How to manage upper esophageal diverticulum?

Management of Upper Esophageal Diverticulum

For symptomatic upper esophageal diverticulum (Zenker's diverticulum), surgical or endoscopic intervention is the recommended treatment approach, with endoscopic diverticulotomy being preferred for elderly or high-risk patients due to lower morbidity and mortality rates. 1

Diagnostic Approach

When evaluating a patient with suspected upper esophageal diverticulum:

1. Initial assessment:

   • Evaluate for key symptoms: dysphagia, regurgitation, aspiration, halitosis, and chronic cough
   • Document duration and progression of symptoms
   • Assess for complications: aspiration pneumonia, malnutrition, weight loss

2. Diagnostic studies:

   • Upper endoscopy to directly visualize the diverticulum and exclude other pathologies
   • Consider barium esophagram to assess diverticulum size and location
   • Manometric studies may be helpful to identify underlying motility disorders

Management Algorithm

1. Asymptomatic Patients

• Observation is appropriate for incidentally discovered diverticula without symptoms 1
• No intervention is recommended for asymptomatic Zenker's diverticula

2. Symptomatic Patients

A. Non-surgical Management (for mild symptoms or poor surgical candidates)

• Dietary modifications: soft diet, small frequent meals
• Proper positioning during meals to minimize aspiration risk
• Consider PPI therapy if reflux symptoms are present 1

B. Endoscopic Management

• Preferred approach for elderly or high-risk patients 2
• Endoscopic diverticulotomy with section of the septum between diverticulum and esophageal lumen
• Advantages:
  • Can be performed without general anesthesia
  • Shorter hospital stay
  • Lower complication rates
  • Significant reduction in upper esophageal sphincter pressure (from mean 54.6 cm H2O to 26.8 cm H2O) 2

C. Surgical Management

• For younger, healthier patients with significant symptoms 3
• Options include:

  1. For Zenker's diverticulum:

     • Transcervical diverticulectomy with cricopharyngeal myotomy
     • Diverticulopexy with cricopharyngeal myotomy

  2. For mid or lower esophageal diverticula:

     • Laparoscopic approach is preferred over thoracotomy (significantly lower morbidity, OR 7.45 for thoracotomy) 3
     • Procedure includes diverticulectomy and myotomy 4
     • Consider adding anti-reflux procedure (fundoplication) when myotomy extends to the gastroesophageal junction 5

Post-Procedure Care

1. Monitoring period:

   • Monitor patients for at least 2 hours in recovery 1
   • Ensure patients are tolerating water before discharge 1

2. Complications to watch for:

   • Perforation (suspect if persistent chest pain, fever, breathlessness, or tachycardia develop) 1
   • Bleeding (rare but potentially serious) 6
   • Recurrence of symptoms

3. Follow-up instructions:

   • Provide clear written instructions regarding diet progression
   • Supply contact information for the on-call team 1
   • Schedule follow-up to assess symptom improvement

Special Considerations

• Risk factors for complications: Female gender, black race, and presence of comorbidities are associated with increased postoperative morbidity in Zenker's diverticulum patients 3

• Rare complications: Upper GI bleeding from esophageal diverticula is rare but can be life-threatening; endoscopic management with hemostatic clips can be effective 6

• Surgical approach selection: Minimally invasive approaches (endoscopic or laparoscopic) should be preferred whenever feasible to reduce morbidity 4, 3

Pitfalls to Avoid

1. Delaying intervention in symptomatic patients, which can lead to aspiration pneumonia, malnutrition, and decreased quality of life

2. Performing thoracotomy when laparoscopic or endoscopic approaches are feasible (thoracotomy has significantly higher morbidity) 3

3. Neglecting to perform myotomy along with diverticulectomy, which can lead to persistent symptoms due to underlying motility disorders 5

4. Failing to add an anti-reflux procedure when myotomy extends to the gastroesophageal junction, potentially leading to post-operative reflux 5