Zenker’s Diverticulum Treatment

Zenker diverticulum is a pouch-like protrusion that forms on the posterior pharyngeal wall in the transition region between the pharynx and the esophagus. It is most commonly seen in elderly individuals and causes symptoms such as difficulty swallowing, bad breath, and regurgitation. It is diagnosed by endoscopy.

The pathophysiology and mechanism of formation are explained as the development of a diverticulum when the pressure formed during swallowing, due to the cricopharyngeal muscle not relaxing, pushes the mucosa outward through a weak area. This structure leads to the accumulation of food in the pouch and the worsening of symptoms.

Diagnostic methods and imaging, the size and location of the diverticulum can be clearly determined with a barium esophagogram. Its internal structure is evaluated by endoscopic examination, but caution should be exercised due to the risk of aspiration. Diagnosis is generally made with clinical and radiological findings.

Treatment options and surgical approaches include removal of the diverticulum with endoscopic or open surgical methods in symptomatic cases, or sphincterotomy to allow the pouch to empty. Endoscopic treatments stand out with a low risk of complications and a short recovery time.

What Is Zenker Diverticulum?

Zenker Diverticulum is a diverticulum formed by the pouch-like protrusion of the mucosa outward from a weak point in the transition region between the pharynx and the esophagus. It is generally seen at an advanced age and may lead to complaints such as difficulty swallowing, foul-smelling food coming back into the mouth, cough, and weight loss. Diagnosis is made by radiological imaging. Endoscopic or surgical methods can be applied in treatment.

Why and how does Zenker Diverticulum form in our body?

Although our body’s swallowing mechanism appears simple from the outside, it is actually an incredible engineering marvel that works with millisecond precision. When we swallow a bite, the muscles in our throat must contract in a certain order, while the muscles just below must relax simultaneously. The main problem in the development of Zenker Diverticulum is the disruption of this synchronization. In particular, the cricopharyngeal muscle, which forms the upper valve of the esophagus, not relaxing sufficiently or contracting early during swallowing causes a very serious pressure increase inside the pharynx.

Anatomically, all of us have a natural weak point on the back wall of the throat, between the transition regions of the muscle fibers, which we call the “Killian triangle.” Under normal conditions, this weak area does not cause us any problems. However, due to the muscle relaxation defect (cricopharyngeal dysfunction) I mentioned, when the pressure inside the pharynx increases, this high pressure starts to push the mucosa, the inner lining of the throat, outward through this weak point instead of pushing food downward. We can compare this to a car tire under increased pressure forming a balloon at a weak point. Over time, this herniation grows, turns into a pouch hanging downward with the effect of gravity, and creates a dead-end street where foods are trapped.

What are the symptoms of Zenker Diverticulum seen in patients?

The disease generally appears in individuals over the age of 60, and the symptoms may be very subtle at first. However, as the diverticulum grows, the complaints may reach the point of ending the patient’s social life. The complaint that our patients most frequently present to us with is difficulty swallowing. The feeling that bites get stuck somewhere in the throat and do not go down is very prominent. However, the most typical and most disturbing condition for the patient in Zenker Diverticulum is that the eaten foods come back into the mouth hours later in an undigested state. Since the foods accumulated in the pouch begin to decay, a very heavy and disturbing bad breath develops in our patients. This may cause the person to hesitate to kiss their grandchild, avoid going out to eat with friends, in short, be dragged into social isolation.

The main complaints caused by this disease are:

• Difficulty swallowing solid foods
• Difficulty swallowing liquids
• Food coming back into the mouth
• Severe bad breath
• A tickling sensation in the throat
• Hoarseness
• A sound coming from the throat while swallowing
• Unintentional weight loss
• A foreign body sensation in the throat
• Chronic cough

Does untreated Zenker Diverticulum damage the lungs?

As thoracic surgery specialists, we do not see this disease only as a swallowing problem; for us, Zenker Diverticulum is a potential enemy of the lungs. The most dangerous and life-threatening aspect of the disease is the damage it causes to the respiratory system. As the diverticulum pouch grows, it accumulates not only food but also saliva and mucus. Especially when the patient lies down and sleeps at night, the swallowing reflex weakens and the protective effect of gravity disappears. At this moment, that dirty and infected material accumulated in the pouch overflows into the windpipe and from there into the lungs.

This condition, which we call “aspiration” in medical language, causes very serious infections in the lungs. This type of pneumonia, which we call “aspiration pneumonia,” progresses quite severely, especially in elderly patients and in those with low body resistance, may require intensive care, and unfortunately carries a life-threatening risk. Repeated aspirations may over time cause permanent damage to lung tissue, permanent widening of the bronchi (bronchiectasis), and lung abscesses. For this reason, the treatment of Zenker Diverticulum is a necessity not only for the patient to eat comfortably but also to protect the lungs and prevent life-threatening complications. If the disease is not treated in the long term, there is also a risk of inflammation due to chronic irritation within the diverticulum, perforation, and very rarely, cancerous transformation.

Which methods do we use when diagnosing Zenker Diverticulum?

In the diagnostic process, the story told by the patient gives us very strong clues. In particular, the sentence “Hours after eating, undigested food comes into my mouth” is almost diagnostic for us. However, to make a definitive diagnosis and clearly see the anatomical structure, we resort to imaging methods. The gold standard, that is, the most reliable method in this regard, is the “Barium Esophageal Transit X-ray.”

In this examination, we make our patient drink a thick liquid containing barium that appears white on X-ray. While the patient swallows this liquid, serial X-ray films are taken or a video recording is made. In this way, we can dynamically observe the moment of swallowing. The barium study clearly shows us the exact location, size, shape of the diverticulum, and most importantly how the muscles are working incorrectly during swallowing. We measure how far the pouch hangs downward and the width of its neck with this film.

The other tools we use in the diagnostic process are:

• Barium swallow study
• Flexible endoscopy
• Computed tomography
• Manometry tests

Endoscopy is also a method we frequently use, but endoscopy should be performed with extreme caution in a patient suspected of having Zenker. Because the wall of the diverticulum is very thin, and if the endoscope accidentally enters this pouch instead of the esophagus, there is a risk of perforation. We generally perform endoscopy to rule out suspicion of a tumor and to see the inside of the esophagus.

In which situations is Zenker Diverticulum surgery necessary?

When a diagnosis of Zenker Diverticulum is made, we weigh the patient’s complaints and the size of the diverticulum when making the treatment decision. We may monitor very small diverticula under 1 centimeter that cause no complaints in the patient and are detected incidentally, without operating. However, our general rule is this: if the diverticulum is symptomatic, that is, if the patient has difficulty swallowing, food comes into the mouth, or most importantly develops lung infections, surgical intervention is mandatory regardless of the size of the diverticulum.

In addition, diverticula larger than 1-2 centimeters are generally operated on due to their potential risks, even if the symptoms are mild. The patient’s age and general health status are also important when making the decision for surgery. However, since this disease is generally a disease of advanced age, most of our patients are elderly. Advanced age alone is not an obstacle to surgery; because the lung problems that may be experienced if left untreated may be much more dangerous than the risk of surgery. Our aim is to ensure that the patient spends the rest of their life as an individual with quality of life, able to eat and breathe.

How is Zenker Diverticulum treated with the open surgical method?

In thoracic surgery practice, especially in large and anatomically complex diverticula, “Open Surgery,” that is, surgery performed through the neck, is the most reliable and most permanent-result method. We call this method the “Transcervical Approach.” Open surgery aims to eliminate the root cause of the disease and minimize the possibility of recurrence.

The operation is performed under general anesthesia. We make an incision of approximately 4-5 centimeters on the left side of the neck, parallel to the line of the muscles. When this incision is closed in accordance with aesthetic rules, it leaves almost no scar in the future. When we pass through the skin and muscle tissues and reach the diverticulum pouch, we perform two basic procedures. The first and most important is “Cricopharyngeal Myotomy.” In other words, to solve the contraction problem that causes the disease, we cut and relax the muscle fibers that create excessive pressure. If we only remove the pouch but do not cut this muscle, the pressure problem may continue, so the disease may recur or there may be leakage from the suture line. The second procedure is “Diverticulectomy,” that is, the complete removal of the pouch from the body by cutting it from its neck.

The advantages of open surgery are:

• Complete removal of the pouch
• Ability to examine tissue pathology
• Complete performance of muscle relaxation
• Very low recurrence rate
• Complete anatomical control
• Being a definitive solution in large diverticula

Is treatment of Zenker Diverticulum possible with the endoscopic method?

Yes, with the advancement of technology, “Endoscopic Diverticulostomy” methods performed by entering through the mouth without making any incision in the neck are also applied. In this method, rigid or flexible endoscopes are used. The logic here is not to cut and remove the pouch, but to cut the wall (septum) between the inner wall of the pouch and the esophagus and merge these two cavities.

In other words, we create a window between the pouch and the esophagus. Thus, swallowed foods are not trapped inside the pouch; they drain into the esophagus through this window that is opened. Special stapling instruments (staplers) or laser devices are generally used for this procedure. The greatest advantages of the endoscopic method are that there is no neck incision, the recovery period is shorter, and the patient can be discharged the next day.

However, not every patient is suitable for this method. In patients whose jaw structure does not allow the endoscope to enter, in those with a very short neck, or in those whose diverticulum is very large, this method may be technically difficult or impossible. In addition, since the pouch remains in the body in the endoscopic method, a tumor that may develop inside the pouch, although very rare, may be overlooked.

What are the differences between open surgery and endoscopic Zenker Diverticulum operations?

Our patients understandably ask which method is better for them. Both methods have their own advantages and disadvantages. When making a decision, the patient’s anatomy, the size of the diverticulum, and the patient’s general condition are decisive. While open surgery is a more “traditional and definitive” solution, endoscopic surgery is a more “minimally invasive and fast” option.

The main differences between the two methods are:

• In open surgery, the pouch is completely removed
• In endoscopic surgery, the pouch remains in place
• The recurrence rate is lower in open surgery
• Recovery is faster in endoscopic surgery
• Hospital stay is somewhat longer in open surgery
• The duration of general anesthesia is shorter in endoscopic surgery
• Open surgery can be applied to diverticula of any size
• Endoscopic surgery may not be suitable for every anatomy

As surgeons, we may generally prioritize open surgery in young, healthy patients with a long life expectancy so that the disease does not recur. However, in the group that is very elderly, has additional diseases, or is risky to receive anesthesia, endoscopic methods are an excellent lifesaver.

What kinds of risks does Zenker Diverticulum surgery have?

No surgical procedure is risk-free, and Zenker operations also have their own points that should be carefully considered. In open surgery, the complication we fear the most is hoarseness. Because the nerves going to the vocal cords pass very close to the surgical field. However, in delicate dissection performed by experienced hands using a microscope or magnifying glasses, this risk is quite low. Another risk is what we call a “fistula,” meaning leakage from the suture line. This condition usually heals on its own or with simple dressings, but it may prolong the hospital stay.

The most feared risk of endoscopic surgery is perforation of the esophagus or the mediastinum (chest cavity) during the procedure. In addition, situations such as the complaints not resolving or the disease recurring in a short time may be encountered if the muscle cannot be cut in the endoscopic procedure. General surgical risks such as infection and bleeding are valid for both methods, but their rates are low.

Possible risks are:

• Temporary hoarseness
• Leakage from the suture line
• Persistence of difficulty swallowing
• Dental injuries
• Development of infection
• Recurrence of the disease
• Formation of narrowing in the esophagus

What is the recovery process like after Zenker Diverticulum surgery?

The postoperative process is generally more comfortable for our patients than they expect. After open surgery, we take our patient to the ward. There may be a small drain in the neck (a tube that prevents fluid accumulation), which we usually remove within 24 to 48 hours. The most important issue is when nutrition will begin.

For the safety of the suture line, we may stop oral feeding for the first few days. During this process, we feed our patient with intravenous fluids or sometimes with a thin tube extending from the nose to the stomach. Around the 3rd or 5th day, we usually perform a “water test” or take a film to check whether there is any leakage in the sutures. If everything is fine, we start a gradual diet, first with water, then strained soups, then purees.

The points to be considered during the recovery period are:

• Only liquid foods should be consumed in the first week
• Pureed consistency should be started in the second week
• Very hot and very cold foods should be avoided
• Bites should be chewed very well
• Carbonated drinks should be avoided
• One should not lie down immediately after eating
• The medications given by the doctor should be used regularly

When the patient is discharged home, they are usually able to take care of themselves. Since the stitches on the neck are placed aesthetically, there is no need to remove them, or self-dissolving sutures are used. In endoscopic surgery, this process is much faster; the patient can take liquid food and go home the next day. Regardless of which method is applied, our patients can sit at their normal tables approximately 2-3 weeks after surgery and become able to eat whatever they want. Those old fearful mealtimes are replaced by pleasant tables.

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