Zenker’s diverticulum

Published on 09/04/2015 by admin

Filed under Surgery

Last modified 09/04/2015

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CHAPTER 1 Zenker’s diverticulum

Step 1. Surgical anatomy

Zenker’s diverticulum is a pulsion diverticulum that occurs between the lowermost fibers of the inferior pharyngeal constrictor and the cricopharyngeal (CP) segment. This segment is the upper esophageal sphincter (UES) and is composed of the cricopharyngeus muscle and a portion of the upper esophagus musculature (Figure 1-1).

The etiology of Zenker’s diverticulum is a failure of timely opening of the CP segment. The diverticular sac forms in a relative weak spot in the posterior pharyngeal wall as contraction of the tongue and pharyngeal musculature builds pressure above a closed CP segment. Therefore, surgical correction of the condition must address not only the diverticulum but also the hypertonic or stenotic CP segment by performing a thorough myotomy.

The transoral approach provides easy access to the diverticular sac and the CP segment (which lies within the common wall between the diverticulum and the cervical esophagus). However, the access to the segment is limited by the size of the diverticulum. Therefore, it is paradoxically easier to perform an adequate operation on patients with large diverticula as these may be stapled. Diverticula smaller than 2.5 cm may be inadequately divided by stapling because of limitations of the device and inadequate access to the CP segment. However, these smaller diverticula may be treated endoscopically with a CO2 laser in similar fashion.

The availability of endostapling devices has decreased the concern of postoperative salivary leakage to a minimum. Improvements in laser technology allow this laser division to be performed safely without hemorrhage or stenosis.

Step 2. Preoperative considerations

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