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Recurrence following treatment of Zenker's diverticulum (ZD) occurs in up to 16 per cent of patients. We have reviewed our experience with cricopharyngeal myotomy (CM) to determine its safety and efficacy in the treatment of recurrent ZD. Eight patients were treated, five with early recurrence (symptoms persisting or recurring within 6 months of their initial surgery) and three with late recurrence. Most patients with early recurrence did not have an adequate CM as part of their initial therapy, suggesting that adequate myotomy is important for early relief of dysphagia. Seven patients underwent CM alone, and one patient underwent CM with diverticulectomy. All patients experienced immediate relief of their dysphagia, with good to excellent results persisting at last follow-up (mean follow-up 53 months). Complications were seen only in the patient who underwent combined myotomy with diverticulectomy. We have found CM alone to be quite safe and effective in the treatment of recurrent ZD.
ZENKER'S (HYPOPHARYNGEAL) DIVERTICULUM is a pulsion diverticulum, created when the pharyngeal mucosa herniates through Killian's triangle, a relatively bare area posteriorly between the oblique fibers of the thyropharyngeus muscle and the transverse fibers of the cricopharyngeus muscle. The symptoms of Zenker's diverticulum (ZD) are pharyngeal dysphagia, choking, noisy deglutition, halitosis, regurgitation of undigested food, weight loss, and aspiration pneumonia.
The pathogenesis of ZD is a matter of some controversy. Most manometric studies show some disorder involving the upper esophageal sphincter (UES), including cricopharyngeal spasm, pharyngosphincteric incoordination, sphincteroesophageal incoordination, poor relaxation of the UES, poor opening of the UES, and early closure of the UES. 3 Two studies have looked at the structure and function of the cricopharyngeus in patients with ZD and have found distinct abnormalities, including fibroadipose replacement, muscle fiber degeneration, atrophy, hypertrophy, inflammation, and decreased absolute force of contraction and slower contraction of the muscle.4 5
Historically, Zenker's diverticuli have been treated surgically, although recently there has been renewed interest in endoscopic therapy. Treatment options include resection of the diverticulum (diverticulectomy), suspension of the diverticulum from the prevertebral fascia (diverticulopexy), cricopharyngeal myotomy (CM), a combination of myotomy with resection or suspension, or endoscopic division of the common wall between the esophagus and the diverticulum with laser or endoscopic stapling devices (Dohlman's procedure).4 6-'9 Because abnormalities in the cricopharyngeus muscle have...