Zenker s diverticulum Jill N. D Souza, MS3 Michael Underbrink, MD University of texas medical branch Department of Ot

1. Zenker�s diverticulum Jill N. D�Souza, MS3Michael Underbrink, MDUniversity of texas medical branchDepartment of OtolaryngologyGranD rounds presentationMay 28, 2010

2. Chief Complaint �Food is getting stuck in my throat, and I feel like I�m going to choke�

3. HPI 72yo CF presenting for evaluation of intermittent dysphagia of several years duration Dysphagia worsened over the weeks prior to admission, and she developed choking spells several times a week She reports regurgitating food several hours after eating as well as foul breath

4. PMH/medications Essential Hypertension Osteoarthritis Hearing loss Furosemide 20mg PO qAM Aspirin 81mg PO daily Calcium and Vitamin D Vitamin supplements Fish oil

5. PSH Septoplasty Colonoscopy Breast biopsy Retinal tear repair

6. FH/SH Stroke � mother Hypertension - mother Esophageal cancer � father CAD � son Lung cancer � brother Married, 3 children, retired chemist Smoking: 5 py history, quit in 1977 EtOH:1-2 drinks/day Drug use: denies Allergic to PCN

7. ROS General: A&O x 4, NAD, no fever, chills, no weight changes Head/face: no headache, trauma Eyes: no vision changes, no discharge Ears: no otorrhea, otalgia, , vertigo, tinnitus or hearing loss Nose/Sinuses: no difficulty breathing, no epistaxis, no snoring or rhinorrhea Oropharynx: + dysphagia, + food regurgitation, + choking during swallow, + frequent throat clearing, no hoarseness Neck: No swelling/stiffness, pain or palpable masses Respiratory: no coughing/wheezing, SOB/DOE, apneic episodes, Cardiac: no chest pain, palpitations, no history of murmurs GI: no heartburn, no abdominal pain, no v/n/d, no constipation MS: no muscle pain/weakness, joint swelling

8. PE

9. Labs

10. Barium Swallow Large hypopharyngeal diverticulum noted within the upper cervical esophagus. Distal to the diverticulum caliber and motility of esophagus is normal. Large hypopharyngeal diverticulum noted within the upper cervical esophagus. Distal to the diverticulum caliber and motility of esophagus is normal.

11. Diagnosis Zenker�s Diverticulum

12. Zenker�s Diverticulum Most common hypopharyngeal diverticulum Motor abnormality of the esophagus Outpouching of mucosa through an area of weakness between the cricopharyngeus and lower inferior constrictor Killian�s hiatus/triangle is most common location False diverticulum 2/3 protrude in the midline Diagnosis confirmed by contrast radiography Pulsion-type diverticulum - Traction diverticula are a result of pulling forces external to the esophagus that are secondary to inflammatory or neoplastic processes and usually occur on the anterior wall of the esophagus near the bifurcation of the trachea. In contrast, pulsion diverticula are a result of herniation of esophageal mucosa and submucosa through an area of weakened esophageal musculature. False diverticula consist of mucosa and submucosa, but do not involve the muscularis layer Other possible locations: Killian-Jamieson area � between oblique and transverse fibers of cricopharyngeus Laimer�s triangle � between cricopharyngeus and superior esophageal wall circular muscles 2/3 of diverticula protrude in midline, 25% to left, 10% to right. Uneven because carotid artery on left is located more laterally, and cervical esophagus and slight convexity to left, so as it enlarges tends to go left Pulsion-type diverticulum - Traction diverticula are a result of pulling forces external to the esophagus that are secondary to inflammatory or neoplastic processes and usually occur on the anterior wall of the esophagus near the bifurcation of the trachea. In contrast, pulsion diverticula are a result of herniation of esophageal mucosa and submucosa through an area of weakened esophageal musculature. False diverticula consist of mucosa and submucosa, but do not involve the muscularis layer Other possible locations: Killian-Jamieson area � between oblique and transverse fibers of cricopharyngeus Laimer�s triangle � between cricopharyngeus and superior esophageal wall circular muscles 2/3 of diverticula protrude in midline, 25% to left, 10% to right. Uneven because carotid artery on left is located more laterally, and cervical esophagus and slight convexity to left, so as it enlarges tends to go left

13. Killian�s triangle Killian�s dehiscence/triangle/hiatus is a natural area of weakness because it is not supported by constrictor muscles. Zenker�s diverticulum is a posterior pharyngeal pouch with a neck proximal to the cricopharyngeus muscle. ZD is found almost exclusively in humans, which is thought to be due to the fact that the human larynx is larger and located more caudally in humans than in other animals. The caudal location results in an oblique orientation of the constrictor muscles, and consequently areas of weakness developKillian�s dehiscence/triangle/hiatus is a natural area of weakness because it is not supported by constrictor muscles. Zenker�s diverticulum is a posterior pharyngeal pouch with a neck proximal to the cricopharyngeus muscle. ZD is found almost exclusively in humans, which is thought to be due to the fact that the human larynx is larger and located more caudally in humans than in other animals. The caudal location results in an oblique orientation of the constrictor muscles, and consequently areas of weakness develop

14. Zenker�s Diverticulum Frequency in US Fluoroscopic studies have shown prevalence of Zenker�s to be 2/100,000 Found in approximately 1/1,000 of patients referred for upper GI studies Men affected 2-3 times more often than women Acquired, 7th-8th decade of life Extremely rare in Asia and Africa Asia and Africa also have very low incidence of GERD, suggesting a link in etiology Pediatric Zenker�s are usually congenital and often fatal due to massive aspiration pneumoniaAsia and Africa also have very low incidence of GERD, suggesting a link in etiology Pediatric Zenker�s are usually congenital and often fatal due to massive aspiration pneumonia

15. Risk factors Older age Male gender Hiatal hernia Gastroesophageal reflux Up to 94% of patients with pharyngeal pouches are found to have GERD and/or hiatal hernias.Up to 94% of patients with pharyngeal pouches are found to have GERD and/or hiatal hernias.

16. Differential Diagnosis Esophageal stricture Achalasia Esophageal cancer Pneumonia

17. Pathogenesis Evagination of the cricopharyngeal sphincter is believed to occur secondary to chronic increased pressure over weakened area of esophagus Multifactorial � many circumstances predispose to herniation within Killian�s triangle Abnormal esophageal motility Esophageal shortening UES dysfunction Pathological analysis � 95% show abnormal histology Data supporting these hypotheses have been obtained via manometry studies. Consensus is occlusive mechanisms are most important: uncoordinated swallowing, impaired relaxation and spasm of the cricopharyngeus muscle lead to an increase in pressure within the distal pharynx, so that its wall herniates through point of maximal weakness � Killian�s triangle Path - of cricopharyngeus and hypopharyngeal musculature resected from Zenker�s patient. Histology shows atrophy, necrosis, fibrosis, and inflammation. Decreased levels of acetylcholinesterase were also found in this tissue when compared to normal tissue Data supporting these hypotheses have been obtained via manometry studies. Consensus is occlusive mechanisms are most important: uncoordinated swallowing, impaired relaxation and spasm of the cricopharyngeus muscle lead to an increase in pressure within the distal pharynx, so that its wall herniates through point of maximal weakness � Killian�s triangle Path - of cricopharyngeus and hypopharyngeal musculature resected from Zenker�s patient. Histology shows atrophy, necrosis, fibrosis, and inflammation. Decreased levels of acetylcholinesterase were also found in this tissue when compared to normal tissue

18. Zenker�s Diverticulum Classification Schemes These are classifications based on contrast radiography. Other schemes include vertebral body measurements, and simple radiologic appearance, but categories are becoming increasingly complex and incorporate elements from several of the classic classification schemes. Clinical utility is not particularly high. These are classifications based on contrast radiography. Other schemes include vertebral body measurements, and simple radiologic appearance, but categories are becoming increasingly complex and incorporate elements from several of the classic classification schemes. Clinical utility is not particularly high.

19. Complications of Zenker�s Diverticulum 30% of patients develop aspiration pneumonia SCC of diverticulum occurs in 0.3-0.5% Ulceration secondary to retained aspirin Esophageal obstruction Compression of trachea Why treat Zenker�s? In the elderly population in particular, the presence of Zenker�s is an additional risk factor in the overall health of the elderly patient. In can cause deterioration of pulmonary function, as well as cachexia/dehydration/malnutrion secondary to �fear of eating�Why treat Zenker�s? In the elderly population in particular, the presence of Zenker�s is an additional risk factor in the overall health of the elderly patient. In can cause deterioration of pulmonary function, as well as cachexia/dehydration/malnutrion secondary to �fear of eating�

20. Therapeutic Approach Surgery is mainstay of treatment in symptomatic Zenker�s diverticulum Standard treatment is excision of diverticulum and cricopharyngeal (CP) myotomy, including upper 3cm of posterior esophageal wall Diverticula <2cm � myotomy alone is sufficient 3-6cm � endoscopic or open procedure Cricopharyngeal myotomy is almost always performed as there is an unacceptably high recurrence rate without it. In fact, small diverticula (1-2cm) can possibly be treated with myotomy alone. Cricopharyngeal myotomy is almost always performed as there is an unacceptably high recurrence rate without it. In fact, small diverticula (1-2cm) can possibly be treated with myotomy alone.

21. Surgical Options External techniques: CP myotomy with excision, inversion or suspension of diverticulum Endoscopic techniques: endoscopic staple diverticulostomy, CO2 laser, electrocautery Endoscopic techniques arose in 1964 Endoscopic techniques arose in 1964

22. External Techniques: Diverticulectomy One stage CP myotomy and transcervical diverticlectomy has become treatment of choice in good surgical candidates Risk of mediastinitis A, Incision line is illustrated. An alternative incision line may be along the anterior border of the sternocleidomastoid muscle. B, Soft tissues are dissected away. The trachea, strap muscles, and thyroid gland are retracted medially, and the sternocleidomastoid muscle is retracted laterally. The omohyoid muscle may also be retracted laterally or, alternatively, divided for exposure. Once the diverticulum and cricopharyngeus muscle are identified, a cricopharyngeal myotomy is performed. The diverticulum itself may be excised and the defect closed with a purse-string suture (C) or a stapler (D).�A, Incision line is illustrated. An alternative incision line may be along the anterior border of the sternocleidomastoid muscle. B, Soft tissues are dissected away. The trachea, strap muscles, and thyroid gland are retracted medially, and the sternocleidomastoid muscle is retracted laterally. The omohyoid muscle may also be retracted laterally or, alternatively, divided for exposure. Once the diverticulum and cricopharyngeus muscle are identified, a cricopharyngeal myotomy is performed. The diverticulum itself may be excised and the defect closed with a purse-string suture (C) or a stapler (D).�

23. External Techniques: Diverticulopexy After a cricopharyngeal myotomy is performed and the diverticulum is freed, the sac is tacked with 2-0 silk sutures superiorly to the prevertebral fascia. Diverticulopexy identifies the pouch and sutures it superiorly to reverse its dependent positioning in the erect patient. Ideal for diverticula between 1 and 4cm.After a cricopharyngeal myotomy is performed and the diverticulum is freed, the sac is tacked with 2-0 silk sutures superiorly to the prevertebral fascia. Diverticulopexy identifies the pouch and sutures it superiorly to reverse its dependent positioning in the erect patient. Ideal for diverticula between 1 and 4cm.

24. External Techniques: Outcome Significant morbidity Symptomatic relief in 80-90% Complication rate 10-30% Fistula formation Recurrent laryngeal nerve palsy Pneumomediastinum Mediastinitis Mortality rate 1-3% Different studies have different complication percentagesDifferent studies have different complication percentages

25. Endoscopic Techniques: Endoscopic Staple Diverticulostomy A, Common wall visualized with a Weerda laryngoscope. B and C, With an ENDOSTITCH suturing device, retraction sutures are placed on the lateral aspects of the common wall. D, The common wall is positioned between the blades of the stapler. E, The common wall is divided after the stapler is activated. The retraction sutures are cut and removed.� By dividing the common wall, an internal cricopharyngeal myotomy is performed, creating a single lumen without removal of the pouch. A, Common wall visualized with a Weerda laryngoscope. B and C, With an ENDOSTITCH suturing device, retraction sutures are placed on the lateral aspects of the common wall. D, The common wall is positioned between the blades of the stapler. E, The common wall is divided after the stapler is activated. The retraction sutures are cut and removed.� By dividing the common wall, an internal cricopharyngeal myotomy is performed, creating a single lumen without removal of the pouch.

26. Endoscopic Technique: CO2 laser and electrocautery

27. Endoscopic Technique: Outcome Short duration of surgery: 30 mins Patient can be discharged home 3-4 hours following procedure with clear liquid diet Operative cost comparable to open-neck technique, but overall cost of stay is decreased ESD 2.6% complication rate, 0.3% mortality CO2 laser/electrocautery 7.4-8.1% complication rate, 0.2% mortality Complications Esophageal perforation Hemorrhage Mediastinitis Statistically significant operative time, hospital time, time tor resume oral feeding � total hospital costs significantly lower for patients treated endoscopically. Lower complication rate, especially with ESD. Patients are not always good candidates for endoscopic approach, limited neck extension/limited oral apertures can make the open approach the only feasible option Esophageal perforation � Esophagus lacks a serosal layer, and thus is at higher risk of rupture or perforation. Patient should be made NPO (nothing by mouth), and broad-spectrum antibiotics initiated. Gastrografin study should be obtained to evaluate level of perforation. Perforation of cervical esophagus can be managed with close observation or with exploration and drainage procedure. Thoracic esophagus perforation requires early exploration. If symptoms resolve in 7-10 days, repeat the gastrografin to evaluate resolution of perforation, antibiotics can be discontinued with no evidence of infection. Close monitoring of vital signs and white blood cell count is essential. Mediastinitis � once esophagus is ruptured, retained gastric content, saliva, bile, and other substance may enter mediastinum. Patient will present with severe dyspnea, chest pain and fever, Diagnosis can be confirmed with CXR or CT scan which will show the characteristic mediastinal widening. Aggressive therapy is required: mortality rate is between 14-40%. Treatment consists of aggressive drainage and IV antibiotics, as well as close monitoring by a thoracic surgery team. Statistically significant operative time, hospital time, time tor resume oral feeding � total hospital costs significantly lower for patients treated endoscopically. Lower complication rate, especially with ESD. Patients are not always good candidates for endoscopic approach, limited neck extension/limited oral apertures can make the open approach the only feasible option Esophageal perforation � Esophagus lacks a serosal layer, and thus is at higher risk of rupture or perforation. Patient should be made NPO (nothing by mouth), and broad-spectrum antibiotics initiated. Gastrografin study should be obtained to evaluate level of perforation. Perforation of cervical esophagus can be managed with close observation or with exploration and drainage procedure. Thoracic esophagus perforation requires early exploration. If symptoms resolve in 7-10 days, repeat the gastrografin to evaluate resolution of perforation, antibiotics can be discontinued with no evidence of infection. Close monitoring of vital signs and white blood cell count is essential. Mediastinitis � once esophagus is ruptured, retained gastric content, saliva, bile, and other substance may enter mediastinum. Patient will present with severe dyspnea, chest pain and fever, Diagnosis can be confirmed with CXR or CT scan which will show the characteristic mediastinal widening. Aggressive therapy is required: mortality rate is between 14-40%. Treatment consists of aggressive drainage and IV antibiotics, as well as close monitoring by a thoracic surgery team.

28. Discussion by Michael Underbrink, MD Dr. Underbrink: That was an excellent presentation. It was very thorough and complete and it gave us a lot of information about the pathogenesis and treatment options for Zenker�s diverticulum. I think the important things to realize is patient selection for the type of surgery that you have. As far as grading the Zenker�s by one of the classification scales noting that in small diverticula, are you going to be able to treat these by myotomy alone? This can be done endoscopically although most people prefer an open technique for that. The size of the diverticulum as was presented being between three and six centimeters is a good size for the approach endoscopically which also reduces the complication rate. So that in some patients, case selection is important. And inbetween that you�ll be watching for the most common complications postoperatively which we all know. The most devastating would be mediastinitis. Good talk. Thank you.� Dr. Francis B. Quinn: How do you find the opening of the diverticulum endoscopically?� Dr. Underbrink: The answer is that using the instrumentation we have in our operating room, the �Weirdoscope� opens in two directions, both distally and proximally, as you enter under the cricoid cartilage just opening a small bit the posterior tine will find the diverticulum, and the anterior tine if opened correctly will find the esophagus and you�re looking for a double bubble on your exam and when you see that you�re advancing slowly being careful not to perforate a large diverticulum with your posterior tine. That might be one of the complications of placement. You want to make sure that the cricopharyngeus muscle or the bridge of mucosa over the muscle easily visible so you can place sutures and retract that so you can make the incision.

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