Zenker\'s Diverticulum

7%Y l,~Ir.Yngl)% Opl’

I,ippincott-Raven Publishers, Philadelphia

0 1997 The American Larvneolomcal.

fihino~o@caland Otologicil sociity, Inc

Zenker’s Diverticulum Hoang C. Nguyen, MD; Andrew C. Urquhart, MD Symptomatic Zenker’s diverticula are usually treated with diverticulectomy and myotomy. Other, more conservative open procedures consist of diverticulopexy, imbrication, and myotomy alone. These more conservative procedures do not result in a breach of esophageal mucosa and should have more rapid postoperative recovery. We performed a retrospective chart review of all open surgical procedures performed at the Marshfield Clinic and St. Joseph’s Hospital between 1976 and 1996. Using Wilcoxon’s rank sum test, the conservative procedures were compared with the standard diverticulectomy for duration of hospitalization and length of time to resumption of oral intake. Fifty-nine patients are reported. Statistically significant differences between the surgery groups were found for hospitalization ( P c 0.001) and days to resumption of oral intake ( P c 0.001). Conservative open surgical procedures for repair of Zenker’s diverticula result in decreased hospitalization and earlier resumption of oral diet compared with diverticulectomy. Laryngoscope, 107:1436-1440,1997

INTRODUCTION Zenker’s diverticula are also known as pharyngoesophageal or hypopharyngeal diverticula. The first case was described as an autopsy finding by Ludlow in 1764. In 1878 Zenker and von Ziemssen reviewed 22 cases from the literature and added five of their own. Zenker’s name subsequently became associated with this entity.l Zenker and von Ziemssen proposed that these diverticula were the result of forces acting within the esophageal lumen against an area of resistance. Killian identified the site of origin, occurring between the oblique fibers of the thyropharyngeus muscle and the more horizonPresented at the Meeting of the Middle Section of the American 13m.yngological,Rhinological and Otological Society, Inc., Kansas City, Missouri, .January 25, 1997. From the Departments of General Surgery (H.c.N.) and Otolaryngology--Me;id and Neck Surgery (A.c.u.), Marshfield Clinic, Marshfield, Wiscons111. Send Reprint Requests to Hoang C. Nguyen, MD, Department of ( k w r a l Surgery, Marshfield Clinic, 1000 N. Oak Avenue, Marshfield, WI 54449, ZJ.S.A.

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tal fibers of the cricorophyaryngeus muscle (Killian’s triangle1.1 The first attempted excision was performed in 1884. The patient, however, died of hemorrhage from the superior thyroid artery. The first successful excision of a Zenker’s diverticulum was reported by the Irish surgeon Wheeler in 1886.2 There is no medical treatment for symptomatic Zenker’s diverticula, and a symptomatic patient should undergo surgery. There are a variety of surgical approaches. Dohlman3 described an endoscopic approach avoiding an external incision. In the original description the wall between the esophagus and diverticulum was divided with electrocautery. Modifications of this procedure have involved the use of lasers and stapling, with the assistance of different diverticuloscopes. Although good results have been reported,4 not everyone is familiar with this technique, relying on the more traditional external procedures. An external surgical procedure consisting of diverticulectomy with a cricopharyngeal myotomy is the traditionally favored procedure performed by most surgeons. This procedure consists of excision of the sac and closure of the pharyngeal mucosa with sutures and, more recently, staples. Diverticulectomy with cricopharyngeal myotomy, however, is associated with a relatively high rate of postoperative wound infection and pharyngocutaneous fistula.5 Other, more conservative external procedures consist of diverticulopexy, imbrication, and myotomy alone. These more conservative procedures do not violate the esophageal mucosa and therefore should have a more rapid postoperative recovery, particularly with regard to resumption of oral intake. Diverticulectomy involves excision of the diverticulum through a left-side incision along the anterior border of the sternocleidomastoid muscle (Fig. 1). Closure of the esophagus and mucosa is usually performed with an inverting suture in two layers. Staples may also be used. Diverticulopexy involves simply mobilizing the pouch and suspending it in the posterior pharyngeal space by suturing it to the prevertebral fascia (Fig. 2). With imbrication, the diverticulum is dissected free and inverted into the lumen of the esophagus. The soft tissues are Nguyen and Urquhart: Zenker’s Diverticulum

Fig. 1. Diverticulectomy.

Fig. 3. Imbrication of sac with purse-string closure.

closed over it with a “purse-string” suture to ensure that the diverticulum remains within the lumen of the esophagus (Fig. 3). With cricopharyngeal myotomy, the fibers of the cricopharyngeal muscle are incised, sparing the mucosa of the esophagus. The myotomy extends a short distance proximal to the origin of the pouch and about 5 cm distal to the o r i gin of the pouch.

retrospective chart review was performed, and specific data sought included the patient’s age, sex, presenting signs and symptoms, complications, recurrent symptoms, and the type of procedure performed (diverticulectomy with or without myotomy, imbrication, diverticulopexy, or myotomy alone). Using Wilcoxon’s rank sum test, the conservative procedures (imbrication, diverticulopexy, and myotomy alone) were compared with diverticulectomy (with o r without myotomy) for duration of hospitalization and length of time to resumption of oral intake.

The purpose of this study was to compare the more conservative external procedures (diverticulopexy, imbrication, and cricopharyngeal myotomy alone) with those of the standard surgical procedure (i.e., diverticulectomy with or without myotomy) specifically with regard to the length of time to resumption of oral intake and duration of hospitalization.

MATERIAlLS AND METHODS All patients with symptomatic Zenker’s diverticula treated surgically from 1975 to 1996 at Marshfield Clinic and St. Joseph’s Hospital were included in this study. A

RESULTS Thirty-seven men and 22 women with a n average age of 71 years were identified. Dysphagia in 48 patients (81%)and regurgitation of food in 31 patients (52%) were the most common presenting symptoms (Table I>.Except for three patients with clinical evidence of pooling of saliva on indirect laryngoscopy, the physical examination contributed little information. All patients underwent a preoperative barium swallow demonstrating the diverticulum (Fig. 4). Twenty-five patients underwent diverticulectomy (18 with myotomy) and 16 underwent more conservative procedures (six had diverticulopexy; five, imbrication; and five, myotomy alone). The type

TABLE I. Signs and Symptoms at Presentation. Signs and Symptoms

Fig. 2. Diverticulopexy: suspension of the sac to prevertebral fascia.

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Dysphagia Regurgitation of food Aspiration, coughing, throat clearing Pneumonia Hoarseness Weight loss Halitosis Neck pain

Number

%

48 31 18 8 3 3 1 1

81 52 30 14 5 5 1.7

1.7

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Fig. 4.Barium swallow demonstrating contrast-filled diverticulum.

of surgical procedure performed varied with time. Most of the diverticulopexies, myotomies, and imbrications were performed between 1991 and 1996, whereas diverticulectomy was more common before 1990. Postoperative complications consisting of salivary fistula (four), vocal cord weakness (one), and wound hematoma (two) were noted in the diverticulectomy group. Wound infection (one) and esophageal stricture (one) were noted in the conservative group.

All patients were followed up for a duration of 1 to 30 months with a n average follow-up of 2 months. There were four recurrences requiring surgical revision. Three of these occurred in patients who had diverticulectomy with myotomy, and one occurred in a patient who had a myotomy alone.

None of the patients who underwent diverticulopexy (with myotomy) or imbrication (with myotomy) had a recurrence. The length of time to resumption of oral intake and duration of hospitalization between the two groups (conservative vs. diverticulectomy) were compared. Table I1 contains descriptive statistics and univariate comparisons of hospital days and days to resumption of diet by gender surgery group for the years of 1975 to 1996. No adjustment was made for the time factor. Since the data were not normally distributed, Wilcoxon’s rank sum test was used to compare surgery groups. A statistically significant difference between surgery groups was found for hospital days (P < 0.001) and days to resumption of diet (P< 0.001). For both factors the median number of days was lower for the conservative group. When a n adjustment was made for the time factor, the same trend was noted. Figures 5 and 6 represent the hospital days by time period and days to resumption of diet by time period, respectively. Within the same time period, patients who underwent more conservative procedures stayed in the hospital for a shorter period of time and resumed their diet sooner compared with patients who underwent diverticulectomy.

DISCUSSION Zenker’s diverticulum or pharyngoesophageal diverticulum is the most common type of esophageal diverticulum.1 The condition usually occurs in elderly individuals, with 50% of cases occurring during the seventh and eighth decades of life. It is more common in men than women.2 The occurrence of Zenker’s diverticula in older patients gives credence to its acquired rather than congenital origin.6In fact, the acquired nature of these diverticula is now widely accepted, although the exact pathophysiologic mechanism responsible for their development is still not completely understood.7

TABLE II. Descriptive Statistics and Univariate Comparisons of Hospital Days and Days to Resume Diet by Sex and Group (1975-1996). Factor

Group

No.

Mean

Std

Minimum

Maximum

Median

Hospital days

Female Male Conservative Diverticulotomy Female Male Conservative Diverticulotomy

22

6.2 8.1 4.6 8.4 3.0 4.7 1.3 5.1

3.4 7.3 3.7 6.6 2.6 6.5 1.4 6.0

2 2 2 2 0 0 0 1

14 37 14 37 10 37 6 37

6.5 6 3 7 2 3 1 3

Days to resume diet

37 16 43 22 37 16 43

P value’

0.76 0.001+ 0.33 c 0.001+

‘Wilcoxon rank sum test. +Statistically significant ( P < 0.05).

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Nguyen and Urquhart: Zenker’s Diverticulum

0

75-80

81-85

86-90

91-96

75-80

Year of Surgery 000

DVectomy

Conservative

Fig. 5. Hospital days by time period.

Cook et a1.8 investigated pharyngeal coordination, sphincter opening, and flow pressures during swallowing in patients with Zenker’s diverticula. The researchers believed this was a disorder of diminished upper esophageal sphincter opening. Dysphagia is most likely caused by incomplete sphincter opening with an increase in the hypopharyngeal pressure during swallowing. Negus,g on the other hand, believed that cricopharyngeal spasm was responsible for the development of these pouches. Ardran and Kemplo in 1961 proposed that incoordination of cricopharyngeal function with premature contraction of the upper esophageal sphincter was the cause of esophageal dysphagia. The natural history of Zenker’s diverticulum is the continued slow enlargement of the sac with time that is due t o the decreased compliance of the skeletal portion of the cervical esophagus.11 It is the degree of cricopharyngeal muscle dysfunction, not the absolute size of the diverticulum, that determines the relative severity of cervical dysphagia experienced by these patients.1 Gastrointestinal tract disorders including hiatal hernia, gastroesophageal reflux, and gastroduodenal ulcers are most commonly associated with Zenker’s diverticula.12Less common disorders include midesophageal diverticulum, difLaryngoscope 107: November 1997

81-85

86-90

91-96

Year of surgery 000

DVectomy

Conservative

Fig. 6. Days to resume diet by time period.

fuse esophageal spasm, nutcracker esophagus, and achalasia.12 The diagnosis of Zenker’s diverticula can be made on history and confirmed by a barium swallow. The sac is usually identified posteriorly and to the left of the esophagus. Endoscopy is not indicated and is thought to be dangerous, owing to obstruction of the true esophageal lumen by the diverticulum and the risk of perforation.11 Diverticulectomy with cricopharyngeal myotomy has been the standard surgical treatment for the vast majority of patients with symptomatic Zenker’s diverticula. The most significant postoperative complications associated with this treatment include pharyngocutaneous fistula, mediastinitis, wound infection, and symptomatic esophageal stenosis or stricture.5J3 The incidence of pharyngocutaneous fistula after diverticulectomy (with or without myotomy) has been reported from 3.2%to 13%5JP17; of wound infection and mediastinitis, 2.8% to 20%5JP17; and stenosis or stricture, up to 7.1%.18 Although Dohlman’s endoscopic procedure has not gained widespread acceptance, there has been renewed interest in this technique. Special endoNguyen and Urquhart: Zenker’s Diverticulum 1439

scopic equipment is required, and great care must be taken to avoid transecting the party wall too far inferiorly. In a large series of 545 patients, a low complication rate and high patient satisfaction rate using this technique have been reported.4 More conservative procedures (diverticulopexy, imbrication, and myotomy alone) do not involve a breach of esophageal mucosa; therefore one would expect these patients to be able to resume an oral diet immediately after surgery with a subsequent decrease in duration of hospitalization. The traditional diverticulectomy results in a breach in the esophageal mucosa, and many of these patients are treated as one would treat a laryngectomy patient, with resumption of oral intake up to 7 days after the procedure. Most of the patients in this group also require a nasogastric tube during this time period. Imbrication with a myotomy is now our standard procedure for all small (c2 cm) and moderate-sized (2 to 4 cm) diverticula. Once adequate oral intake is achieved on the first postoperative day, the patient is discharged. Larger lesions (>4cm) are still excised in the traditional fashion.

CONCLUSION There are many surgical options for the treatment of symptomatic Zenker’s diverticulum. Most methods require an external incision; however, by keeping the esophageal mucosa intact, one is able to avoid contaminating the wound with saliva and these patients can be treated postoperatively as for any standard neck procedure. Once the mucosa is breached, however, the potential for a salivary fistula exists and the surgeon must take this into account when starting the patient on an oral diet. Conservative external procedures (imbrication, diverticulopexy, and myotomy alone) result in a decreased length of hospitalization and earlier resumption of oral intake compared with diverticulectomy (with or without myotomy). The long-term results suggest that these procedures are effective in controlling patient’s symptoms and that therefore

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they should be considered as an alternative to the more traditional diverticulectomy.

BIBLIOGRAPHY 1. Sabiston DC Jr. Textbook of Surgery: the Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: WB Saunders; 1997:712-4. 2. Ellis FH Jr. Pharyngoesophageal (Zenker’s) diverticulum. Adv Surg 1995;28:171-89. 3. Dohlman G. Endoscopic operations for hypopharyngeal diverticula. In: Proceedings of the Fourth International Congress on Otolaryngology: London, 1949. London: British Medical Association, 1951;2:715-7. 4. Van Overbeek JJ. Meditation on the pathogenesis of hypopharyngeal (Zenker‘s) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994; 103:17885. 5. Morton RP,Bartley JRF. Inversion of Zenker’s diverticulum: the preferred option. Head Neck 1993;15(3):253-6. 6. Holinger PH, Johnston KC. Endoscopic surgery of Zenker’s diverticulum: experience with the Dohlman technique. Ann Otol Rhinol Laryngol 1995;104:751-7. 7.Migliore M, Jayne H, Jeyasingham K. Pathophysiologicbasis for operation on Zenker‘s diverticulum. Ann Thorac Surg 1994; 57:161&21. 8. Cook IJ,Gabb M, Panagopoulos V, et al. Pharyngeal (Zenker’s) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology 1992;103:1229-35. 9. Negus VE.Pharyngeal diverticula: observations on their evolution and treatment. Br J Surg 1950;38:129-46. 10. Ardran GM, Kemp FH. The radiography of the lower lateral food channels. J Laryngol Otol 1961;75:358-70. 11. Schwartz SI,Shires GT, Spencer FC. Princzples of surgery. 5th ed. New York McGraw-Hill, 19941078-81. 12. Lerut T, vanRaemdonck D, Guelinckx P, et al. Pharyngoesophageal diverticulum (Zenker‘s): clinical therapeutic and morphologic aspects. Acta Gastroenterol Belg 1990;53:330-7. 13. Johnson J, Weissman J. Diverticular imbrication and myotomy for Zenker’s. Laryngoscope 1992;102:1377-8. 14. Maran AGD, Wilson JA, Al Munana R. Pharyngeal diverticula. Clin Otolaryngol 1986;11:219-25. 15. Bowdler DA, Stell PM. Surgical management of posterior pharyngeal diverticula: inversion versus one-stage excision. Br J Surg 1987;78:988-90. 16. Morton RP,Giles ML. Surgery for pharyngeal pouch. Aust N 2 J Surg 1986;56:77-9. 17. Freeland AP, Bates GJ. The surgical treatment of pharyngeal pouch:inversion or excision. Ann R Coll Surg Eng 1987;6957-8. 18. Laccomeye 0,Menard M, Cauchois R, et al. Esophageal diverticulum: diverticulopexy versus diverticulectomy. Laryngoscope 1994;1042369-92.

Nguyen and Urquhart: Zenker’s Diverticulum