Zenker Diverticulum

Zenker diverticulum is a pulsion pseudodiverticulum of the hypopharyngeal mucosa through Killian triangle, between the oblique thyropharyngeus and transverse cricopharyngeus muscles.

• Prevalence is about 0.01 to 0.1%, men more than women, usually over 60 years.
• Cause: incomplete relaxation or poor compliance of the cricopharyngeus (upper oesophageal sphincter) with raised intrabolus pressure during swallowing.
• Associated: gastro oesophageal reflux disease, hiatal hernia.
• Complications: aspiration pneumonia, weight loss, malnutrition, rare perforation, squamous cell carcinoma within the pouch (0.4 to 1.5%), vocal cord paralysis from compression, fistula.

• Oropharyngeal dysphagia, regurgitation of undigested food hours after eating, halitosis, gurgling noise in the neck, chronic cough, aspiration, voice changes, weight loss.
• Visible or palpable neck mass that gurgles on pressure (large pouches).
• Differential diagnosis: oesophageal carcinoma, achalasia, stricture, oropharyngeal dysphagia, stroke.

• Barium swallow (videofluoroscopy): posterior outpouching at the pharyngoesophageal junction at C5 to C6, lateral view best, with retained contrast, and cricopharyngeal bar.
• Upper endoscopy must be done with caution (risk of perforation from blind intubation of the pouch), to exclude carcinoma; biopsies if mucosal irregularity.
• Manometry is not routine.
• Pouch size classification (Brombart: stage I under 2 cm, II 2 to 4 cm, III over 4 cm; or by length: under 3 cm, 3 to 5 cm, over 5 cm).
• Assess nutritional status and aspiration risk.

• Asymptomatic small pouches: observation.
• Symptomatic diverticula need intervention:
  • Flexible endoscopic septotomy (division of the septum including the cricopharyngeus using needle knife, stapler or harmonic scalpel): success 80 to 90%, shorter stay, higher recurrence (10 to 20%) in smaller pouches; contraindicated for pouches under 2 to 3 cm.
  • Rigid endoscopic stapler diverticulostomy (Collard), for pouches over 3 cm, with excellent outcomes, 80 to 90% symptom relief, low morbidity.
  • Peroral endoscopic myotomy (Z-POEM) similar results.
  • Open surgery (cricopharyngeal myotomy with diverticulectomy or diverticulopexy/inversion) via left cervical incision: success over 90%, but morbidity of 10 to 30% (recurrent laryngeal nerve injury, leak, fistula, mediastinitis).
• Cricopharyngeal myotomy alone suffices for small pouches (under 2 cm).
• Perioperative cefazolin 2 g IV; nil by mouth until swallow study if leak concern.
• Treat reflux and aspiration, nutritional support.
• Follow up for recurrence (10 to 15%).