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BackTable / ENT / Article
Zenker’s Diverticulum Surgery Decision Making
Julia Casazza • Jan 3, 2024 • 34 hits
When present, Zenker’s diverticulum causes challenges with regurgitation and swallowing, which reduces patients’ quality of life. Zenker’s diverticulum surgery is the only treatment. Endoscopic and open approaches are available for repair. Many patients discharge the same day and Zenker’s diverticulum complications are rare. Want to learn more? Keep reading to hear laryngologist Dr. Sarah Howell’s pearls on managing Zenker’s diverticulum.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Zenker’s diverticulum sugery is the only treatment. ZD can be surgically repaired using either open or endoscopic (laser or stapler-assisted) approaches. No medical management currently exists.
• Not all patients with Zenker’s diverticulum require surgical repair, though those who suffer from difficulty eating or anxiety about choking should strongly consider surgical management.
• While Zenker’s diverticulum complications from surgery are uncommon, esophageal leak, seroma, and hematoma are possible. Monitor for potential cases of leak by palpating for crepitus in post-operative patients.
• In Dr. Howell’s experience, most patients who undergo Zenker’s diverticulum surgery can discharge within 24 hours after tolerating a soft diet. All patients should adhere to a soft diet for two weeks after Zenker’s diverticulum surgery.
Table of Contents
(1) Zenker’s Diverticulum Surgery vs Observation
(2) Open vs Endoscopic Approaches to Zenker’s Diverticulum Surgery
(3) Potential Zenker’s Diverticulum Complications
Zenker’s Diverticulum Surgery vs Observation
Since no medical therapies are currently available for Zenker’s diverticulum, patients may elect for either Zenker’s diverticulum surgery or observation as management. When counseling her patients, Dr. Howell emphasizes that their ZD is a quality – not quantity – of life issue. She recommends Zenker’s diverticulum surgery to patients who believe diverticula repair will help them enjoy eating and/or stop their worrying about choking. For patients who opt not to have surgery, she communicates with their primary care physician and suggests they re-establish care with laryngology if they experience any unintentional weight loss, aspiration pneumonia, or difficulty eating.
[Dr. Ashley Agan]
Yes, it's tricky. You've seen your patient, you've gotten the imaging, and now you're having that discussion about Zenker’s diverticulum treatment, about the patient who's ready to maybe do something, or maybe even the patient that's not ready to do something. I think a lot of us we know as far as Zenker’s diverticulum surgical treatments are open and endoscopic. I guess before we get into those, is there anything to do from a non-surgical standpoint? When a patient's not ready for Zenker’s diverticulum surgery, is there anything that helps it not progress, is there anything else to do, or is it just like, well, at some point we might be talking about surgery again?
[Dr. Rebecca Howell]
It's a good question. I tend to take the observation approach. I've sent some of them to my speech pathologist too for some swallowing therapy, and they said that's not really useful. We've dabbled in it. We've tried it. I don't think it really does much. What I'll usually do is just tell people like, "Hey, why don't we just have you come back in six months? Let's see how you're doing. We'll have the conversation again. In a year, we'll repeat your imaging and see if there's any difference." I think it'll be a really interesting cohort of patients to be able to look at like the ones that opted not to have surgery and sort of how they change over time.
Our database has been open since 2017, so we've got a good five years of data, but again, it just takes time just to first accumulate them and then watch them long-term. I think it will depend. I think observation is always an option. That's what I tell them. Again, I think to get better buy-in, it's better to be honest with patients. I tell them, I'm like, "Listen, this is not cancer. You don't have to have this done." The other way that I explain my practice to patients is I tell them that I'm not a quantity of life doctor, I'm a quality-of-life doctor.
"This is not going to extend your life, but it's going to make you enjoy eating and enjoy going out to dinner and enjoy being around company rather than becoming fearful that you're going to choke." I think when you phrase it in that way, I think patients are a little bit more open too. Even when they come in thinking like, "I'm just going to hear it, but I'm not interested." I think if you phrase it in a way that is more palatable, then it's an easier conversation. I think just the surgery or not surgery, that's sort of how I think about it and how I counsel them.
[Dr. Ashley Agan]
Some patients need to hear it more than once and think about it a little bit longer and takes time. Do they need to be observed if a patient's like, "You know what? I'm good. I'll let you know if I need you, but I'm going to go on my way." Is that okay too or do they need observation for any particular reason?
[Dr. Rebecca Howell]
I again, can't say for sure, but I think it's fine. I've told patients like, "Hey, I'm here if you need me." I've done that for a variety of different voice and swallowing disorders, not just this particular one. Yes, I don't think there's anything wrong with reaching out to their PCP and just saying like, "Hey, we had this conversation. They do have a Zenker’s. It's not bothering them right now, but I would be happy to see them if it does." I've had that happen. I've had a couple of patients that have said like, "Oh, I'm okay." They have physician, children or family members. Some of them do and some of them don't. I've had a couple that have just passed with their Zenker’s and that's okay too.
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Open vs Endoscopic Approaches to Zenker’s Diverticulum Surgery
Zenker’s diverticulum treatment includes both open and endoscopic surgical approaches. Dr. Howell prefers open approaches for younger patients with bigger diverticula (those larger than 5 cm) and all patients with recurrent diverticula. Older patients and those with smaller diverticula are candidates for less-invasive endoscopic approaches. In endoscopic cases, either a laser or a stapler is used to excise the diverticula: though both are effective, meta-analyses show that lasers are slightly more so.
[Dr. Ashley Agan]
When you're talking to patients about what type of surgery you're going to do, is it shared decision-making about whether it's going to be open or endoscopic? Or do you say, "Hey, I think in my hands, this is going to be a really great slam dunk endoscopic case," or what does your conversation look like with them?
[Dr. Rebecca Howell]
Ashley, my surgeon bias is young patients. If patients are-- so definitely in their fifties or sixties is still a little bit young, not too young, but if you're in your fifties, for sure. If they have a really big diverticulum, I usually recommend an open approach. Again, the three to four is borderline for me, but if they're five to six, then I do, I recommend it.
[Dr. Ashley Agan]
Five to six centimeters?
[Dr. Rebecca Howell]
Those are my own biases. Those are the ones that I tend to tell them to do an open and recurrent ones as well.
[Dr. Ashley Agan]
The rationale for that is that you just have better exposure, better ability to feel like you're treating it comprehensively.
[Dr. Rebecca Howell]
I think in recurrence, it just means that they've got like a different disease, is sort of how I think about it. Now, one could argue, and certainly I've been there that maybe-- especially with stapler, so it has been shown even through meta-analyses, et cetera, that laser tends to be better than stapler, which I think makes sense just because you're going to do a longer myotomy. Sometimes those staplers, people will do all kinds of different things to figure out how to cut the end of the stapler, et cetera, et cetera.
Sometimes it doesn't get all the way down, so you leave a little bit of a lip of that CP. Who that's important in and who it's not, I'm not sure. It's tough to say, again, this is what we're looking at, which is how much better should you be. Again, in my mind, I think of the recurrent patients as having a different type of disease. Yes, it's still called a Zenker’s, but I think there's probably something else more underlying that caused them to have it again.
Potential Zenker’s Diverticulum Complications
While Zenker’s diverticulum complications from surgery are uncommon, esophageal leak, seroma, and hematoma are possible. Most patients can discharge within 24 hours of surgery after tolerating a soft diet. When present, Zenker’s diverticulum complications typically occur within 24 hours of surgery. Dr. Howell monitors for esophageal leak by palpating for crepitus, and for seroma/hematoma by checking drain outputs. In those where esophageal leak is possible, patients are held NPO.
[Dr. Ashley Agan]
What red flags are you telling them to look for? "If this or this happens, you need to call me." What's that conversation going?
[Dr. Rebecca Howell]
Ashley, I don't even have it. Once they get out of my 23-hour window because that's what I tell them, like my complications. I think I've had one guy come back that ended up having-- it was just a wound infection. He had an open approach and had a delayed wound infection. Knock on wood, if they get out of that first 24 hours, it's going to declare it right away. I don't even bother having that conversation with them.
…
[Dr. Ashley Agan]
As far as getting into the Zenker’s diverticulum complications of the bad things that can happen, what do you counsel patients on as far as what can happen in that first 24 hours after surgery?
[Dr. Rebecca Howell]
I tell all of them, "I am intentionally cutting your esophagus." A hole in the esophagus, that's the biggest one. That's what I'm watching for. That is the complication that I'm looking for. I tell them, "Usually it presents with, you have some swelling of your neck." Sometimes air gets in. I said, "We're going to push on your neck for the next 24 hours." Just palpating for crepitus is really what I end up doing.
The drain for the open folks, I just make sure that it's serosanguineous. Again, that comes out right at the end because it's also there for a leak. It's not just there for a seroma or hematoma, but it's really there in case they have a leak. Because then you just have to wait, which is incredibly painful and nobody wants to do it. At least you already have your drain there, it's already done. You just have to give them some time.
Podcast Contributors
Dr. Rebecca Howell
Dr. Rebecca Howell is the division chief of laryngology at University of Cincinnati in Ohio.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, March 28). Ep. 99 – Management of Zenker’s Diverticula [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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