Can a Zenker's diverticulum recur after a myotomy?

Recurrence of Zenker's Diverticulum After Myotomy

Yes, Zenker's diverticulum can recur after myotomy, with approximately 30% of patients experiencing symptom recurrence within months of the initial procedure. 1

Recurrence Rates and Timeframe

• Clinical recurrence rates after endoscopic treatment range from 15-30% of cases 2, 1
• Symptom recurrence typically occurs within an average of 4.4 months (range 1-40 months) after the initial procedure 1
• Long-term follow-up studies show that despite initial success rates of nearly 100%, recurrence remains a significant concern 1

Risk Factors for Recurrence

Several factors have been identified that increase the risk of Zenker's diverticulum recurrence after myotomy:

1. Diverticulum size: Large diverticula (>3 cm) have a higher recurrence risk 2
2. Amount of redundant mucosa remaining after the procedure 2
3. Patient characteristics:
   • Male gender
   • Higher initial dysphagia score
   • More severe pre-treatment symptoms (especially vomiting)
   • Longer duration of symptoms before initial treatment 1

Management of Recurrent Zenker's Diverticulum

The UK guidelines on esophageal dilatation provide guidance for managing recurrent cases:

• Repeat endoscopic treatment is generally effective for recurrent cases, with most patients achieving symptom relief 3
• Pneumatic dilatation (PD) may be performed for recurrence of dysphagia following myotomy 3
• Surgical options may be considered for recurrent cases that fail endoscopic management, with 43% of recurrent cases in one study successfully treated via cervical approach 2

Monitoring and Follow-up

For patients who have undergone myotomy for Zenker's diverticulum:

• Regular follow-up is recommended to monitor for symptom recurrence
• Consider barium swallow studies to assess for anatomical recurrence 4
• Patients should be monitored for signs of aspiration pneumonia, especially in elderly patients 4
• Proton pump inhibitor therapy should be considered after dilatation procedures to reduce reflux-related complications 3

Prevention Strategies

To minimize recurrence risk after myotomy:

• Complete cricopharyngeal myotomy is essential during the initial procedure 5
• Consider diverticulectomy with myotomy for larger diverticula, which shows excellent clinical and functional results in the medium to long term 5
• Endoscopic re-treatment achieves good results even in recurrent cases 1

Clinical Approach to Suspected Recurrence

When patients present with recurrent symptoms after myotomy:

1. Evaluate symptoms: Dysphagia, regurgitation, aspiration
2. Perform diagnostic imaging: Barium swallow to assess for anatomical recurrence
3. Consider repeat endoscopy: To evaluate the surgical site and plan re-intervention
4. Select appropriate re-treatment: Based on diverticulum size, patient condition, and local expertise 6

Endoscopic treatment remains the preferred approach for recurrent cases, particularly in elderly or high-risk patients, with open surgical approaches reserved for cases where endoscopic management fails 6.