Surgery>>>>>The Esophagus and Diaphragmatic Hernia
Question 29#

Successful treatment of a Zenker diverticulum involves:

A. Diverticulopexy
B. Resection of the diverticulum
C. Observation
D. Either diverticulopexy or resection with cricopharyngeal myotomy

Correct Answer is D

Comment:

When a pharyngoesophageal diverticulum is present, localization of the pharyngoesophageal segment is easy. The diverticulum is carefully freed from the overlying areolar tissue to expose its neck, just below the inferior pharyngeal constrictor and above the cricopharyngeus muscle. It can be difficult to identify the cricopharyngeus muscle in the absence of a diverticulum. A benefit of local anesthesia is that the patient can swallow and demonstrate an area of persistent narrowing at the pharyngoesophageal junction. Furthermore, before closing the incision, gelatin can be fed to the patient to ascertain whether the symptoms have been relieved, and to inspect the opening of the previously narrowed pharyngoesophageal segment. Under general anesthesia, and in the absence of a diverticulum, the placement of a nasogastric tube to the level of the manometrically determined cricopharyngeal sphincter helps in localization of the structures. The myotomy is extended cephalad by dividing 1 to 2 em of inferior constrictor muscle of the pharynx, and caudad by dividing the cricopharyngeal muscle and the cervical esophagus for a length of 4 to 5 em. If a diverticulum is present and is large enough to persist after a myotomy, it may be sutured in the inverted position to the prevertebral fascia using a permanent suture (ie, diverticulopexy). If the diverticulum is excessively large so that it would be redundant if suspended, or if its walls are thickened, then a diverticulectomy should be performed. This is best performed under general anesthesia by placing a Maloney dilator (48F) in the esophagus, after controlling the neck of the diverticulum and after myotomy. A linear stapler is placed across the neck of the diverticulum and the diverticulum is excised distal to the staple line. The security of this staple line and effectiveness of the myotomy may be tested before hospital discharge with a water soluble contrast esophagogram. Postoperative complications include fistula formation, abscess, hematoma, recurrent nerve paralysis, difficulties in phonation, and Horner syndrome. The incidence of the first two can be reduced by performing a diverticulopexy rather than diverticulectomy.