Zenker`s Diver,culum

Zenker’s Diver,culum Sunil Verma, M.D.
Director, University Voice and Swallowing Center Phone: (714) 456-­‐7017 3 “Ea,ng makes you feel human” 4 Abrham Ludlow, Surgeon, 1764 5 Friedrich Albert von Zenker 1877 6 Symptoms of a Zenker’s Diver,culum ! Difficulty swallowing ! RegurgitaMon of foods ! “Lump in the throat” sensaMon ! Coughing on foods ! Pills geRng stuck ! RegurgitaMon of undigested foods 7 Other symptoms ! Pill dysphagia !  Pills geRng “stuck” !  Burning of pills in throat ! Excess saliva ! Coughing while eaMng ! Gurgling in throat 8 What about this? 9 Who? ! 60-­‐80 year old ! Males > females ! Related to GERD 10 Why? Hypertonic
muscle
11 Natural
area of
pharyngeal
weakness
12 Killian’s dehiscence ! Between inferior constrictors & cricopharyngeus http://drkamaldeep.files.wordpress.com/2010/06/phary_pouch5b175d.jpg
13 Killian’s dehiscence 14 http://www.elsevierimages.com/image/24594.htm
Killian-­‐Jamieson area ! Between fibers of cricopharyngeus http://drkamaldeep.files.wordpress.com/2010/06/phary_pouch5b175d.jpg
15 Laterality of Zenker’s Diver,culum ! Le^ sided predominance 16 Diagnosis Laryngoscopy Endoscopy – EGD Esophagogram – gold standard 17 Laryngoscopy 18 19 Management op,ons ! ObservaMon ! DilaMon ! Botulinum toxin ! Open resecMon ! Endoscopic cricopharyngeal myotomy 20 Observa,on ! How best to counsel paMents? ! Is it really necessary to treat? ! Consider age and cormorbidiMes http://www.cartoonstock.com/lowres/jfa0279l.jpg
21 Risks of Zenker’s Diver,culum ! Weight loss ! MalnutriMon ! AspiraMon 22 Pa,ent counseling ! Dysphagia exacerbated when weak ! Size of pouch increases with Mme ! Easier to manage when small 23 http://www.elsevierimages.com/image/24594.htm
Increase in size over ,me Belafsky PC, Rees CJ, Allen J, Leonard RJ. Pharyngeal dilation in cricopharyngeus muscle dysfunction and Zenker diverticulum. /
24 Laryngoscope.
2010 May;120(5):889-94.
Will I feel bePer? 25 Will I feel bePer? ! 80-­‐90% success rate ! Quality of life improves 26 How do pa,ents do? ! Reduced food avoidance ! Less regurgitaMon ! Less pill dysphagia ! Less choking episodes ! Less coughing ! Less difficulty finishing meals ! Less heartburn ! Less halitosis 27 Palmer AD, et. al. Dysphagia after endoscopic repair of Zenker’s Diverticulum.
Interven,on 28 Interven,on ! CP overacMvity causes diverMculum ! Disable the cricopharyngeus muscle ! Treat the muscle, treat the condiMon 29 Temporary measures ! Upper esophageal sphincter dilaMon ! Balloon dilators ! Bougie catheter ! Temporary procedure !  Results last ~ months 30 Dila,on ! Perform esophagoscopy ! Pass dilators through esophagus ! Stretching the upper esophageal sphincter ! Less resistance for food to enter esophagus 31 Botulinum toxin ! Cricopharyngeus muscle ! Performed in-­‐office or in O.R. ! Temporary relief 32 Local anesthesia ! Transcervical route ! EMG guidance ! Pass needle behind cricoid carMlage ! Ask paMent to swallow ! Deposit botulinum toxin 33 Botox under general anesthesia ! Transoral approach ! DiverMculoscope ! Ridge of Mssue at cricopharyngues muscle ! Place botox with long straight needle 34 Defini,ve management ! Open cricopharyngeal (CP) myotomy ! Open CP myotomy and resecMon of sac ! Endoscopic CP myotomy 35 Endoscopic treatment ! Endoscopic management first described in 1917 ! Knife used to cut the party wall ! Seventh paMent died of mediasMniMs Mosher, HP. Webs and pouches of the esophagus, their diagnosis and treatment. Surg Gyencol Obst. 1917. 25:
175-87.
36 Endoscopic treatment ! Sac is not removed ! Mucosa is cut ! Cricopharyngeal myotomy ! Sac is “connected” to the esophagus” 37 Endoscopic Diver,culotomy ! PaMent intubated ! DiverMculoscope exposes party wall ! Mucosa divided ! Cricopharyngeus muscle lysed ! Feeding tube placed 38 Endoscopic treatment ! Stapler ! Laser ! “Bovie” 39 Diver,culoscope use ! Weerda Bivalved DiverMculoscope ! Not the only opMon ! Holinger-­‐Benjamin diverMculoscope ! Laser diverMculotomy 40 41 42 43 44 45 46 47 48 49 50 Carbon Dioxide Laser 51 52 Stapler versus laser ! Which is bener? ! Both efficacious ! Longer hospital stay? 53 Modified stapler ! Cuts and staples the same length Morse, et. al. Preliminary Experience by A Thoracic Service with Endoscopic Transoral
54 Stapling of Cervical (Zenker’s) Diverticulum.J Gastrointest Surg (2007) 11:1091–1094
Endos,tch ! Assists in exposure ! Provides tension on party wall 55 Retrac,on s,tch 56 Endos,tch in party wall !Nicholas BD, et al. EndosMtch-­‐assisted endoscopic Zenker’s diverMculostomy: a tried approach for difficult cases. Diseases of the Esophagus (2010) 23, 296–
299 57 Mucosal closure ! Biggest fear is mediasMniMs ! Will it limit these occurrences? 58 Open CP myotomy ! General anesthesia ! Transcervical approach ! Cut muscle ! Remove pouch 59 Open CP myotomy ! Examine film to ensure sac is midline/le^ward ! Typically use le^ sided incision ! In the room during intubaMon 60 Step 1: Esophagoscopy ! IdenMfy the entrance to the esophagus & sac ! Pac the sac with gauze transorally ! Pass a large bougie into esophagus 61 Step 1: Esophagoscopy ! SucMon all debris ! Irrigate sac ! O^en difficult to introduce into esophagus 62 63 64 Step 2: Open approach ! Horizontal incision at level of cricoid carMlage ! Le^ side ! IdenMfy the SCM ! Lateralize the great vessels ! Medialize the strap muscles and larynx 65 Step 3: Iden,fy omohyoid 66 Step 4: Iden,fy sac 67 Step 4: Iden,fy sac Palpate Feel for larynx Feel for esophagus with bougie Feel for strip gauze 68 Step 5: Free sac 69 70 CP Myotomy ! Recurrent laryngeal nerve travels in tracheoesophageal groove 71 Step 5: CP Myotomy ! Stay posterior to avoid the RLN 72 http://www.saintluc.be/en/services/foregut/images/or_tech_zenker_01.jpg
Open treatment 73 Step 6: Cut sac Remove gauze Staple or sew…or both http://cdn.medgadget.com/img/BlackReload_highres.jpg
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