Endoscopic Zenker's Diverticulotomy

Description:

Endoscopic Zenker's diverticulotomy is a method of treating a Zenker's diverticulum, or herniation of the hypopharyngeal tissues between the cricopharyngeus and inferior constrictor muscles. This technique does not actually remove or repair the diverticulum. Rather, the common wall between the esophagus and the diverticulum is simultaneously cut and stapled using an endoscopic stapler. This leaves a large opening between the diverticulum pouch and the esophagus. The procedure includes division of the cricopharyngeus muscle to prevent recurrence.

Indications for Surgery:

Symptomatic Zenker's diverticulum resulting in dysphagia or regurgitation.

Contraindications to Surgery:

  • Medical comorbidities that would preclude surgical or anesthesia risk
  • Suspicion for hypopharyngeal or esophageal malignancy
  • Difficult transoral endoscopic access
  • Short segment Zenker's diverticulum (less than 3 cm)

Pre-Operative Evaluation:

  • Diagnosis of Zenker's diverticulum is made on barium swallow radiography.

Anesthesia:

General endotracheal

Surgical Technique:

  1. The patient is placed supine on the operating table and general anesthesia is induced via endotracheal intubation.
  2. The table is rotated 180 degrees. A shoulder roll is placed and the neck is extended.
  3. A dental guard is placed over the maxillary teeth. A Weerda bivalved pharyngoscope is inserted transorally to the level of the diverticulum and placed in suspension.
  4. After obtaining adequate exposure of the common wall between the esophagus and the diverticular lumen, an endoscopic stapler is inserted, with one blade in the esophageal lumen and the other blade in the diverticulum. The stapler is then fired, dividing the diverticular common wall. Multiple firings of the stapler may be required, depending on the size of the diverticulum.
  5. The cricopharyngeus muscle is incised internally, either during the stapling, or using scissors to cut the inferior muscle fibers. If the cricopharyngeus needs to be cut with scissors, the resulting mucosal incision can be repaired with a single suture.
  6. The patient is suctioned and the esophagus, diverticulum, and incision are inspected with a rigid endoscope for dehiscence or perforation.
  7. The laryngoscope is taken out of suspension and withdrawn, and care of the patient is returned to the anesthesiologist for extubation and recovery.

Post-Operative Care

  • Endoscopic Zenker's diverticulotomy may be performed on an elective, outpatient basis, or the patient may be admitted overnight postoperatively depending on age and general health.
  • The patient should be monitored for at least several hours after surgery for signs and symptoms of perforation or dehiscence (e.g., subcutaneous emphysema, tachycardia, tachypnea, fever, chest pain).
  • A clear liquid diet is prescribed for the first 24 hours following surgery, following which the diet may be advanced as tolerated.
  • The patient is discharged on a proton pump inhibitor to minimize the effects of reflux on healing.
  • No follow-up barium swallow is recommended, unless symptoms do not resolve.

Complications:

  • Bleeding
  • Injury to local structures, including recurrent laryngeal nerve injury and esophageal perforation
  • Staple line dehiscence, leading to leakage, neck infection, and possible mediastinitis
  • Dysphagia/foreign body sensation
  • Recurrence of diverticulum




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