Treatment Options for Zenker Diverticulum

What are the current recommendations for treatment of a moderately symptomatic Zenker diverticulum in a healthy 75-year-old man who takes no medications?

- Richard D. Coan, DO   Plantation, Fla

Most Zenker diverticula can be treated with a transoral endoscopic operation that is performed as an outpatient procedure. The 2 goals of the procedure are:

• To divide the common wall between the esophagus and the Zenker diverticulum, thereby allowing the sac to empty into the esophagus rather than the throat; this results in amelioration of symptoms.
• To divide the obstructing cricopharyngeus muscle located in the common wall (diverticula are caused by an overly tight cricopharyngeus muscle, which constricts the hypopharyngeal esophageal junction).

Improvements in technology (ie, the diverticuloscope used to expose the involved structures transorally, better telescopes and cameras for visualization, and endoscopic staplers that both divide the muscle and seal the mucosal edges) have increased the safety of surgical treatment of Zenker diverticula. The overall morbidity of the transoral operation is lower than that of procedures that use a more traditional open transcervical approach (cricopharyngeal myotomy and Zenker diverticulectomy). Moreover, patients can resume a regular diet immediately, and pain and swallowing problems are often diminished.

Consequently, surgery may now be more readily considered for the typical older patient with a Zenker diverticulum, who is likely to have significant comorbidities. In the past, the increased risk associated with the transcervical approach meant that surgery would have been contraindicated for such a patient.

Symptomatic diverticula of more than 2.5 to 3 cm in length can be treated transorally in patients who have a reasonable mouth opening and neck mobility and who can tolerate brief general anesthesia. Patients with shorter diverticula do better with open cricopharyngeal myotomy, which resolves the mucosal redundancy and obstruction.

The best approach can be determined by an office examination (to evaluate the severity of symptoms, comorbidities, and mouth opening), together with a modified barium swallow (to assess diverticulum length [on the lateral views] and evaluate any coexisting pharyngeal and esophageal motility issues). Both the transoral and transcervical approaches can significantly ameliorate symptoms and restore reasonably normal swallowing in appropriately selected patients.

- James Cohen, MD, PhD
   Professor, Head and Neck Surgery
   Department of Otolaryngology/Head and Neck Surgery
   Oregon Health Sciences University
   Portland