Zenker’s Diverticulum Flashcards
Why is Zenker’s diverticulum considered a pulsion pseudodiverticulum?
Because it is composed of mucosa/Submucosa only, not all wall layers.
Are most patients with esophageal diverticula symptomatic or asymptomatic?
-A large proportion are asymptomatic.
Dysphagia (MC Symp)
Regurgitation
weight loss
chest pain
halitosis (bad breath), and aspiration.
Where does pharyngoesophageal diverticulum occur?
In areas of muscular gap at the transition of the cricopharyngeal muscle, inferior constrictor of the pharynx, and esophageal intrinsic muscles.
What is necessary to create a high-pressure zone in the upper esophageal sphincter that leads to the formation of a diverticulum?
Altered motility of the upper esophageal sphincter.
What condition is associated with up to 95% of patients with Zenker’s diverticulum?
Gastroesophageal reflux disease (GERD).
What diagnostic tool is usually performed to diagnose a diverticulum
Upper endoscopy :
for Diagnosis and Rule out malignancy
Barium swallow :
estimation of the size and location better than the endoscopy
Esophageal manometry :
to diagnose the upper sphincter dysfunction
Ambulatory pH monitoring :
may be indicated in patients with suspected GERD
What are the two main approaches to treating Zenker’s diverticulum?
Treating only symptomatic diverticula
or treating all diverticula to prevent complications like aspiration, even if asymptomatic.
What are the four treatment options for Zenker’s diverticulum?
-Myotomy of the cricopharyngeal muscle alone.
-Myotomy plus diverticulectomy.
-Myotomy plus diverticulopexy.
-Endoscopic division of the septum between the diverticulum and esophagus (Dohlman’s procedure, or diverticulo-esophagostomy).
What is the preferred incision for most surgeons when treating Zenker’s diverticulum?
left cervical incision following the medial border of the sternocleidomastoid muscle.
Skin
Subcutaneous tissue conjoined with the platysma muscle
Superficial cervical fascia
The infrahyoid muscles exposed
sternohyoid muscle is retracted medially
the omohyoid muscle is retracted superiorly
diverticulum below omohyoid muscle
Why is circumferential dissection of the esophagus avoided during surgery?
To reduce the risk of damaging the left recurrent laryngeal nerve, which is located in the groove between the esophagus and the trachea.
What might be necessary if the diverticulum is not identified during surgery?
The esophagus should be rotated to expose the posterior side, and esophageal intubation or intraoperative endoscopy may be needed.
Why is myotomy of the cricopharyngeal muscle always performed in Zenker’s diverticulum surgery?
assumption that upper esophageal sphincter dysfunction is part of the pathophysiology of the disease
How far should the myotomy be extended?
About 3 cm downward onto the esophageal wall.
Is it necessary to resect small diverticula (<2 cm)?
No, because the risk of complications and cancer is low
What are the treatment options for larger diverticula?
Larger diverticula may be resected
or fixed upward to the prevertebral fascia (diverticulopexy).
Why is a bougie placed inside the esophagus before transecting the neck of the diverticulum?
To avoid pulling too much mucosa and causing narrowing of the esophageal lumen
Complications
may occur in up to 15% of cases and usually present as leakage and vocal cord paralysis.
What are the advantages of the endoscopic approach for Zenker’s diverticulum?
It provides symptom relief with a low complication rate, short hospital stay, and prompt return to an oral diet
Why is the endoscopic approach favored in cases of primary treatment failure or recurrence of symptoms?
A second attempt can be made without increasing the risk of complications, such as nerve palsy
What are the two different endoscopic approaches that can be used to treat Zenker’s diverticulum?
Rigid endoscopy and flexible endoscopy
What has become the standard approach to Zenker’s diverticulum since the 1990s?
Endoscopic stapled-assisted diverticulostomy.
What instrument is used to perform the endoscopic stapled-assisted diverticulostomy?
The Weerda diverticuloscope
What is the overall success rate of the endoscopic stapled-assisted diverticulostomy procedure?
More than 90% in all large published series
What are the most common complications of the procedure?
Dental injuries (2%) and esophageal mucosal perforation (1.6%).
What are some limitations of the rigid endoscopic approach for Zenker’s diverticulum?
The need for general anesthesia
inability to perform neck hyperextension
difficulty with diverticula less than 3 cm (unsuitable for proper stapler positioning).
What is always done under direct vision during these flexible endoscopic procedures?
The procedure is done under direct vision of the cricopharyngeal muscle fibers.
