Esophagus—Zenker’s Diverticulum
Concept
Upper esophageal muscle dyscoordination with lower pha- ryngeal constrictor contracting against an unyielding cricopharyngeus muscle. This causes an acquired (false diverticulum) mucosal out-pouching of the esophageal wall between these muscles on the left posterolateral side (Killian’s triangle).
Way Question May be Asked?
“A 78 y/o male presents on referral from his family doctor complaining of trouble swallowing with occasional regur- gitation of undigested food, mainly at night.” Rarely will you get the patient with obvious bad breath, dysphagia to solids and liquids, regurgitation of undigested food, a sen- sation of a lump in the throat, and gurgling in the neck.
Weight loss and aspiration are late symptoms.
How to Answer?
Must work through an algorithm for dysphagia and rule out mainly achalasia and cancer
History
Solids vs. liquid dysphagia Weight loss
Smoking GERD/Barrett’s Coughing up solid food Halitosis (bad breath) Gurgling in neck
Physical Exam
Neck and lymph node basins (will never feel diverticulum)
Diagnostic Tests
Labs, EKG, CXR
Don’t forget in elderly patients an assessment of the preoperative status (pulmonary, cardiac, and renal evaluation if necessary pre-op)
UGI first maneuver—always before EGD, especially because EGD may perforate a Zenker’s as two lumens will be visualized on EGD
Surgical Treatment
Left cervical incision over anterior border of SCM Diverticulum located in plane between carotid sheath
and trachea
Bougie in esophagus to prevent narrowing when performing diverticulectomy with TA stapler May invert and perform a diverticulopexy to
precervical fascia in elderly, high risk, with diverticulums greater than 3 cm to reduce risk of sta- ple line leak, but they will likely push you to perform resection
May leave alone if less than 2 cm
Always perform a cricopharyngeal myotomy—gentle cephalad traction on the diverticulum will expose fibers of the cricopharyngeus muscle which are divided and bluntly dissected from the underlying mucosa and continued onto the esophagus for several centimeters
Always drain the incision!
Don’t mention endoscopic alternatives to open resection
Common Curveballs
Pt develops a leak or wound infection post-op
Performing a pexy leads to perforation of the diverticulum
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Injury to the rec. laryngeal identified post-op
Diverticulectomy lead to narrowing of the esophagus after not using a bougie
Injury to esophagus intra-op
Strikeouts
Forgetting to leave a drain
Not describing operative procedure properly
Forgetting to perform the cricopharyngeal myotomy Forgetting to perform UGI or not performing prior to
EGD
Discussing the endoscopic treatment that you’ve never seen (never describe an operation you’ve never done.
It’s better to say something like “I do not perform this operation, but I know the key aspects are the fol- lowing...”)
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