Zenker`s Diverticulum and CP Dysfunction

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Zenker’s Diverticulum and
CP Dysfunction
Fact and Fiction
Joshua S. Schindler, MD
Assistant Professor
Department of Otolaryngology
ASHA 2011 San Diego
November 18, 2010
Zenker’s Diverticulum:
Zenker’s Diverticulum
Zenker’s Diverticulum
Esophagus
Sac
Myth 1:
All posterior cervical diverticula are
Zenker’s diverticula
Killian-Jamieson Diverticulum
• Originate below the
CP muscle
• Often project
laterally
• May account for 4/9
diverticula
• Implications for
treatment?
– RLN
– Recurrence
Sac
Esophagus
Forestier’s Syndrome
• Dysphagia
• Cervical Osteophytes
(DISH)
• Esophageal Diverticula
– Traction
Diffuse Idiopathic Skeletal Hypertrophy
Post-traumatic Diverticulum
Post-traumatic Diverticulum
Management of Zenker’s
Diverticula
Diverticulotomy: External Approaches
1877 – 1st Attempted Drainage
(Nicoladoni)
1884 – 1st Attempted Excision
(Niehaus)
1886 – 1st Successful Excision
(Wheeler)
1892 – Diverticulectomy with 1
Closure (Kocher)
1896 – Endoluminal Inversion of the
Sac (Girard)
1917 – Diverticulopexy (Hill)
1936 – CP Myotomy with
Diverticulotomy (Aubin)
o
Emil Theodor Kocher
Myth 2:
Recent technological advances have
allowed endoscopic treatment of Zenker’s
diverticula
Diverticulotomy: Endoscopic Approaches
1917 – 1st Endoscopic
Diathermy (Mosher)
Harris P. Mosher
Diathermy (Mosher)
1960 – Endoscopic
Diathermy (Dohlman)
Gosta Dohlman
Endoscopic Diverticulotomy
Dohlman Esophagoscope
Diathermy (Mosher)
1960 – Endoscopic
Diathermy (Dohlman)
1981 – Endoscopic CO2
Laser (van Overbeek)
Geza Jako
Challenges:
– Dohlman procedure
• Prone to recurrence
• Occasional mediastinitis/death
• Occasional stenosis
– Laser Diverticulotomy
• Variable success rates
• Variable (some high)
recurrence rates
• Occasional fistula
• Rare mediastinitis/death
• Often multiple procedures
Dohlman Esophagoscope
Diathermy (Mosher)
1960 – Endoscopic
Diathermy (Dohlman)
1981 – Endoscopic CO2
Laser (van Overbeek)
1992 – Endoscopic KTP
Laser (Kuhn)
1993 – Endoscopic GIA
Stapler (Collard & MartinHisrch)
USS EndoGIA 30 Stapler
Staple-assisted (SA) Diverticulotomy
Advantages:
– Minimally invasive
– Technically simple
– Safe
– Easy to repeat
– Fast
– Outpatient
Staple-assisted (SA) Diverticulotomy
Limitations:
– Massive exposure
– Dental injuries
– Fails with small
diverticula
Kastenbauer-Wollenberg Diverticuloscope
SA Diverticulotomy Limitations
EndoGIA Stapler Limitations
27 mm
10 mm
28 mm Diverticulum
28 mm Diverticulum
28 mm Diverticulum
17 mm Diverticulum
Minimal Length About
2-2.5 cm for Staple-assisted
Diverticulotomy
EndoGIA Stapler Modification
Removal of
Stapler Tip
27 mm
10 mm
EndoStitch Technique for
Staple Purchase
Staple Purchase
Staple Purchase
Myth 3:
If you make a hole in the pharynx and
esophagus and don’t close it the patient
will get mediastinitis and die
Laser-assisted (LA) Diverticulotomy
1.8 cm
Sub 2 cm Zenker’s Diverticulum
Initial Cut
Complete Division of Cricopharyngeus
Exposure of Esophageal Serosa
LA Cricopharyngeal Myotomy
Revision Following SA
Diverticulotomy
Revision Following SA
Diverticulotomy
OHSU Experience 2006-2010
70 Patients
– 66 Endoscopic Procedures (94%)
• 16 Stapler-assisted (24%)
– 0 major complications
– 1 dental injury
• 50 Laser-assisted (76%)
– 0 major complications
– 3 SQ emphysema
– 1 dental injury
Myth 4:
Cricopharyngeal dysfunction without
Zenker’s diverticulum can only be treated
via open approach
Cricopharyngeal Dysfunction
Cricopharyngeal Bar
Cricopharyngeal Botox Injection
Myth 5:
Massive diverticula require an open
approach to successfully manage them
Massive Zenker’s Diverticulum
Myth 6:
All patients with Zenker’s diverticulum will
swallow better following treatment of the
Zenker’s diverticulum
Paraesophageal Hernia
Esophageal Dysmotility
Thank You
Mt. Hood at Sunset

Zenker`s Diverticulum and CP Dysfunction

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