[Zenker's diverticulum. The endoscopic-microscopic, staple-assisted esophagodiverticulostomy]

Surgical treatment of hypopharyngeal diverticulum (Zenker's diverticulum)

The goal of this study was to evaluate the outcome of various modalities in the treatment of hypopharyngeal diverticulum (Zenker's diverticulum, HD) as performed in the ENT department, University of Ulm. A retrospective analysis of 40 consecutive patients with the diagnosis of a HD was conducted. The three different modalities of surgery applied had been endoscopic laser diverticulotomy (ELD), conventional endoscopic esophagodiverticulotomy (CEE) and transcervical open technique involving diverticulectomy and cricopharyngeal myotomy. Medical records had been reviewed to determine preoperative symptoms and diagnostic findings, operative time, length of hospital stay, time of oral intake, postoperative laboratory parameters, and postoperative complications. Significant differences (P < 0.05) could be observed between the three surgical groups concerning the postoperative time to oral intake, the length of the hospital stay, and the length of time with a nasogastric tube. Patients after ELD had statistically significantly less thoracic pain than patients after CEE. In conclusion, the comparison of three different surgical approaches in the treatment of HD showed that endoscopic techniques versus open-neck technique result in statistically significant shorter operative times and shorter hospital stays. Conventional endoscopic diverticulotomy is not safer than ELD or transcollar open technique.

Extraösophagealer Reflux und Zenker-Divertikel

INTRODUCTION

Patients with Zenker's diverticulum often present with a hiatal hernia. Theoretically, the gastric acid fluid could rise up to the hypopharynx producing an injury to the mucosa of Killian's triangle and hypertrophy of the cricopharyngeal muscle. We performed dual-channel pH monitoring in healthy people as a control group and in patients with a Zenker's diverticulum to elucidate the relationship between Zenker's diverticulum and gastroesophageal reflux disease (GERD) as well as extraesophageal reflux (EER).

METHODS

Patients with Zenker's diverticulum underwent dual-channel 24-h pH monitoring to exclude the possibility of an EER or a GERD. The measurements were performed in 4 patients preoperatively and postoperatively as well as in 14 patients only postoperatively. The control group consisted of healthy volunteers who did not suffer from a reflux disease (n=20). In each group we determined the number of refluxes, the fraction time, the RAI (reflux area index), and the DeMeester Score Index. In addition we classified the severity of the EER with a grading system which was developed in an earlier study in our department.

RESULTS

Patients with a Zenker's diverticulum suffered significantly from EER (p<0.01). The difference between the patients measured preoperatively and the patients postoperatively was minor. More than 72% of the patients suffered from a severe EER.

CONCLUSIONS

Patients with a Zenker's diverticulum have a high possibility of suffering from EER and GERD. The pathophysiology of this relationship can only be speculated. In addition to a cricopharyngeal myotomy, long-term therapy with a PPI (proton pump inhibitor) seems indicated.