Alexander Langerman, MD, FACS, discusses his topic in Zenker’s Diverticulum.
ALEX LANGERMAN: Hi, everyone. Thank you for letting me speak today. My name is Alex Langerman, and I'm going to talk a little bit about how we treat Zenker's diverticulum at the University of Chicago Medicine. So first a little bit about what a Zenker's diverticulum is. So on this diagram, you can see this is sort of a side view of a head. You get a sense of where that tongue is and the epiglottis leading down to the trachea there. The key is what I want you to focus on is that little red band. And that is the cricopharyngeus muscle. Now the cricopharyngeus muscle is a key component of the swallowing mechanism. However, it can have dysfunction. Now you see on the diagram that that arrow is showing where food should be going. But if the cricopharyngeus is too tight, food can push through the back of the throat and actually create a little hernia sac. And it's that sack that's the Zenker's diverticulum. And that can be a big problem for patients. Here's an example on a x-ray where you can see the little thumbprint sign in the little curve there. And that's the diverticulum itself. Now patients who have this can have problems with choking and regurgitation or gurgling sound coming out of their mouth. They can also complain of some bad breath, essentially because food is getting caught in that sack. And then it's sort of sitting there and getting funky, and occasionally regurgitating. Patients can also have problems with hoarseness or aspiration, even aspiration pneumonia. Now what that means is the sort of foul stuff that collects in the sack, it can gurgle back up and go right into the voice box. It can irritate the vocal cords. It can also dribble down in the lungs and cause problems like pneumonia. Now patients who present with pain or bleeding associated with a Zenker's diverticulum, then I get a little bit more concerned. There's a very small association with malignancy. Most patients, that's not the case, but we always have to think about that in the back of our heads to make sure that we're treating patients appropriately. Once you fix a Zenker's diverticulum, which I'll explain how we do it, essentially you're removing the action of that cricopharyngeus muscle. Now the cricopharyngeus muscle is like a check valve in the sense that it prevents anything from refluxing up through the esophagus into the throat. Now because it's having an effect on limiting flow down, we do have to cut it. But the act of cutting it does mean that there's going to be a little bit more free flow in the reverse direction. This means some patients can have some burping or increase in reflux symptoms. But more importantly, they have a significant reduction in their choking, regurgitation, and all the other symptoms. And so it's a pretty good trade off. And this is by far the most effective treatment. There's two main ways to approach the cricopharyngeus muscle and the Zenker's diverticulum sac-- that's the endoscopic sac, which I do in about 90 to 95% of patients that I treat. And then there is the transcervical or open approach. This is in patients who have particularly unusual problems, or more likely, they just have the kind of anatomy that makes it hard to get down effectively to the cricopharyngeus to do the job you need to do. Patients who have endoscopic treatment, either by lasering, which is my preference, or stapling, which is another option, they have no scar, because everything's through the mouth, and they tend to have a very short hospital stay. Patients who require an open approach still have a small scar on their neck here. And they can have a slightly longer hospital stay, but in part, depends on what I need to do to be able to resolve the issue through the neck. So a little bit about what we're doing pre and postoperatively if we're doing endoscopic treatment, here again is our sac. And you see the cricopharyngeus muscle. And then after endoscopic treatment, we've actually connected the sack and divided the cricopharyngeus muscle at the same time. I'm going to show you some pictures of how we do that. But the result then is better flow through the esophagus. So here, these images, what they're showing is my view of the esophagus and the Zenker's diverticulum sack. And so on the photo to the left, you can see that there's a suction and long metal rod going down into the esophagus. And there's a really tight muscle holding that. That muscle is the cricopharyngeus muscle. And in the slide to the right, I've dilated, opened the esophagus a little bit to try to stretch out that cricopharyngeus muscle to better get at it. Again, on the left, you can see below that cricopharyngeus muscle that little cave in there. And what that is, is that's actually the Zenker's diverticulum sac. You can see it disappearing off to the side. So here I have my instrumentation in to isolate the common wall between the sac and the esophagus, which includes that cricopharyngeus muscle. And then I take a laser, and I divide that sac. Now to be sure that we're extra careful with dividing that sack, but then maintaining the integrity of the esophagus, we also sew it up afterwards. And so here's an example of where the common wall has been divided. And now those are my sutures that I tie down through the instrumentation I have in the throat. Open treatment involves approaching this sac through the left side of the neck. It tends to go off to the left side. This is the easiest approach. We carefully dissect down through the muscular tissue to identify the sack, and most importantly, of course, the cricopharyngeus muscle. Here's an intraoperative photos. And I have a close up here demonstrating the sac, which is marked with an asterisk, and the cricopharyngeus muscle, which is marked with those arrows there. And so the key is not only either cutting or imbricating a sac-- sort of tying a special purse string suture to get it to collapse on itself-- but also dividing those cricopharyngeus muscle fibers to make sure that this does not recur. Here's an example of the postoperative appearance. This is a patient that's just three weeks postop. And you can see that we can hide it typically in a prominent neck crease, and that this fades very nicely with time. So patients do not tend to be dissatisfied with their appearance, even if we have to do an approach. And then here's an example of what the postoperative treatment might look like for patient. So this is again a barium swallow. And you remember from the previous x-ray, that there was that little thumb print, that little hooked diverticulum sac. And now that's gone. And it's a much smoother flow through there. So in summary, Zenker's diverticulum causes troublesome symptoms that can be with alleviated and usually with a minimally invasive approach. Some patients do require an open approach to a small neck scar. We can also make it easy on them. Regardless of the approach, this is a low risk surgery with a very high success rate. And it is an important option for patients who are suffering from this disease thank you very much.
