Which of the following is TRUE about Zenker’s diverticulum -
1.It is asymptomatic
2.Occurs in the mid esophagus
3.Treatment is simple excision
4.It occurs in children
Explanation
Zenker’s or Pharyngo-esophageal diverticula
Zenker’s diverticula are mucosal outpouchings occurring through the triangular bare area (Killian’s triangle) between the upper oblique fibres (also known as thyropharyngeus muscle) and lower horizontal fibres (also known as cricopharyngeus muscle) of the inferior constrictor muscle.
Underlying pathology is neuromuscular incoordination in this region [this may be due to the fact that different nerves supply the two parts of the inferior constrictor muscle - the thyropharyngeus (oblique fibres) supplied by the pharyngeal plexus and the cricopharyngeus (horizontal fibres) by recurrent laryngeal nerve]
Zenker’s diverticulum is a pulsion diverticulum.
Esophageal Diverticula are of two types: pulsion & traction
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In pulsion diverticulum, increased intraluminal pressures (secondary to abnormal esophageal motility) push the mucosa and submucosa through a muscular defect in the wall of the esophagus creating a pulsion diverticulum. It’s not true diverticula (not containing all the layers of the esophageal wall)
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In traction diverticula extraluminal forces (like inflammed & scarred peribronchial & mediastinal lymph nodes) pull the full thickness of the esophagus out, creating a true diverticula.
Zenker’s is the most common esophageal diverticula.
The diverticula arises posteriorly in the midline of neck. The mouth of the diverticula is in the midline but the sac projects laterally (usually left laterally)
Zenker’s diverticula are rarely seen below 30 yrs of age, most patients are over 50.
Dysphagia is the most common symptom.
Undigested food is regurgitated into the mouth, especially when the patient is in the recumbent position.
Swelling of the neck, gurgling noises after eating, halitosis (bad mouth odour) and a sour metallic taste in the mouth are common symptoms.
Barium swallow is diagnostic
Management (Maingot’s 11/e chapter 8; Sabiston 18/e p1062; Schwartz 9/e p848)
Surgical therapy is the treatment of choice. Methods used are:
Cricopharyngeal myotomy - a myotomy alone is usually sufficient for small diverticula (<2cm).
Myotomy with Diverticulopexy
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larger diverticulum may be sutured in the inverted position to the prevertebral fascia using a permanent suture (i.e., diverticulopexy).
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diverticulopexy avoids the complication of infection due to leak from a resected diverticulum (diverticulectomy)
Myotomy with excision of sac - done for large (> 5 cm) diverticula
- If the diverticulum is excessively large so that it would be redundant if suspended a diverticulectomy should be performed.
Diverticulo-esophagostomy using a linear cutting staple gun
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the septum between the esophagus and the diverticula is divided
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also known as Dohlman procedure
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advantage is that it takes less time to complete, does not require an incision, and therefore may have less morbidity. This is an important consideration since this disease most commonly presents in the elderly.
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This procedure is effective for diverticula >2 cm, and may be impossible to perform for the small diverticulum. Sabiston writes- " For these reasons, this technique has gained favor and is advocated in patients with diverticula between 2 and 5 cm."