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A Zenker diverticulum is a pulsion diverticulum that occurs between the cricopharyngeus muscle inferiorly and the inferior constrictor superiorly as a result of relative obstruction to swallowing at the esophageal introitus by a “tight” cricopharyngeus muscle (Figure 1A). As the diverticulum develops and extends inferiorly and posteriorly, the cricopharyngeus muscle is enveloped by mucosa from the posterior wall of the esophageal introitus and the anterior wall of the diverticulum (Figure 1B). This relationship allows transoral division of the common wall between the esophagus and diverticulum, and cricopharyngeal myotomy with a single firing of a linear stapler inserted into the diverticulum (one jaw) and across the upper esophageal sphincter (cricopharyngeus muscle) (Figure 1C). An important anatomic fact that supports the safe performance of the cricopharyngeal myotomy is that the hypopharynx, diverticulum, and cervical esophageal complex are surrounded by the middle layer of the deep cervical fascia, which protects against leakage into the mediastinum.
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Surgical management of Zenker diverticulum is indicated in individuals who have hypopharyngeal, laryngeal, or swallowing symptoms that can be correlated with the presence of the diverticulum and its associated cricopharyngeal spasm. Typical symptoms include: (1) pharyngeal regurgitation of food often in association with coughing, sometimes with a long latency after eating; (2) difficulty swallowing, particularly solid boluses; (3) cough from the microaspiration that occurs when food and liquid matter in the diverticulum refluxes into the hypopharynx. (4) As symptoms worsen, weight loss may become a major issue.
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Because of the low morbidity of the endoscopic approach to Zenker diverticulum and cricopharyngeal myotomy as compared to the external approach, many patients are now eligible for surgical management who, in the past, would have been felt to be at high risk for general anesthesia. Many of these patients are old and cachectic with significant pulmonary comorbidities. Endoscopic management of this condition can generally be performed on an outpatient basis with less than 60 minutes of general anesthesia. It is contraindicated in relatively few patients.
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PREOPERATIVE PREPARATION
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A modified barium swallow performed by a qualified team of speech and language pathologists and radiologists is a prerequisite to surgical management of this disease process. The purpose of the swallowing evaluation is not only to determine the size and location of the diverticulum but also to look at associated problems with swallowing in the oral, pharyngeal, and esophageal phases. Many patients with a Zenker diverticulum have associated esophageal dysmotility that may ultimately influence their swallowing result. Although these patients can still undergo surgical management, preoperative counseling as to the likelihood of resumption of normal swallowing will be tempered by these findings. Generally, a modified barium swallow examination will look at all aspects of swallowing with particular focus on the oropharyngeal, hypopharyngeal, and esophageal phases, ...