Zenker's diverticulum surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ajay Gade MD[2]]

Surgery is the most definitive therapy for the Zenker’s diverticulum (ZD). If small and asymptomatic, no treatment is necessary. Larger, symptomatic cases of Zenker’s diverticulum have been traditionally treated by neck surgery to resect the diverticulum and incise the cricopharyngeus muscle. However, in recent times non-surgical endoscopic techniques have gained more importance, and the currently preferred treatment is endoscopic stapling i.e. closing of the diverticulum via a stapler inserted through a tube in the oral cavity. This may be performed through a fiberoptic endoscope. Other non-surgical treatment modalities exist, such as endoscopic laser, but recent evidence has shown it to be less effective than stapling.

• If small and asymptomatic, no treatment is necessary.
• Larger, symptomatic cases of Zenker’s diverticulum have been traditionally treated by neck surgery to resect the diverticulum and incise the cricopharyngeus muscle.
• However, in recent times non-surgical endoscopic techniques have gained more importance as they allow for much faster recovery, and the currently preferred treatment is endoscopic stapling (i.e. closing of the diverticulum via a stapler inserted through a tube in the mouth).^[1][2]
• This may be performed through a fibreoptic endoscope^[3].
• Other non-surgical treatment modalities exist, such as endoscopic laser, but recent evidence has shown it to be less effective than stapling.^[4]
• Various surgeries performed for the ZD are as follows:
  • Rigid endoscopic diverticulotomy
  • Flexible endoscopic diverticulotomy

Four types of procedures are performed using rigid scope

Endoscopic electrocautery may be used as a treatment option for Zenker’s diverticulum:^[5][6]

• This is suitable for smaller lesions and is performed via an endoscope.
• A double-lipped esophagoscope is used and the wall between the diverticulum and esophageal wall is exposed.
• The hypopharyngeal bar is divided with diathermy or laser.
• Shorter duration of anaesthesia.
• More rapid resumption of oral intake.
• Shorter hospital stay.
• Quicker recovery.

Complications:

• Sub-cutaneous emphysema
• Mediastinitis
• Aspiration from the pouch

2.Endoscopic CO2 laser technique

Endoscopic CO2 laser technique may also be used as a treatment option for Zenker’s diverticulum:^[7][8]

• This technique offers high energy and high focused beam.
• Very minimal tissue trauma.
• It also provides a better visualization of the diverticular bridge and easier control of the operation.

Complications:

• Mediastinitis
• Sub-cutaneous emphysema

3.Endoscopic stapling

Endoscopic stapling is one the preferred treatment options for Zenker’s diverticulum:^[9]

• This cuts and seal the edge of the wound simultaneously,
• Low incidence of perforation and bleeding.
• Thermal damage to the recurrent laryngeal nerve can be prevented with this procedure.

4.Endoscopic harmonic scalpel

Flexible Endoscopic Diverticulotomy

• The procedure is done with an extended neck under sedation, general anesthesia is not required.
• The septum between the diverticulum and esophageal lumen can be visualized by the hood, endoscopic cap, and overtube and stabilized without overextension of the neck.
• The knives used for the incision are as follows
  • Needle-knife
  • Hook-knife
  • Argon plasma coagulation
  • Monopolar forceps

Complications of the Endoscopic procedures^[10]

• Emphysema (mediastinal/cervical)
• Esophageal perforation
• Dental Injury
• Bleeding
• Mediastinitis
• Leak
• Recurrent laryngeal nerve injury
• Infection

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