Zenker
The oblique fibers of the thyropharyngeus muscle, the upper portion of the inferior pharyngeal constrictor, are separated from the more horizontal folds of the cricopharyngeal sphincter by a point of potential weakness Killian's triangle , which is the site of formation of the Zenker's diverticulum. Formation of pharyngoesophageal Zenker's diverticulum.
Left herniation of the pharyngeal mucosa and submucosa occurs at the point of transition arrow between the oblique fibers of the thyropharyngeus muscle and more horizontal fibers of the cricopharyngeus muscle Killian's triangle.
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Center and right— as the diverticulum enlarges, it dissects toward the left side and downward in the superior mediastinum in the prevertebral space. Diverticula and miscellaneous conditions of the esophagus. WB Saunders, Philadelphia, pp The logical conclusion which must be drawn from this is that there is incoordination of the upper esophageal sphincter with swallowing resulting in increased intraluminal pharyngeal pressure proximal to the sphincter and a subsequent outpouching of the mucosa and submucosa at the point of potential weakness in the pharyngeal wall just proximal to the sphincter.
To attack the diverticulum surgically without relieving the distal obstruction from neuromotor dysfunction is to ignore the underlying cause of the patient's complaint. It is the degree of cricopharyngeal motor dysfunction, not the size of the diverticulum, which determines the severity of the patient's complaint of dysphagia. Impaired cricopharyngeal motor function is the key to understanding the symptoms of dysphagia in these patients, and as is true of all pulsion diverticula, it is the underlying motor dysfunction causing obstruction and formation of the pouch which must be relieved if the problem is to be treated successfully.
It was long ago recognized that when operating upon pulsion diverticula of the thoracic esophagus, a concomitant esophagomyotomy is mandatory if serious complications of unrelieved obstruction blow out of the suture-line are to be avoided [ 4 ]. The case is no different with pharyngoesophageal Zenker's diverticula.
Pulsion diverticula recur because the underlying obstruction responsible for their formation was not relieved at the initial operation. Dig Dis Sci Open diverticulectomy includes a lateral neck incision, exposure and excision of the offending pouch, and meticulous closure of the pharyngotomy wound site.
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A cricopharyngeal myotomy is also performed at this time. Postoperatively, oral feedings are performed for approximately 5 days while the pharyngotomy site is allowed to heal. Over the years, other less invasive techniques have evolved in an attempt to avoid the pharyngotomy, thereby reducing postoperative healing time and time to resume oral intake as well as reducing potential complications associated with a pharyngotomy.
Many authors during the s and s reported that ZD could be treated with CP myotomy alone without addressing the reservoir itself. There are a number of open surgical procedures that were designed to eliminate the dependent diverticulum, while avoiding the creation of a pharyngotomy that would require closure and a delay in instituting oral intake of nutrition as well as the attendant risks of infection and fistula formation.
Diverticulopexy involves suspending the diverticulum sac superiorly to the prevertebral fascia, thereby removing it from a dependent position. Imbrication involves dissecting the diverticulum and inverting it into the lumen of the esophagus and closing the mucosa over with a "purse string" suture. Both techniques have been shown to be successful and are generally associated with a decreased hospital stay and time to resume oral intake because the pharyngoesophageal mucosa is not violated.
The endoscopic approach is the only approach in which an external excision is avoided. This technique, originally described by Mosher 1 in , was abandoned early because of an increased complication rate, in particular, mediastinitis, which in the preantibiotic era had devastating consequences.
Treatment of Zenker's diverticulum
The endoscopic stapling technique has revolutionized the treatment of ZD. With this technique, not only is a lateral neck incision avoided, but the patient is allowed to resume oral intake rapidly, usually within 24 hours of surgery. A further advantage is the decreased morbidity associated with this technique. Most patients had no complications, and the 1 minor complication of mild postoperative bleeding resolved quickly and spontaneously with no long-term sequelae.
In our charge analysis, we found the intraoperative charges to be slightly higher for the endoscopic approach, although the difference between the 2 procedures did not reach statistical significance. Because the endoscopic technique is faster, it is logical to think that this would result in lower operative charges. However, this benefit is offset by the specialized equipment needed, specifically the EndoGIA stapler.
Our analysis did not include the enhanced revenue that could be generated by "back filling" the operating room following a shorter endoscopic procedure.
Hans Zenker
This analysis would surely favor the endoscopic approach. However, the major benefit from the endoscopic procedure is derived from the greatly reduced postoperative hospital stay. By reducing the hospital stay by a mean of 3. One might argue that patients should be able to go home earlier following an open procedure and continue their tube feedings as an outpatient. While this strategy may be entertained in a younger population, there are often extenuating circumstances in the older population who most often present with ZD, which make shorter hospitalizations more difficult.
Zenker Diverticulum - Gastrointestinal - Medbullets Step 2/3
Finally, one other parameter that was not analyzed in this study was the days in lost earnings to the patients from undergoing either of the 2 procedures. Clearly, for those individuals who are employed, the shortened procedure would provide an optimal financial analysis that would further favor the minimally invasive approach. It is important to state that not all patients with a diagnosis of ZD are candidates for an endoscopic stapling approach.
Exposure of the diverticulum and the esophagus is critical to provide access to the common party wall for application of the stapling device. Patients with limited neck extension or limited oral apertures are not favorable candidates, and transition to an open procedure may be required to resolve the patient's symptoms. The endoscopic stapling technique for the treatment of ZD has been proven to be as equally effective and safe as the open procedure, with a marked reduction in the postoperative recovery time. This results in a statistically significant shorter hospital stay and time to resume oral feedings compared with the standard open technique.
This faster recovery time translates into a markedly reduced hospital fee for the patient and easily counterbalances the slightly increased charges of the surgery.
Corresponding author and reprints: Aust N Z J Surg. Otolaryngol Head Neck Surg. Ann Otol Rhinol Laryngol. Ann R Coll Surg Engl. J Thorac Cardiovasc Surg. Surg Clin North Am. Smith, MD ; Eric M. Genden, MD ; Mark L. Patients, materials, and methods. Length of hospital stay. Time to oral intake. Sign in to access your subscriptions Sign in to your personal account.
Friedrich Albert von Zenker
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