, close it a little bit and make sure it works and opens. Good. Okay, so I'm holding gentle traction as you slide that in as far as it'll go. Okay, that feels good. Go ahead and take it. Close it all the way. Good. And then confirm that you're good, look at the other side. Good. Okay. And then fire. Firing. All the way. Good. Let go. Releasing. Yep, open up the - device all the way. Good. And you can come on out. Great. Okay, so take that out. Maybe - a little bit. So just be a little bit gentle pushing. Okay. But we do want to get a sense of - is there room for more, or - how are we doing? Because we do have this retracted. All right, let me just take a quick look and feel as well, see if we want to do one more staple line or not. And I'll take the suction. So that's all divided there. So we've got division all the way - to there. So if something came here, it should - and there's always a little - the staple line doesn't go all the way to the very bottom. Makes you wonder if you can get one more little… Because there's your last staple, is right there. And that's the bottom. So that's pretty darn good. Let me just see what one more would feel like. If there's any way to get a tiny bit more, just to try to minimize any residual symptoms. Let's just see what it feels like here. So I'm trying to push that down. Okay, give me a little gentle traction now. All right. I think that's about as far as we can go. I'm going to fire. We'll get rid of those excess staples. Here you go, Audrey. And I'll take suction. I'll get rid of those staples in a second, but let me just look. There's a staple right there. So we're divided all the way down now to really that esophageal inlet, which is right here. Mm hmm. So that was a big common wall because we started all the way up here. Yeah. So I think we have a good division there, let me just clean up these staples. And then we'll cut our sutures and take a last look. All right, let's take out our sutures here.
I'll take a scissors, please. No - give me a longer scissors, just so I can cut it closer to - where it's going in. And then I'll take suction. And so, that shows our division from the base right into the esophagus there. But that big wall is all divided there. So again, just showing - so now we have a pouch that should lead into the esophagus there a lot more easily than before. Okay.