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Other reported complications include chest pain, odynophagia,
ulceration, bleeding, perforation, and death. One advantage of APC
is that the equipment is widely available and is relatively inexpensive.
However, as noted in the RCTs, it often requires multiple treatments
over time to achieve regression of disease.
Cryotherapy
Cryotherapy directly destroys tissue by freezing it, resulting in both
immediate and delayed tissue destruction. There are several cryotherapy systems available, but the most widely studied is liquid nitrogen. In a retrospective study of patients treated with liquid nitrogen,
Shaheen etal. found that after an average of four treatments, 97% of
patients had resolution of HGD, 87% had resolution of intestinal dysplasia, and 57% had resolution of intestinal metaplasia. There were
no serious complications, but 3% of patients developed strictures that
were managed with endoscopic dilation.
At the 5-year follow-up, 93% of patients had complete resolution of high-grade dysplasia, 88% had resolution of dysplasia, and
75% had resolution of intestinal metaplasia, although some of these
patients underwent “touch-up” therapy after the initial round of
treatment. As with other endoscopic methods of treatment, ongoing
endoscopic surveillance is required.
One advantage of cryotherapy is that it can be used both as a firstline treatment for BE with dysplasia and as a second-line treatment
in patients who have failed other treatments. As with other therapies, however, it often requires multiple treatments to completely
eradicate disease. In a recent review of liquid nitrogen cryotherapy,
the complication rate ranged from 0% to 3% with the most frequent
complication being pain requiring narcotics (10% of patients), followed by stricture requiring dilation (up to 9%), then bleeding and
perforation.
required to achieve complete eradication of dysplasia, with close
follow-up following eradication.
In an RCT comparing RFA with sham endoscopy, complete eradication of LGD occurred in 90.5% of patients and complete eradication of HGD occurred in 81% of patients following RFA, compared
with only 22% and 19% in the sham group, respectively. Among all
patients, RFA completely eradicated evidence of intestinal metaplasia
in 77.4%, compared with only 2.3% in the control group. All these
results were statistically significant. There is a known rate of progression to esophageal cancer, and in this study 19% of patients with
HGD progressed to cancer over a 1-year timeframe. At 2-year follow-up, these results were found to be durable: complete eradication
of dysplasia occurred in 95% of patients, and complete eradication of
intestinal metaplasia occurred in 93% of patients; results were similar
at 3-year follow-up.
The primary side effects of RFA are chest pain and dysphagia
lasting up to 4 days, and strictures occur in up to 8% of patients.
Bleeding is rare. No deaths have been reported following RFA. RFA
is the preferred therapy for nonnodular BE.
CONCLUSION
The management of BE continues to evolve as new technology
and more effective treatments become available. Compared with
esophagectomy, endoscopic techniques have the advantage of being
less invasive with fewer complications; however, in all cases, it is
important to ensure that the correct technique is being used, which
requires a baseline understanding of each technique. In general,
patients with nodular disease should have this resected, and patients
with early esophageal cancer should be referred for discussion at a
multidisciplinary cancer group or tumor board to discuss alternative
therapies to endoscopic ones.
Radiofrequency Ablation
The most commonly used ablative technique is RFA. Using either a
balloon catheter or a focal catheter, a generator and a bipolar electrode array deliver a fixed amount of thermal energy, resulting in a
uniform burn to a depth of 0.5 mm. RFA can be performed in the
outpatient setting and is targeted as either a circumferential ablation
(using the balloon catheter) or a focal ablation (using the focal catheter). Circumferential ablation is for circumferential segments of BE
that are longer than 2 cm, whereas focal ablation is for shorter segments, or tongues, of BE. After treatment, follow-up is recommended
in approximately 2 months, and often multiple sessions of RFA are
Management of
Paraesophageal Hernia
Repair
Richard J. Battafarano, MD, PhD
he most common acquired diaphragmatic hernia is the hiatal
hernia. Widening of the esophageal hiatus and weakening of
T
the phrenoesophageal ligament is associated with herniation of the
stomach and other intraabdominal organs through the hiatus and
into the mediastinum. Many patients are noted to have hiatal hernias
with minimal symptoms. However, the most common symptoms
S u g g e S t e d R e a d i n g S
Hvid-Jensen F, Pedersen L, Drewes AM, etal. Incidence of adenocarcinoma
among patients with Barrett’s esophagus. N Engl J Med. 2011;365:1375–
1383.
Ning B, Abdelfatah MM, Othman MO. Endoscopic submucosal dissection
and endoscopic mucosal resection for early stage esophageal cancer. Ann
Cardiothorac Surg. 2017;6:88–98.
Peter S, Monkemuller K. Ablative endoscopic therapies for Barrett’s-
esophagus-related neoplasia. Gastroenterol Clin North Am. 2015;44:337–
353.
Shaheen NJ, Falk GW, Iyer PG, etal. ACG clinical guideline: diagnosis and
management of Barrett’s esophagus. Am J Gastroenterol. 2016;111:30–50.
associated with hiatal hernia are gastroesophageal reflux disease
(GERD) and early satiety. Patients who develop abdominal pain after
eating or who present with anemia in the setting of a hiatal hernia
often have larger paraesophageal hernias with at least partial organo-axial volvulus of the stomach. Patients with these symptoms are
at greater risk for the potentially lethal consequences of complete volvulus, strangulation, incarceration, and perforation. Paraesophageal
hernias are classified into four types (Box 1) based on the location
of the esophagogastric junction (EGJ) and the herniated abdominal
contents. Type I hiatal hernias are the most common; they account
for 90% to 95% of all hernias and most frequently present with
GERD. Patients with type II, type III, and type IV paraesophageal
hernias often present with the additional symptoms of early satiety,
anemia, and postprandial abdominal or chest pain, vomiting, dysphagia, and weight loss.
30 MANAGEMENT OF PARAESOPHAGEAL HERNIA REPAIR
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BOX 1 Classification of Paraesophageal Hernias
Type I: The esophagogastric junction (EGJ) herniates above the
diaphragm into the mediastinum (“sliding hernia”).
Type II: A portion of the stomach is herniated into the medias-
tinum alongside a normally positioned (i.e., intraabdominal)
EGJ.
Type III: The EGJ is above the hiatus, and a portion of the stom-
ach is folded alongside the esophagus.
Type IV: An intraabdominal organ other than the stomach also is
herniated through the hiatus.
SURGICAL INDICATIONS AND
PREOPERATIVE EVALUATION
The indications for surgery in patients with paraesophageal hernia
depend on the severity of the patient’s symptoms and the patient’s
other comorbid medical conditions. Patients with paraesophageal
hernias whose symptoms are well controlled on acid suppression
medications and who do not have dysphagia, weight loss, or pain
may be followed closely and do not require immediate repair of
the paraesophageal hernia. However, patients with other symptoms
should be thoroughly evaluated before proceeding with paraesophageal hernia repair. As part of the evaluation for patient’s symptoms,
many will have either a contrast esophagram (Fig. 1) or a computed
tomography (CT) scan (Fig. 2) at the time of presentation. Although
these two radiographic studies often complement one another, the
current thin-cut CT scans, with coronal and sagittal reconstructions,
are quite helpful for delineating the anatomy of the paraesophageal
hernia and for determining if additional organs have also herniated
into the mediastinum (type IV paraesophageal hernia). An upper
endoscopy is important to determine the presence of esophagitis,
gastritis, Cameron ulcers, and peptic ulcer disease and to rule out
malignancy. Esophageal manometry is very important in patients
with type I and type II paraesophageal hernias to assess esophageal
motility, which will guide the decision for the appropriate fundoplication at the time of the paraesophageal hernia repair. The use
of esophageal manometry in patients with large type III or type IV
paraesophageal hernias is often quite difficult to accurately perform because the catheters often curl in the esophagus or herniated
stomach, limiting the data that can be obtained. In these patients, a
partial fundoplication should be performed. The use of pH testing
in patients with paraesophageal hernia does not usually add significant information in patients whose EGJ is above the diaphragm.
However, pH monitoring is critically important in patients who have
significant symptoms of gastroesophageal reflux disease without the
presence of a paraesophageal hernia.
SURGICAL TECHNIQUE
Type I and type II paraesophageal hernias can almost always be
successfully repaired using the laparoscopic technique. Laparoscopic
repair of these hernias has been associated with decreased operative
morbidity, especially when compared with thoracotomy. However,
the choice of operation for large type III and type IV paraesophageal hernias is somewhat more controversial. Patients with more
advanced type III and type IV paraesophageal hernias often develop
dense adhesions between the hernia sac and the pericardium, lung,
and even the airway itself. Dissecting the sac and its contents away
from these structures often results in pneumothorax with subsequent loss of pneumoperitoneum and subsequent visualization. In
addition, visualizing the structures above the level of the inferior
pulmonary veins becomes much more difficult using a laparoscopic
approach. In these large paraesophageal hernias, open repair using
either an upper midline laparotomy or a left thoracotomy may be
Herniated
stomach
Gastric Volvulus
FIG. 1 Barium esophagram showing a large paraesophageal hernia with a
gastric volvulus.
more efficacious. Other relative indications for open repair rather
than laparoscopic repair of paraesophageal hernias include a previous paraesophageal hernia repair (especially if mesh was used at
the hiatus), extension of the paraesophageal hernia into one or both
pleural spaces, and proximal extension of the paraesophageal hernia
to the level of the carina.
Laparoscopic Repair of Paraesophageal Hernias
Positioning of the Patient and Placement of Ports
After adequate general anesthesia has been performed, a nasogastric
tube is placed to decompress the stomach. Although many surgeons
utilize the low lithotomy position for this procedure, we have chosen
to keep the patient in the supine position with a footboard to allow
the steep reverse Trendelenburg position. A total of five ports are
used for the procedure: one for the camera (port 1, 10 mm); two for
the operating surgeon (port 4, 10 mm; port 5, 5 mm); one for the
assistant (port 2, 5 mm); and one for the liver retractor (port 3, 5
mm). The first port is usually placed in the midline approximately
14 cm below the xiphoid process and is utilized for the camera. We
prefer to place this port via an open technique to minimize the risk
of injuring any intraabdominal contents upon entry. The remaining
ports are all carefully placed under direct vision (Fig. 3). At the completion of the procedure, the fascia around each of the two 10-mm
ports is closed with absorbable suture to decrease the risk of port
site hernias.
Dissection and Reduction of the Hernia Sac
We begin by opening the gastrohepatic ligament up to the level of
the right crus of the diaphragm. Great care is taken to identify the
presence of a replaced or accessory left hepatic artery. If one of these
is identified during this portion of the dissection, they are encircled
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Diaphragm
Colon
Stomach
Diaphragm
Diaphragm
Stomach
Colon
Diaphragm
A B C
FIG. 2 CT scans showing a type IV paraesophageal hernia.
of the procedure and greatly reduces the risk for gastric injury or
perforation. With the stomach reduced into the abdomen, we mobilize the greater curvature of the stomach, dividing all of the short
gastric vessels using a harmonic scalpel. Our focus on removing the
entire hernia sac during the procedure often results in small tears
in the pleura, creating capnothorax with associated hypotension or
increased airway pressure. Reduction of the insufflation pressure and
close cooperation between the surgical and anesthesia teams almost
always allows completion of these procedures laparoscopically without conversion to laparotomy.
Colon
Stomach
Diaphragm
14 cm
1
4
2
5
3
FIG. 3 Port placement for laparoscopic paraesophageal hernia repair.
(From Patti MG, Fisichella PM. Laparoscopic paraesophageal hernia repair. How I
do it. J Gastrointest Surg. 2009;13:1728-1732.)
with a vessel loop and gently retracted during the remainder of the
dissection and creation of the fundoplication. The periesophageal
tissues are then dissected away from the right crus, and the anterior
and posterior vagus nerves are identified. This dissection is then
continued anteriorly to dissect the sac away from the pericardium
and extended to the left crus of the diaphragm. The hernia sac is
then dissected away from the left crus of the diaphragm exposing
the posterior aspects of both the right and left crura just above the
aorta. The posterior dissection is completed allowing the herniated
stomach and the hernia sac to be reduced into the abdomen, and
the esophagus is encircled in the lower mediastinum with a Penrose
drain. Mobilization of the hernia sac and its contents in this manner
decreases the amount of force applied to the stomach during this step
Esophageal Mobilization and Lengthening
The hernia sac is then resected taking great care to preserve both
vagus nerves, and the EGJ is identified. The mediastinal dissection
is extended proximally by dividing the small esophageal arterial
branches using the harmonic scalpel. The dissection is continued
up into the mediastinum to achieve at least 3 cm of intraabdominal esophagus. It is quite helpful to decrease the insufflation from
15mm Hg to 8 mm Hg and to not utilize any caudal traction of the
stomach at this time so an accurate measurement of intra-abdominal
esophagus can be achieved. Once an accurate measurement of
intra-abdominal esophagus has been made, the insufflation is
returned to 15 mm Hg, and attention is directed toward posterior
approximation of the right and left crura.
Closure of the Esophageal Hiatus
Retraction of the esophagus upward and toward the patient’s left with
the Penrose drain optimizes visualization of the posterior right and
left crura. Interrupted 0 Ethibond sutures are placed to reapproximate the posterior right and left crura just above the aorta using a
laparoscopic needle driver through the left upper quadrant 10-mm
port. Although many surgeons perform intracorporeal knot tying,
we prefer to utilize the Ti-KNOT. It is important to accurately space
these posterior crural sutures on each crus because the left crus is
often much longer than the right crus. In addition, it is important
for the surgeon to carefully place these sutures, being mindful that
both the aorta and inferior vena cava are in close proximity to the
posterior crura. Before the last crural sutures are tied, a 52F or 56F
bougie is carefully inserted down the esophagus, and there should
be room for a closed grasper to easily slide between the esophagus
and crura. Although there was initial enthusiasm for the use of
biologic mesh for reinforcement of the crural closure, more recent
studies have demonstrated that the long-term recurrence rates are
32 MANAGEMENT OF PARAESOPHAGEAL HERNIA REPAIR
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similar between cruroplasty alone versus cruroplasty with biologic
mesh. However, the overall morbidity seems to be higher in patients
repaired with nonabsorbable mesh.
Creation of the Fundoplication
For a Nissen (360-degree) fundoplication, the 56F bougie remains in
the lumen of the esophagus, and the fundus of the stomach is passed
behind the esophagus, taking great care to ensure sufficient mobilization to avoid having part of the gastric fundus above the wrap.
A total of three 2-0 Ethibond sutures are used to create the Nissen
fundoplication. Each stitch is placed through the seromuscular wall
of the stomach on the left side of the fundus, the muscular wall of
the esophagus, and the right side of the fundus at 1-cm intervals. At
the completion of the fundoplication, the anterior portion of the fundoplication should be approximately 2 cm in length and should sit
comfortably below the hiatus. Many surgeons place sutures between
the superior aspect of the wrap and the right and left sides of the
crural closure, creating a gastropexy to anchor the wrap below the
hiatus (Fig. 4). It is critical that the wrap is not created under tension.
When the patient’s esophageal motility will not allow a Nissen
fundoplication, a Toupet fundoplication (posterior 240-degree fundoplication) is created by placing a total of six 2-0 Ethibond sutures.
Three are placed through the seromuscular right and left sides of the
fundus and are separately sutured to the right and left sides of the
muscular wall of the esophagus, leaving 120 degrees of the anterior
esophageal wall uncovered (Fig. 5).
FIG. 5 Crural repair and partial posterior fundoplication. (From Townsend
CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 20th
ed. Philadelphia: Elsevier; 2017.)
Open Repair of Large Paraesophageal Hernias
Repair through an Upper Midline Laparotomy
Although a number of surgeons will repair large paraesophageal
hernias (type III and type IV) and reoperative paraesophageal hernias using laparoscopic and/or a combination of laparoscopic and
thoracoscopic techniques, operative times are longer, and the risk
for complications such as gastric or esophageal perforation is higher.
For this reason, we often repair large paraesophageal hernias and
Esophagus
Wrap
FIG. 4 Crural repair and total 360-degree fundoplication. (From Townsend
CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery. 20th
ed. Philadelphia: Elsevier; 2017.)
reoperative paraesophageal hernias through a limited upper midline
laparotomy. The postoperative morbidity of an upper midline laparotomy is minimal and offers a number of advantages over a difficult
laparoscopic dissection. First, without utilizing insufflation, entrance
into either the left or right pleural space as part of resection of the
sac does not negatively affect or limit the ability to complete the
procedure. Reduction of the sac and its contents from the mediastinum or the pleural space can often be performed more gently with
one’s hands in comparison with using Babcock or other laparoscopic
clamps, and complete resection of the sac can be accomplished in
all cases. Because large paraesophageal hernias are more likely to be
associated with an EGJ that does not comfortably sit 3 cm below the
hiatus despite extensive proximal mobilization of the hiatus, accurate assessment of esophageal length and the creation of esophageal
lengthening procedures such as a Collis gastroplasty or a fundic
wedge gastroplasty are more easily performed. In reoperative cases,
takedown of the adhesions from the previous repair can be more
safely achieved, especially when mesh was utilized at the time of the
primary repair. CT images of a representative large type III paraesophageal hernia performed through an upper midline laparotomy
are shown (Fig. 6).
walter retractor system, and the steps of the operation are performed
exactly as described earlier. When an esophageal lengthening procedure is necessary, it is performed over a 56F bougie using an
endoscopic stapler with a closed staple height of 2 mm. A Toupet
fundoplication is performed (instead of a Nissen fundoplication) to
prevent postoperative dysphagia.
Repair through a Left Thoracotomy
Historically, the transthoracic repair of paraesophageal hernias was
the standard approach for patients with this disease led by Dr. David
Skinner and Dr. Ronald Belsey. Because of the increased postoperative pain associated with a thoracotomy, procedures performed using
laparoscopy or through an upper midline laparotomy are currently
preferred. However, transthoracic repair of large paraesophageal
hernias still has a role in the care of patients with this disease (Fig. 7).
140˚± 20
Esophagus
Wrap
Upper abdominal exposure is achieved using a standard book-
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FIG. 6 Coronal and sagittal images of a large type III paraesophageal hernia extending up proximally in the mediastinum up to the level of the pulmonary
veins.
33
FIG. 7 Sequential axial images of a large type III paraesophageal hernia
C
extending up to the level of the pulmonary veins and into both pleural
spaces in a patient who presented with bleeding from a Cameron ulcer.
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Transthoracic repair allows the surgeon to more easily divide dense
adhesions between the hernia sac and its contents from the lungs
and pericardium. It also allows the esophagus to be mobilized up to
the level of the aortic arch behind the carina, generating maximal
tension-free esophageal length. In the rare cases in which this degree
of esophageal mobilization does not achieve enough length to allow
the EGJ to sit comfortably below the hiatus, a Collis gastroplasty can
be easily performed. Although the traditional fundoplication utilized
by Skinner and Belsey was the Belsey Mark IV repair (270-degree
fundoplication), this procedure can be conceptually more difficult to
understand and to teach to others. Therefore, a standard Toupet fundoplication can be created in the left chest and then returned to the
abdomen before tying the final two posterior crural approximation
stitches to complete the repair.
POSTOPERATIVE CARE
No matter which surgical approach is utilized, patients are extubated
immediately after the completion of the procedure. Nasogastric tubes
are not necessary for patients with type I or type II paraesophageal
hernias. However, patients with type III and type IV paraesophageal
hernias often have significant gastric distension and benefit from
tube decompression. I obtain a contrast esophagram on the first
postoperative day to ensure flow of contrast through the fundoplication and to ensure gastric emptying. Patients are discharged on
full liquids and a limited soft diet until they are seen at follow-up
in approximately 2 weeks. Although patients whose repair was performed through a midline laparotomy or a left thoracotomy initially
have more incisional pain, complete recovery and return to work is
achieved in approximately 4 weeks.
OUTCOMES
Laparoscopic and open repair of paraesophageal hernias is associated with excellent recovery and long-term symptom relief. The
choice between laparoscopic and open repair depends on the paraesophageal type and the patient’s previous surgical history. Many
series have demonstrated a relatively high radiographic recurrence
rate. However, the need for reoperation remains quite low, especially
in patients initially treated for type I and type II paraesophageal
hernias.
ACKNOWLEDGMENTS
I recognize the authors of this chapter in the previous editions, as I
have revised and updated their excellent work.
S u g g e S t e d R e a d i n g S
Angeramo CA, Schlottmann F. Laparoscopic paraesophageal hernia repair:
to mesh or not to mesh. Systematic review and meta-analysis. Ann Surg.
2022;275(1):67–72.
Dallemagne B, Kohnen L, Perretta S, etal. Laparoscopic repair of paraesoph-
ageal hernia. Long-term follow-up reveals good clinical outcome despite
high radiological recurrence rate. Ann Surg. 2011;253(2):291–296.
Hietaniemi H, Ilonen I, Järvinen T, etal. Health-related quality of life after lap-
aroscopic repair of giant paraesophageal hernia: how does recurrence in
CT scan compare to clinical success?. BMC Surgery. 2020;20(1):109–116.
Lidor AO, Steele KE, Stem M, etal. Long-term quality of life and risk factors
for recurrence after laparoscopic repair of paraesophageal hernia. JAMA
Surg. 2015;150(5):424–431.
Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces
recurrence after laparoscopic paraesophageal hernia repair: a multicenter,
prospective, randomized trial. Ann Surg. 2006;244(4):481–490.
Oelschlager BK, Pellegrini CA, Hunter JG, etal. Biologic prosthesis to prevent
recurrence after laparoscopic paraesophageal hernia repair: long-term
follow-up from a multicenter, prospective, randomized trial. J Am Coll
Surg. 2011;213(4):461–468.
Schlottmann F, Strassle PD, Allaix ME, Patti MG. Paraesophageal hernia
repair in the USA: trends of utilization stratified by surgical volume
and consequent impact on perioperative outcomes. J Gastrointest Surg.
2017;21(8):1199–1205.
Schlottmann F, Strassle PD, Farrell TM, Patti MG. Minimally invasive sur-
gery should be the standard of care for paraesophageal hernia repair.
J Gastrointest Surg. 2017;21(5):778–784.
Schlottmann F, Strassle PD, Patti MG. Laparoscopic paraesophageal hernia
repair: utilization rates of mesh in the USA and short-term outcome analysis. J Gastrointest Surg. 2017;21(10):1571–1576.
Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus
hernia: long term results with 1,030 patients. J Thorac Cardiovasc Surg.
1967;53(1):33–54.
Management of Zenker’s
Diverticulum
Fernando A.M. Herbella, MD, Riccardo Rosati, MD, and
Marco G. Patti, MD
GENERAL CONSIDERATIONS
Zenker’s diverticulum is a rare disease that occurs in the pharyngoesophageal area. It is a pulsion pseudodiverticulum because it is
composed of mucosa only and not all wall layers. A large proportion
of patients with esophageal diverticula are asymptomatic. Dysphagia
is the most common symptom, but regurgitation, weight loss, chest
pain, halitosis, and aspiration are also common complaints.
PATHOPHYSIOLOGY
Pharyngoesophageal diverticulum occurs in areas of muscular gap
at the transition of the cricopharyngeal, inferior constrictor of the
pharynx and esophageal intrinsic muscles. Three separate weak
areas have been described (Laimer’s, Killian’s, and Killian-Jamieson’s
triangles); however, even though there are different eponyms for the
diverticula in each area, they are usually collectively called Zenker’s
diverticulum and are similarly treated because of their proximity and
pathophysiology (Fig. 1).
An altered motility of the upper esophageal sphincter is necessary to create a high-pressure zone and force the mucosa through
these areas of weakness. Gastroesophageal reflux disease (GERD)
is associated in up to 95% of patients, and this association may be
related to esophageal longitudinal muscles reflex contraction and
consequent widening of the gap between pharyngeal constrictors and cricopharyngeal muscles, or upper esophageal sphincter spasm. The incidence of cancer in a diverticulum is almost
negligible.
DIAGNOSIS
Upper digestive endoscopy is usually performed to diagnose the
diverticulum and to rule out malignancy and associated diseases.
Endoscopists should be aware of the possibility of this diagnosis
to prevent missing small diverticula or causing perforation of large
diverticula misdiagnosed as the esophageal lumen (Fig. 2).
Inferior
Diverticulum
Trachea
Cricopharyngeus
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constrictor
FIG. 1 Zenker’s diverticulum at the pharyngoesophageal area.
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septum
diverticulum
FIG. 2 Zenker’s diverticulum at upper digestive endoscopy.
esophageal
lumen
Barium swallow allows estimation of the size and location better
than the endoscopy because the contrast distends the diverticulum
(Fig. 3). Esophageal manometry may be used to diagnose the upper
sphincter dysfunction, even though most experts believe that a
motor disorder is always present and esophageal manometry is no
more than an academic curiosity. Ambulatory pH monitoring may
be indicated in patients with suspected GERD to allow planning of a
combined procedure or guide medical therapy.
TREATMENT
Some propose treating only symptomatic diverticula, while others
advise treatment to prevent complications such as aspiration, even
in the absence of symptoms. The diverticulum may be treated by:
(1) myotomy of the cricopharyngeal muscle alone; (2) myotomy plus
diverticulectomy; (3) myotomy plus diverticulopexy; or (4) endoscopically by division of the septum between the diverticulum and the esophagus (diverticulo-esophagostomy [Dohlman’s procedure]) (Fig. 4).
SURGICAL MANAGEMENT
Surgical Anatomy and Access
Most surgeons prefer a left cervical incision following the medial
border of the sternocleidomastoid muscle, while others opt for a
FIG. 3 Barium swallow disclosing a Zenker’s diverticulum (arrow).
bilateral arciform incision. The layers to be dissected are: (1) skin; (2)
subcutaneous tissue that is conjoined with the platysma muscle; and
(3) superficial cervical fascia. After these planes are dissected, the
infrahyoid muscles will be exposed. Usually there is no need to divide
muscles. The sternohyoid muscle can be retracted medially and
the omohyoid superiorly. The diverticulum is usually located below
the omohyoid muscle. After the muscles are retracted, the esophagus
is exposed. There is no need for circumferential dissection of the
esophagus as it increases the risk of damage to the left recurrent
laryngeal nerve located in the groove between the esophagus and
the trachea. If the diverticulum is not yet identified, the esophagus
should be rotated to expose the posterior side. Sometimes esophageal
intubation by the anesthesiologist or intraoperative endoscopy is
necessary to identify the diverticulum.
Dysmotility Treatment
The myotomy of the cricopharyngeal muscle must always be performed based on the assumption that an upper esophageal sphincter
dysfunction is part of the pathophysiology of the disease. If the neck
of the diverticulum is properly dissected, the myotomy is easily performed because the diverticulum is composed entirely of mucosa,
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AB
CD
FIG. 4 Treatment options for Zenker’s diverticulum. (A) Myotomy of the cricopharyngeal muscle. (B) Stapled diverticulectomy. (C) Diverticulopexy.
(D) Endoscopic diverticulo-esophagostomy. (From Herbella FA, Patti MG. Modern pathophysiology and treatment of esophageal diverticula. Langenbecks Arch Surg.
2012;397:29–35.)
effortlessly found. The myotomy must be extended about 3 cm
downward onto the esophageal wall.
Diverticulum Treatment
There is no need to resect small diverticula (<2 cm) because of the
low risk of complications and cancer. Larger diverticula may be
resected or fixed upward to the prevertebral fascia (diverticulopexy).
Resection may be performed with manual sutures or staplers. Before
transecting the neck of the diverticulum, it is important to place a
mucosa and causing narrowing of the esophageal lumen.
Some authors adopt a tailored approach choosing among the
previous modalities based on the size of the diverticulum.
Outcome
Symptomatic relief is obtained in over 90% of patients. Complications may occur in up to 15% of cases and usually present as leakage
and vocal cord paralysis.
ESOPHAGUS
AB
DE F
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37
ENDOSCOPIC TREATMENT OF ZENKER’S
DIVERTICULUM
The treatment of Zenker’s diverticulum has evolved over the past
two decades from an invasive surgical procedure to an endoscopic
approach that achieves favorable results in terms of symptom relief
with a low complication rate, short hospital stay, and prompt return
to an oral diet. Another factor in favor of the endoscopic approach
is the possibility of a second attempt in cases of failure of primary
treatment or recurrence of symptoms, without increasing the risk of
complications such as nerve palsy.
Two different approaches can be used: rigid endoscopy or flexible
endoscopy. To date, no controlled trials have been performed to demonstrate the superiority of one technique over the other, and consequently
there are no accepted guidelines for patient management. The ability to
access the diverticular common wall endoscopically may be limited by
the patient’s anatomy; therefore, a careful evaluation of the dimension
of the diverticulum and its septum, clinical examination with evaluation
of the anatomy of the oral cavity, and head hyperextensibility at the
cervical spine level are mandatory to decide which technique is best.
Rigid Endoscopic Technique
Endoscopic diverticulostomy was first described by Mosher in 1917
using a cold knife. After initial success, the technique was abandoned
and did not gain popularity until the 1960s, when Dohlman and
Mattson described with success the endoscopic use of electrocautery to divide the common wall in a series of 100 patients. Since the
1990s, the endoscopic stapled-assisted diverticulostomy has become
the standard approach to Zenker’s diverticulum because of its low
morbidity rate and excellent outcomes.
The procedure is performed with the patient under general anesthesia, lying supine with a fully extended neck. Under direct view, the
Weerda diverticuloscope (Karl Storz, Tuttlingen, Germany) is carefully
introduced through the mouth with the inferior blade into the pouch
and the superior blade into the esophageal lumen (Fig. 5A). When a
good view of the septum is achieved, the diverticuloscope is secured.
To expose the diverticular septum and pouch and allow the insertion
of the stapler, the two blades are gently opened. Any undigested food,
saliva, or pills are aspirated. Two stay sutures (Endo Stitch 10-mm
suturing device) are positioned on each side of the septum to maximize
exposure and obtain traction (see Fig. 5B), therefore allowing insertion
of the stapler deeper in the diverticular pouch. A modified linear
stapler (AutoSuture Endo GIA 3.5, 30 mm) is introduced through the
diverticuloscope with the jaws across the septum (see Fig. 5C) that
is sealed and cut by firing the stapler, thus creating a common cavity
between the esophagus and the diverticular sac (see Fig. 5D). A modification of the anvil by cutting the edge of the jaw (Fig. 6) introduced
in the diverticular sac is mandatory to obtain the full-length division
of the septum. In cases of big diverticula, more than a cartridge can be
used to complete the section (see Fig. 5E, F). The residual millimeters
of uncut staple line are sectioned with scissors or a coagulating hook;
FIG. 5 Endoscopic therapy for Zenker’s diverticulum. (A) Exposure of septum by the Weerda diverticuloscope. (B) Positioning of two anchoring stitches
(Medtronic Endo Stitch 10-mm suturing device) at both septum sides. (C) Introduction of the linear stapler (AutoSuture Endo GIA 3.5, 30 mm) with the
modified jaw into the diverticulum pouch. (D) Partial dissection of the septum after one stapler suture. (E) Further introduction of the linear stapler to
obtain the full-length dissection of the septum. (F) Final appearance of the complete dissection of the septum and pouch obliteration.
C
38 MANAGEMENT OF ZENKER’S DIVERTICULUM
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FIG. 6 Design of the modified anvil of the AutoSuture Endo GIA linear
stapler, by Riccardo Rosati, and comparison with the traditional one.
any bleeding is controlled by electrocautery. In some series, division
of the septum was performed using CO2 laser, a Harmonic scalpel, or
other devices as alternatives to the stapler (see Fig. 6).
This procedure is very effective, with an overall success rate of
more than 90% in all large published series and a complication rate
around 7.0%. The most common complications were dental injuries
(2%) and esophageal mucosal perforation (1.6%).
Inability to access and fully divide the diverticular septum is a
concern of this procedure. Data in the literature have shown a rate
of procedure abandonment resulting from incomplete visualization
that ranges between 3% and 26%. The reasons for this problem are
a small oral inlet, limited neck extension, presence of osteophytes, a
very small diverticular pouch, or concern regarding dental injuries.
In addition, limited experience in the insertion of the diverticuloscope plays a major role.
Historically, diverticula smaller than 2 to 3 cm have not been
amenable to the endoscopic technique because of the risk of a tooshort myotomy length, but use of the stay sutures facilitates anchoring of the stapler in the diverticular pouch. Furthermore, a higher
success rate using sutures with a single session has been achieved
than without stay sutures (87.3% vs. 65.3%, respectively).
Flexible Endoscopic Technique
The rigid endoscopic approach has some limitations such as the need
for general anesthesia, the inability of neck hyperextension, and anatomic problems such as a diverticulum less than 3 cm (not suitable
for correct positioning of the stapler). Flexible endoscopic techniques
have been proposed to overcome such difficulties. They vary from
the “classic” flexible endoscopic septum division to the most cutting-edge third-space approaches. In every case, the procedure is
done under direct vision of the cricopharyngeal muscle fibers. All of
the procedures are performed with the patient in the left decubitus,
with the patient either under conscious sedation or under narcosis.
Endoscopic Septum Division
The first technique proposed in the mid-1990s was endoscopic septum division, which shares the same principles of rigid endoscopy
and involves a full-thickness incision of the mucosa, submucosa, and
muscular fibers of the septum to obtain a common cavity with the
esophageal lumen.
Before performing the procedure, a nasogastric tube is inserted
into the esophagus as a guide to recognize the lumen. Since its
introduction, many tools have been proposed, and the technique has
improved: some endoscopists use a soft rubber diverticuloscope as
overtube (Zenker’s Diverticulum Overtube, Cook Endoscopy, Winston-Salem, NC) to obtain a better view and set the surgical field, or
a short cap on the tip that also improves visibility and stabilizes the
endoscope. Septotomy is performed with no need of submucosal
injection. The most common devices used are the needle-knife and
the hook-knife, but others can be used such as monopolar forceps
or argon plasma coagulation, depending on the endoscopist’s preference and personal experience. After the septotomy is completed, one
or more endoclips are placed to close the incision to reduce the likelihood of a leak or bleeding. Outcomes of the septotomy are similar to
the previous technique, with nearly 90% symptom relief and a recurrence rate of 11%. A retrospective comparative review showed that
both rigid endoscopy septotomy and the flexible endoscopic technique have similar results and provide symptom control comparable
with open surgery, with a decreased risk of serious complications.
Z-POEM
Recent advances in natural orifice transluminal endoscopic surgery
(NOTES), especially for treatment of achalasia, have given rise to
novel myotomy techniques for the treatment of Zenker’s diverticulum. In 2016, the first septum division via a submucosal tunneling
approach was reported, later called Z-POEM.
The advantage of this approach is that it is easier to perform a
complete transection of the entire muscular septum by operating
within a submucosal tunnel, thus maintaining mucosal integrity and
lowering recurrence of symptoms because of incomplete transection
of the muscle.
The procedure starts with submucosal injection and mucosotomy
nearly 3 cm proximal to the septum. This is very difficult because
the area involved as muscular spasm and anatomic limitations of
the upper esophageal sphincter may reduce the ability to properly
manage the mucosal incision. Then a submucosal tunnel is created
along both sides of the septum, ending in the normal esophagus, 1
to 2 cm distally to the end of the septum. The muscular fibers are at
this point clearly visible and can be safely transected. After removal
of the endoscope, the mucosotomy site is closed with clips. It is a
technically challenging procedure, but the success rate is comparable
with other endoscopic approaches, with 92% achieving favorable
results and 6.7% experiencing complications such as bleeding or perforation. As it is a new procedure, long-term results and comparative
studies are lacking as well as the rate of recurrence.
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