Ann Thorac Surg 1998;66:347-350
© 1998 The Society of Thoracic Surgeons
Original articles: general thoracic
Zenker’s diverticulum in the elderly: is operation justified?
Donald G. Crescenzo, MDa,
Victor F. Trastek, MDa,
Mark S. Allen, MDa,
Claude Deschamps, MDa,
Peter C. Pairolero, MDa
a Section of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Address reprint requests to Dr Trastek, Mayo Clinic, 200 First St SW, Rochester, MN 55905
Presented at the Forty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Naples, FL, Nov 6–8, 1997.
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Abstract
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Background. Surgical correction of symptomatic Zenker’s diverticulum is effective; however, elderly symptomatic patients may be denied surgical intervention because of perceived increased risks.
Methods. To address this concern, we reviewed 75 patients (46 men and 29 women) found to have this condition during the past two decades.
Results. Median age was 79 years (range, 75 to 91 years). Preoperative symptoms included dysphagia in 69 patients (92%), regurgitation in 61 (81%), pneumonia in 9 (12%), halitosis in 3 (4%), and weight loss in 1 (1%). Gastroesophageal reflux symptoms were noted in 27 patients (36%). Diagnosis was made by barium swallow in 63 patients, esophagoscopy in 5, and a combination of both in 7. Surgical procedures included both diverticulectomy and myotomy in 57 patients (76%), myotomy alone in 9 (12%), diverticulopexy and myotomy in 5 (7%), and diverticulectomy alone in 4 (5%). There was no in-hospital mortality. Complications occurred in 8 patients (11%) and included esophagocutaneous fistula in 4, pneumonia and urinary tract infection in 1, and wound infection, myocardial infarction, and persistent diverticulum in 1 each. Follow-up was available in 72 patients (96%) and ranged from 8 days to 17 years (median, 3.3 years). At follow-up, 64 patients (88%) were asymptomatic and 4 (6%) were improved with minimal symptoms. The remaining 4 patients (6%) have had varying degrees of dysphagia and all have been treated with periodic esophageal dilations.
Conclusions. Operation for symptomatic Zenker’s diverticulum in the elderly is safe and effective and will result in resolution of symptoms and improved quality of life in most patients
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Introduction
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Pharyngoesophageal or Zenker’s diverticulum is an acquired false diverticulum of the upper digestive tract that frequently affects elderly patients [1, 2]. The natural history of this condition is progressive enlargement of the diverticulum with increasing symptomatology. Dysphagia in the elderly decreases quality of life, increases morbidity secondary to aspiration pneumonia, and is associated with a higher mortality rate [3]. Treatment has varied over the years but more recently has focused on cricopharyngeal myotomy for small diverticulum and diverticulectomy combined with the cricopharyngeal myotomy for larger diverticulum [4]. Results with this approach have been excellent [5]. Nonetheless, elderly patients with dysphagia secondary to a Zenker’s diverticulum are frequently denied surgical correction because of a perceived increased surgical risk. The purpose of this report is to determine both the safety and efficacy of surgical resection in patients 75 years and older with a symptomatic Zenker’s diverticulum.
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Material and methods
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All patients 75 years and older who underwent operation between 1976 and 1996 for Zenker’s diverticulum at the Mayo Clinic were reviewed. The records of these patients were reviewed for type and duration of preoperative symptoms, complications related to the diverticulum, operative procedure, operative morbidity and mortality, length of hospital stay, and postoperative follow-up. All procedures were performed under general anesthesia, and the technique has been previously reported [6]. Follow-up was conducted by questionnaire, review of subsequent patient visits, or telephone interview. The date of last follow-up was either the date of last contact or the time of death.
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Results
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There were 75 patients (46 men and 29 women). Median age was 79 years (range, 75 to 91 years). All were symptomatic including dysphagia in 69 patients, regurgitation in 61, pneumonia in 9, halitosis in 3, and weight loss in 1. Gastroesophageal reflux symptoms were noted in 27 patients (36%) (Table 1 ). The duration of symptoms could be determined in 30 patients (40%) and ranged from 1 to 336 months (median, 42 months). Diagnosis was confirmed by barium swallow in 63 patients (84%), esophagogastroduodenoscopy in 5 (7%), and a combination of these modalities in 7 (9%). Surgical procedures included both diverticulectomy and myotomy in 57 patients (76%), cricopharyngeal myotomy alone in 9 (12%), diverticulopexy and myotomy in 5 (7%), and diverticulectomy alone in 4 (5%). Of the 61 patients having diverticulectomy, the esophagus was closed with staples in 42 patients (69%) and with suture in 19 (31%). There were no inpatient deaths and all patients were dismissed either to their home or a chronic care facility. Complications occurred in 8 patients (11%). An esophagocutaneous fistula developed in 4 patients (5.3%) in the early postoperative period. All had a diverticulectomy and myotomy. All 4 were managed conservatively, withholding oral intake until the drainage resolved and the barium swallow showed that the leak was healed. Two procedures were closed with staples and 2 were repaired with suture. One patient who had only a cricopharyngeal myotomy remained symptomatic and was noted to have a persistent diverticulum on a postoperative barium swallow. At a second operation during the same stay, a diverticulectomy was performed without incident. Myocardial infarction and wound cellulitis occurred in 1 patient each. A final patient had both a urinary tract infection and pneumonia. Overall, the median hospitalization was 5 days (range, 1 to 42 days). In the 4 patients in whom a fistula developed, the median hospital stay was 13 days (range, 10 to 23 days).
Follow-up was available in 72 patients (96%) and ranged from 8 days to 17 years (median, 3.3 years) (Fig 1 ). Although asymptomatic at the time of discharge, 3 patients were subsequently lost to follow-up. Twenty-seven patients have died a median of 24 months (range, 1 to 204 months) since operation. Cause of death was known in 8 patients and included myocardial infarction in 5, cancer in 1, complications from unrelated operation in 2; cause of death was unknown in 19 at last follow-up. Sixty-four patients (88%) were asymptomatic and 4 (6%) were improved but had minimal symptoms including aerophagia and dyspepsia in 2 each. The remaining 4 patients (6%) continued to have dysphagia and all have been palliated with periodic dilation. Procedures performed in these patients included diverticulectomy and myotomy in 2 patients and diverticulopexy and myotomy and myotomy alone in 1 each. Finally, none of the 27 patients with preoperative reflux had problems with aspiration after correction.
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Fig 1. Postoperative results in 75 patients undergoing correction for symptomatic Zenker’s diverticulum. Follow-up was complete in 72 patients (96%) and ranged from 8 days to 17 years (median, 3.3 years). Sixty-four patients (88%) were asymptomatic, 4 (6%) had mild symptoms, and 4 continued to have dysphagia. Three patients were lost to follow-up.
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Comment
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The cause of a cricopharyngeal diverticulum remains unclear; however, it appears to involve dysfunction or incoordination of the upper esophageal sphincter. A number of researchers have noted the association of hiatal hernia and gastroesophageal reflux in these patients [7]. Although 36% of our patients had gastroesophageal reflux, this alone cannot fully explain the etiology in the remaining patients.
Most patients with pharyngoesophageal diverticulum have varying degrees of dysphagia. Additional symptoms include hoarseness, regurgitation of undigested food, halitosis, and frequent episodes of aspiration pneumonia. In some patients, the dysphagia can lead to malnutrition and death [4]. The diagnosis of a Zenker’s diverticulum is suspected in patients who present with the above symptomatology and is confirmed with a contrast barium swallow. Rarely is upper endoscopy or esophageal manometry indicated.
Current treatment options include cricopharyngeal myotomy for small diverticula (<4 cm) and a myotomy combined with a diverticulectomy for larger diverticula. Diverticulopexy, as first described by Schmid [8] and later popularized by both Belsey [9] and Skinner and colleagues [10], continues to be used in some centers [11, 12]. We first reported our surgical results in 1973, which included 809 patients between 1944 and 1972 who underwent diverticulectomy with or without myotomy. Operative mortality was 1.4%. An esophagocutaneous fistula occurred in 1.7% of patients. Long-term follow-up from 5 to 14 years was available in 164 patients, and a highly satisfactory result was obtained in 93% of patients. A recurrent diverticulum occurred in 3.3% of patients [13].
No in-hospital deaths occurred in our series of 75 elderly patients. The most common complication was the development of a self-limiting esophagocutaneous fistula in 4 patients (5.3%). Long-term results showed improvement in 94% of patients, and 88% were totally asymptomatic. This functional result was present at a median of 3.3 years and extended up to 17 years. In the 62 patients having diverticulectomy, there were no diverticular recurrences. Of interest, of the 27 patients who had preoperative symptoms of gastroesophageal reflux, none had problems with aspiration after correction. In this series, four different procedures were used in the surgical correction of a Zenker’s diverticulum. Although the majority of patients underwent a diverticulum combined with a myotomy, no conclusions as to the optimal surgical approach can be made from this study.
We conclude that surgical treatment of symptomatic Zenker’s diverticulum in the elderly patient is safe and effective. Our results demonstrate that surgical intervention in this age group alleviates symptoms and improves the quality of life in most patients. Therefore, we strongly urge consideration for correction at the time of the initial diagnosis not only to alleviate symptoms and improve quality of life but also to prevent progression with development of aspiration, pneumonia, and malnutrition.
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Acknowledgments
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We acknowledge Betty Anderson, RN, for her technical assistance in the database management for preparation of the manuscript.
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References
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- Payne W.S., King R.M. Pharyngoesophageal (Zenker’s) diverticulum. Surg Clin North Am 1983;63:815-824.[Medline]
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[Abstract]
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Abstract
Introduction
