May 29, 2013

Why Would a Zenker's Diverticulum Recur After Surgical Treatment?

Zenker's diverticulum is an extremely rare disorder whereby a pouch develops in the throat leading to food and liquids getting caught causing symptoms of swallowing difficulties and food regurgitation. One of the best ways to address this rare condition is a procedure called endoscopic staple diverticulostomy (ESD).

Unfortunately, with any Zenker's treatment including ESD, there is a small percentage (~10%) that the Zenker's diverticulum recurs typically within one year of treatment (average 8.5 months).

Why might that be?

There are some known (and unknown) issues that may lead to recurrence including:

Incomplete division of the cricopharyngeus muscle: If the pouch is small, the cricopharyngeus muscle may not be completely divided using the ESD method. It is a shortcoming inherent to the method itself and not a lapse on the surgeon's part. The only way to completely address the muscle when the pouch is small (less than 1 .5cm) is via external approach or use of a laser with its associated increased risk of complications.
Unaddressed or persistent laryngopharyngeal reflux: Proton pump inhibitor medications are ALWAYS prescribed before and after surgery... even if heartburn symptoms are absent. However, even with such medications, there may be a certain sub-population that suffer from persistent throat-level reflux that may trigger the Zenker's diverticulum to reform. This factor is probably the single most important reason why recurrence may occur within months.
Loose staples: After surgery is performed, all loose staples are removed to minimize recurrence from this factor.
Idiopathic scarring of the common wall: Some unindentified inflammatory process leads to restenosis of the common wall.
Unknown: Whatever factor lead to the Zenker's formation in the first place may cause it to happen again. Indeed, we actually don't precisely know what causes the Zenker's pouch to occur in the first place.

As such, if recurrence occurs years after treatment, it usually will suggest an incomplete cricopharyngeus muscle division. Repeat ESD can be performed with good results.

If recurrence occurs within one year of treatment, I typically will consider the possibility of persistent throat-level reflux (laryngopharyngeal reflux) that was not or incompletely addressed with reflux medications. Before performing ESD again after a recurrence, I will obtain a few studies to determine how significant throat-level reflux may be present.

That typically entails getting a 24 hour multi-channel pH and impedance testing with manometry. The most important result from this study is the frequency of proximal esophageal reflux events and as such, any other type of reflux study that does not include proximal esophageal or hypopharyngeal sensors would be considered inadequate. Ideally, it should be as close to zero as possible. If proximal esophageal reflux events are present, this needs to be thoroughly eliminated prior to revision Zenker's surgery... otherwise, the Zenker's pouch may yet again recur.

Manometry is performed to ensure the cricopharyngeus muscle (if present) is adequately "loose".

Of course, the barium swallow needs to be repeated as well.

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

1 comment:

Unknown said...

Regarding your statement that not a lot is known about the causes of Zenkers, I wonder if tonsilectomy or other neck/throat procedures can contribute? I am 48yo with what seems to be an early stage pouch forming. I have recently (in the last 3 years) had Hodgkins (NLPHL) within a submandibular node, and have had it removed surgically, with local radiation but no chemotherapy. Since the treatment I have developed Lehrmites for a brief time (which I was told would NOT be due to the radiation) and have been having issues with food regurgitation. After eating, I am unaware of any food presence in the throat, but from 1 to 3 hours after the meal I will become aware of food presence, roughly around or slightly above pharynx level, and with a gentle cough about 5 to 10ml of material is regurgitated. There is no appearance of having been fully swallowed, ie it does not look like vomit or reflux material, but simply looks like chewed up food. I do wonder if this can be a complication or side effect of the lymph removal? I did have tonsilectomy after the lymph removal and prior to the radiation, as there was concern over high levels of uptake there during the staging, which was just background infection.

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