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Ann Thorac Surg 2002;74:1677-1683
© 2002 The Society of Thoracic Surgeons

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Original article: general thoracic

Management of pharyngoesophageal (Zenker’s) diverticulum: which technique?

^a Unit of Upper G-I Surgery, Louvain Medical School, Brussels, Belgium
^b Unit of ENT Surgery, Louvain Medical School, Brussels, Belgium
^c Unit of Radiology, Louvain Medical School, Brussels, Belgium

* Address reprint requests to Dr Collard, Upper G-I Surgery Unit, St. Luc Academic Hospital, Hippocrate Ave 10, B–1200, Brussels, Belgium.
e-mail: collard{at}chir.ucl.ac.be

Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 
BACKGROUND: Incomplete symptomatic relief of pharyngoesophageal (Zenker’s) diverticulum after endoscopic stapling or laser division has been reported by some authors. The clinical relevance of cricomyotomy, although supported by experimental data, remains controversial.

METHODS: Operative procedures consisted of transcervical resection (n = 34, group I), transcervical resection plus cricomyotomy (n = 12, group II), transcervical cricomyotomy (n = 8, group III), transcervical cricomyotomy plus diverticulopexy (n = 47, group IV), endoscopic stapling division (n = 31, group V), and endoscopic laser division (n = 55; group VI).

RESULTS: The percentage of totally asymptomatic patients was significantly (p < 0.004) higher after open procedures (combined groups I to IV) than after endoscopic treatment (combined groups V and VI) regardless of the size of the pouch (<3 cm, 85% versus 25%; 3 cm, 86% versus 50%). The percentage of patients with no or occasional (ie, fewer than twice a week) symptoms was significantly (p < 0.001) higher after open procedures (98%) than after endoscopic treatment (57%) for less than 3-cm diverticula whereas it was not higher (p = 0.409) for 3-cm or greater pouches (open, 97%; endoscopic, 88%). Furthermore, this percentage was similar (p > 0.286) after endoscopic stapling division and after endoscopic laser division (<3 cm, 50% versus 58%; 3 cm, 96% versus 80%). It was also similar (p > 0.197) after resection alone (group I) and after open operations including myotomy (combined groups II to IV) (<3 cm, 100% versus 98%; 3cm, 92% versus 100%). Unlike endoscopic stapling and division, laser division was complicated by mediastinitis (2 patients), and 1 patient was referred because of cervical esophageal disruption during laser division. Five of six postoperative fistulas after resection occurred in patients who did not have myotomy, and 4 patients were referred 12 to 49 years after resection without myotomy for true recurrence of the pouch.

CONCLUSIONS: Open techniques afford better symptomatic relief than endoscopic techniques, especially in patients with small diverticula. Endoscopic stapling and division is safer than laser division. Although very effective at midterm, resection without myotomy predisposes to the development of postoperative fistula and to recurrence of the pouch after many years.

	Introduction

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Since its description by Ludlow [1] in 1769 and by Zenker and von Ziemssen [2] in 1877, numerous surgical techniques have been developed to treat pharyngoesophageal diverticulum [3]. Transcervical resection of the diverticular pouch has been the procedure of choice as it was believed that the pouch itself constituted the disease [4, 5]. However, with the observations of Belsey [6], the concept was introduced that the diverticular sac was in fact the consequence of the disease, ie, a high pharyngeal pressure secondary to a lack of compliance of the cricopharyngeus muscle in relation to local fibrosis [7–9]. Consequently, proximal esophageal myotomy in combination with diverticulopexy was recommended for the management of the physiologic abnormality [10, 11]. However, no study has been published to demonstrate a superiority in terms of symptomatic relief of the myotomy-pexy technique over resection without myotomy.

As another form of therapy, the concept of endoscopic division of the wall separating the diverticular and esophageal lumina and containing the musculature that forms the upper esophageal sphincter was introduced by Mosher [12]. This technique was later improved by the application of diathermic [13] or laser [14, 15] coagulation. Recently, one of us (J.M.C.) described a stapling technique, which allowed an endoscopic suture of the cut margins [16, 17]. Although all published series [18–25] demonstrate that more than 90% of patients are substantially improved after endoscopic diverticuloesophagostomy, some authors [22–25] have reported that a substantial number of patients continue to have residual pharyngoesophageal symptoms at follow-up.

We reviewed our 16-year experience in the management of Zenker’s diverticula to assess six different techniques in terms of both postoperative and long-term outcomes and to address the three following issues. Are the endoscopic approaches as safe and effective as the open techniques? In the endoscopic approach, is it preferable to cut and suture the common wall between the esophageal and diverticular lumina by stapling or to burn and cut it by laser? And lastly, in patients operated on by cervicotomy, what is the clinical relevance of performing a cricomyotomy?

	Material and methods

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Study population
From 1984 to 2000, 184 patients (109 males and 75 females, aged 27 to 92 years with a median of 71 years) were referred to the Louvain Medical School Hospital (122 to the Upper G-I Surgery Unit and 62 to the ENT Surgery Unit) for management of a Zenker’s diverticulum. Nineteen of these 184 patients had a remedial operation because of unsatisfactory outcome after resection without myotomy (n = 8) or endoscopic laser division (n = 11) of the pouch, for a total of 188 operations on 184 patients.

One hundred sixty-one patients were operated on for a diverticulum alone whereas 23 patients had a total of 27 other surgical conditions treated during the same operating session. Concomitant operations consisted of esophageal resection or bypass (n = 2), pleural drainage (n = 1), antireflux fundoplication (n = 13), cholecystectomy (n = 2), thyroidectomy (n = 4), vagotomy (n = 1), carpal tunnel division (n = 1), and abdominal wall hernia repair (n = 3). The preoperative symptoms consisted of dysphagia (n = 166), food regurgitation (n = 145), or respiratory complaints (n = 84).

Patients were classified into six groups (Table 1) according to surgical technique: transcervical resection of the pouch without cricomyotomy (group I), transcervical resection of the pouch with cricomyotomy (group II), cricomyotomy without diverticulopexy (group III), cricomyotomy with diverticulopexy (group IV), endoscopic stapling division (group V), and endoscopic laser division (group VI). An additional patient was referred to our institution after complete disruption of the cervical esophagus during endoscopic laser division that was managed by combined pharyngostomy, esophagostomy, and feeding jejunostomy. Diverticula were classified into two distinct categories depending on whether the common wall between the diverticular and esophageal lumina was shorter than 3 cm (small diverticulum) or longer than 3 cm (large diverticulum) on preoperative barium swallow radiographs.

Resection (group I)
Thirty-four patients underwent resection of the diverticular pouch without cricomyotomy through a left cervical incision. In 24 patients, the collar of the pouch was transected with scissors and the pharyngeal defect closed primarily with 4-0 Vicryl (Johnson and Johnson, Somerville, NJ). Ten patients had their diverticular collar stapled using a TA-30 linear stapler (US Surgical Corporation, Norwalk, CT).

Resection plus myotomy (group II)
Twelve patients underwent combined resection of the diverticular pouch and division of both the cricopharyngeus muscle and esophageal muscle fibers for a 5-cm distance through a left cervical incision. The pharyngeal defect was either hand-sewn (n = 6) or stapled (n = 6).

Myotomy (group III)
Eight patients with a 1-cm diverticulum were operated on through a left cervical incision by posterior division of both the cricopharyngeus muscle and esophageal muscle fibers for a 5-cm distance.

Myotomy plus diverticulopexy (group IV)
Forty-seven patients with a more than 1-cm diverticulum were treated by anchorage of the diverticular pouch to the posteriorpharyngeal wall or the prevertebral fascia in combination with a myotomy similar to that performed in patients of group III.

Endoscopic stapling division (group V)
Thirty-one patients were treated endoscopically with stapled division of the wall separating the diverticular and esophageal lumina according to a technique devised in 1991 and published in 1993 [16] by one of us (J.M.C.). The common wall was exposed between the two limbs of the Weerda-Collard diverticuloscope (Karl Storz, Tuttlingen, Germany) for application of one or more cartridges of an endo-GIA-30 stapler (US Surgical Corporation). The anvil of the stapler had its distal tip sawn off [17] to minimize the length (ie, 3 mm) of the residual spur at the bottom of the diverticulum after division.

Endoscopic laser division (group VI)
Fifty-two patients referred to the ENT Surgery Unit underwent 55 operations consisting of endoscopic laser division of the wall separating both lumina. Technical principles have previously been reported [14, 15]. Briefly, a bivalved Holinger-Benjamin diverticuloscope (Karl Storz) was fixed to a chest support, and wet neurosurgical cottonoids (cotton sponges) were plugged in the esophageal lumen and at the bottom of the diverticulum to protect the mucosa from the laser. A 1040 Sharplan laser source (Sharplan, Tel Aviv, Israel) was coupled with an operative microscope equipped with a micromanipulator. The incision began in the mucosa of the common wall and extended down through the cricopharyngeus muscle and proximal esophageal muscle fibers. Occasional bleeding was controlled by electrocoagulation through an insulated suction device.

Data recording and interpretation
Information of the existence of residual symptoms (ie, cervical dysphagia, food regurgitation, and respiratory symptoms) was obtained from 148 patients (80%). All these 148 patients were interviewed on the telephone by one of us (C.A.G.) using a standardized questionnaire. Thirty-six patients (20%; ie, 16 from group I, 2 from group II, 1 from group III, 6 from group IV, 4 from group V, and 7 from group VI) were not suitable for symptomatic evaluation because they had died (n = 32) or were lost to follow-up (n = 4). Patients were classified into three groups on the basis of symptoms. The first group was very satisfied with the operation because they were totally asymptomatic (excellent result). The second group was satisfied with the operation but still had occasional (ie, twice a week or less) residual symptoms (good result). The final group was dissatisfied as they still had residual daily symptoms (fair result). Data analysis according to the size of the diverticulum was based on the radiographs from 144 patients (146 operations).

Fisher’s exact and ² tests were used for statistical analysis of categorical variables, and Kruskal-Wallis and Mann-Whitney rank sum tests were used for continuous variables with significance taken as p 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 
Postoperative course
Both postoperative in-hospital stay and fasting period were significantly longer in patients who underwent resection of the pouch with or without myotomy (groups I and II) than in those who underwent transcervical myotomy with or without diverticulopexy (groups III and IV; p < 0.001) and in those treated endoscopically (groups V and VI; p < 0.001). Furthermore, both the postoperative in-hospital stay and fasting period in group V (endoscopic stapling division) were significantly shorter (p < 0.001) than in group VI (endoscopic laser division; Table 2).

View larger version (32K): [in this window] [in a new window]   Fig 1. Symptomatic outcome after open (blank columns) and endoscopic (hatched columns) treatments according to whether diverticulum was smaller than 3 cm (left) or 3 cm or larger (right).

View larger version (31K): [in this window] [in a new window]   Fig 2. Symptomatic outcome after endoscopic stapling (blank columns) and laser (hatched columns) division according to whether diverticulum was smaller than 3 cm (left) or 3 cm or larger (right).

View larger version (37K): [in this window] [in a new window]   Fig 3. Symptomatic outcome after resection without cricomyotomy (blank columns) and open techniques including a cricomyotomy (hatched columns) according to whether diverticulum was smaller than 3 cm (left) or 3 cm or larger (right).

Ten of the 11 patients who underwent primary endoscopic laser division of the diverticulum still had a relatively long residual spur at the bottom of the pouch owing to incomplete division of the common wall between the esophageal and diverticular lumina. The 11th patient had had complete disruption of his cervical esophagus because of improper use of the laser source.

Four patients admitted to our institution 3 to 36 months after diverticulectomy without myotomy had no improvement of symptoms because of incomplete resection of the pouch. Four patients with a history of previous resection without myotomy sought consultation for recurrent pharyngoesophageal symptoms after a symptom-free period ranging from 12 to 49 years. In these 4 patients, there was evidence of progressive reappearance of a large diverticulum (Fig 4).

View larger version (104K): [in this window] [in a new window]   Fig 4. Radiographs showing a large diverticulum before resection without myotomy (left), a small pseudopouch caused by the imprint of the cricopharyngeal muscle (arrow) 1 year later (center), and the reappearance of a large diverticulum 22 years after the operation (right).

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

Even though endoscopic division of the wall between the diverticular and esophageal lumina decreases resistance to a bolus through Killian’s mouth [19], there are two main causes of incomplete symptomatic relief after endoscopic treatment. A first cause of failure is the existence of a short common wall to cut (ie, <3 cm). This condition precludes a long myotomy [10] and widening of the esophageal lumen sufficiently [17]. This is supported by the fact that after endoscopic treatment, patients with a small diverticulum had poor symptomatic relief compared with those with a large diverticulum. A second cause of failure is an insufficient division of the common wall between the esophageal and diverticular lumina. This leaves a relatively long residual spur at the bottom of the common cavity and persistence of stasis. We found that 10 of 11 patients reoperated on because of unsatisfactory outcome after endoscopic laser treatment had had incomplete division of the common wall.

This study fails to show any significant superiority for symptomatic relief with the endoscopic stapling technique over the laser technique irrespective of the diverticular size. However, endoscopic stapling division was shown to be safer than laser division of the common wall. Because the incision ends 3 mm proximal to the distal tip of the anvil and the cut margins are stapled, perforation is unlikely with the stapling technique [17]. In contrast, difficulty in determining the point where laser division of the common wall must end predisposes to the persistence of dysphagia (too long a residual spur) and to perforation with mediastinitis (too long a cut). In addition, the use of the laser may cause dramatic damage such as complete disruption of the cervical esophagus (as occurred in one referred patient).

This study demonstrates that simple resection of the pouch without cricomyotomy [4, 5] provides patients with the same chance at a midterm excellent outcome as do open techniques that include an esophageal myotomy [6–11]. Cricomyotomy has been recommended because dysfunction of the upper esophageal sphincter has been shown to play a role in the genesis of the diverticulum [9]. However, to date no comparative study has been published that confirmed the benefit of symptomatic relief of the myotomy-pexy technique over resection of the sac without myotomy. The high success rate achieved by resection of the sac alone [4, 26] indicates that once the diverticulum has developed, pharyngoesophageal symptoms are mainly caused by the existence of the sac itself, which retains ingested material and pushes the cervical esophagus forward so as to collapse it against the trachea. However, this study shows that resection of the diverticulum without myotomy predisposes to the development of a cervical fistula postoperatively and to the long-term recurrence of the pouch. This may be explained by the persistence of a high intrapharyngeal pressure that acts on the posterior pharyngeal wall just proximal to the upper esophageal sphincter [7, 9]. Although a very low recurrence rate after resection alone was reported by the Mayo Clinic team [26], our experience indicates that many years can pass until the patient seeks consultation again for recurrent pharyngoesophageal symptoms. Most of the elderly patients may die before experiencing clinical recurrence. Although radiologic recurrence may remain asymptomatic for a long period [5], the clinical history of 4 patients referred to our institution because of persistent symptoms after resection without myotomy demonstrates that incomplete symptomatic relief may be related to partial removal of the pouch.

Another advantage of the myotomy-pexy technique over resection of the sac [4, 5, 26] is that in the former technique, the pharyngeal lumen is not opened unless inadvertently injured. This allows earlier oral feeding after the operation [8, 10, 11] and shortens the hospital stay.

In conclusion, any patient referred with a Zenker’s diverticulum must be informed of the increased risk of residual symptoms with endoscopic treatment rather than after open procedures. This is especially true if the diverticulum is small. The endoscopic stapling technique is as effective but safer than the laser technique and may be indicated in selected patients with a large diverticulum. Omitting a cricomyotomy predisposes to the development of a fistula postoperatively and to pouch recurrence in the long term.

	Acknowledgments

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We thank Nadine Thiebaut for typing the manuscript.

Doctor Christian Gutschow, resident in the Upper G-I Surgery Unit, received financial support from UCB Pharma, Braines, Belgium.

	Discussion

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DR STEVEN R. DEMEESTER (Los Angeles, CA): Thank you for that fascinating review of your experience. I had a question though. It was intriguing that you found that the small diverticulum with the stapled technique did not seem to do as well as the larger diverticula with the stapled technique, and your assumption was that is was because you were not getting an effective myotomy with the division in those small pouches. Maybe you could enhance our understanding a little bit by describing the symptoms that they were complaining about. Was it dysphagia or regurgitation? The regurgitation should go away if you get rid of the pouch. And the corollary, then, is it is intriguing if that is the case why you did not see a difference in symptoms in the open group between myotomy and no myotomy. How can you explain no difference in symptoms in the open group, and yet postulate that the incomplete myotomy led to more symptoms in the transorally stapled patients with small pouches?

Thanks.

DR GUTSCHOW: The symptoms in these patients with a cricopharyngeal problem and a small diverticulum were mainly dysphagia and not regurgitation.

Can I have your second question again, please?

DR DEMEESTER: How does that fit, then, with the open group that had a myotomy versus no myotomy, why there was no difference in symptoms?

DR COLLARD: With the open technique we used the myotomy or myotomy plus pexy mainly for small diverticula. In fact, when you perform an open myotomy for a small diverticulum, this myotomy is very long. It includes not only the cricopharyngeus muscle but also the 5 cm of the cervical esophagus. When you try to perform the same operation endoscopically for a small diverticulum, it is impossible to perform a very long myotomy. The myotomy is limited by the length of the common wall between the small diverticulum and the esophagus.

On the other hand, most patients operated on by resection without myotomy had a large diverticulum. After removal of the large sac, the esophageal lumen is no longer collapsed, and retention of food material is impossible, of course. This is why we did not find any significant difference in terms of symptomatic relief between patients who had a myotomy and those who had not. In contrast, we found that omitting a myotomy in patients who had their diverticulum resected predisposed to the development of a cervical fistula postoperatively and to pouch recurrence in the very long term, probably because of the persistence of a high intrapharyngeal pressure at swallowing.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gutschow, C. A. Articles by Collard, J.-M. Search for Related Content PubMed PubMed Citation Articles by Gutschow, C. A. Articles by Collard, J.-M. Related Collections Esophagus - other