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Making Eating More Fun—For All Ages

Advances in the management of Zenker diverticulum

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By Brandon Prendes, MD, and Brian Burkey, MD, MEd

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Zenker diverticulum is a condition in which a pulsion diverticulum sac forms in the cervical esophagus above the cricopharyngeus muscle. Overall, this is a relatively uncommon problem, but one that is frequently referred to otolaryngologists. Symptoms include regurgitation of food, chronic cough, foul-smelling breath, and slow and labored eating, all of which can disrupt a patient’s quality of life. Elderly patients face an increased risk of malnutrition and aspiration pneumonia, which can be life-threatening.

The traditional treatment for a symptomatic Zenker diverticulum has been surgery via an open transcervical approach. This procedure entails excision of the Zenker pouch, division of the cricopharyngeus muscle and closure of the esophageal wall. But with the increasing popularity of endoscopic techniques, the paradigm at many medical centers has swung clearly toward endoscopic diverticulostomy (ESD), with transcervical treatment reserved for patients who fail ESD. The reported advantages of ESD include less operative time, avoidance of a neck scar, less risk to the superior and recurrent laryngeal nerves, and a shorter time to oral intake.

An older procedure for younger patients

We keep our options open. Instead of the one-size-fits-all treatment strategy that is used in most centers, surgeons at Cleveland Clinic’s Head & Neck Institute apply a personalized approach to the management of this disease. And that means that we have not abandoned the older open transcervical type of surgery. Thanks to our multiarm surgical algorithm, our approach has resulted in better outcomes, which we detailed in a published study.

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A: Preoperative barium swallow study demonstrates a 10-cm Zenker pouch (arrow) in a 78-year-old man who presented with worsening dysphagia, regurgitation and a 100-pound weight loss over the preceding year. B: Intraoperative photo shows the transcervical approach to mobilization of a large diverticulum (arrow). C: Intraoperative photo of the diverticulopexy technique shows the Zenker pouch suspended from the prevertebral fascia (arrow). D: Postoperative barium swallow study shows no pooling of barium in the suspended pouch. The patient tolerated a full liquid diet on postoperative day 1, and he remained symptom-free at last follow-up three months out from surgery.

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In that article, members of the Head & Neck Institute described our comparison of postoperative symptom scores in 55 patients, roughly half of whom were treated with ESD and half via the transcervical approach. While both groups experienced significant short-term symptomatic improvement, outcomes over the long term were quite different; 94 percent of patients in the transcervical group maintained long-term improvement or resolution of symptoms, whereas only 67 percent of the ESD patients had sustained benefit. This suggests that while the ESD approach is quicker and avoids a neck scar, the more durable benefit of the transcervical approach may be attractive to younger, healthier patients with a long life expectancy.

These data confirm that an open transcervical approach still has an important role in the management of this disease. This is especially important in view of (1) the difficulty of performing ESD in patients in whom transoral exposure is limited and (2) the frequent failure of ESD in patients with a small (< 2 cm) diverticulum.

Another older procedure has its place

Another recent advancement in Zenker management at the Head & Neck Institute is the use of transcervical diverticulopexy instead of diverticulectomy. While there are historical reports of the safety of diverticulopexy, little has been published about it in recent years.

Our surgeons’ approach to diverticulopexy involves first isolating the diverticulum and then performing a cricopharyngeal myotomy. Next, rather than excising the diverticulum and closing it with a suture or staple, we leave the pouch unviolated, and then we invert it and suture it to the prevertebral fascia. The result prevents the trapping of food while maintaining the crucial step of cricopharyngeus division to prevent the recurrence of symptoms. Further, this technique avoids the risk of pharyngeal leak from a mucosal closure.

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Our surgeons have experienced outstanding results with diverticulopexy, even in patients with massive diverticula who have failed previous attempts at treatment (Figure). Patients who undergo diverticulopexy can return to an oral diet and are discharged home on the first postoperative day with little or no risk for salivary fistula.

Age-appropriate therapy

With all of these treatments available, patients who present to the HNI for treatment of Zenker diverticulum can expect to be engaged in a comprehensive discussion regarding the benefits and drawbacks of each approach. Patients with significant comorbidities in whom prolonged anesthesia is risky are often encouraged to consider the shorter operative time involved with ESD. Since most of these patients are elderly, the shorter duration of symptomatic benefit is not as critical. Conversely, we place greater emphasis on the transcervical approach for younger patients, for whom long-term benefit is more important.

In the experienced hands of HNI surgeons, the complication rate is similarly low with either approach. Regardless of the type of treatment, the HNI delivers personalized and highly successful care to patients of all ages to make eating fun again.

Dr. Prendes is a member of the Section of Head and Neck Surgery and Oncology and the Section of Facial and Reconstructive Surgery. He can be reached at 216.444.0578 or prendeb@ccf.org.
Dr. Burkey is Head of the Section of Head and Neck Surgery and Oncology and Vice-Chairman of the Head & Neck Institute. He can be reached at 216.445.8837 or burkeyb1@ccf.org.

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