Which of the following is TRUE about Zenker's diveiculum -
Ans. is 'c' i.e., Simple excision Zenker's or Pharyngo-esophageal diveicula Zenker's diveicula are mucosal outpouchings occurring through the triangular bare area (Killian's triangle) between the upper oblique fibres (also known as thyropharyngeus muscle) and lower horizontal fibres (also known as cricopharyngeus muscle) of the inferior constrictor muscle. Underlying pathology is neuromuscular incoordination in this region Zenker's diveiculum is a pulsion diveiculum Esophageal Diveicula are of two types: pulsion & traction - In pulsion diveiculum, increased intraluminal pressures (secondary to abnormal esophageal motility) push the mucosa and submucosa through a muscular defect in the wall of the esophagus creating a pulsion diveiculum. It's not true diveicula (not containing all the layers of the esophageal wall) In traction diveicula extraluminal forces (like inflammed & scarred peribronchial & mediastinal lymph nodes) pull the full thickness of the esophagus out, creating a true diveicula. Zenker's is the most common esophageal diveicula. The diveicula arises posteriorly in the midline of neck. The mouth of the diveicula is in the midline but the sac projects laterally (usually left laterally) Zenker's diveicula are rarely seen below 30 yrs of age, most patients are over 50. Dysphagia is the most common symptom. Undigested food is regurgitated into the mouth, especially when the patient is in the recumbent position. Swelling of the neck, gurgling noises after eating, halitosis (bad mouth odour) and a sour metallic taste in the mouth are common symptoms. Barium swallow is diagnostic Management (Maingot's 11/e chapter 8; Sabiston 18/e p1062; Schwaz 9/e p848) Surgical therapy is the treatment of choice. Methods used are: a) Cricopharyngeal myotomy - a myotomy alone is usually sufficient for small diveicula (<2cm). b) Myotomy with Diveiculopexy - larger diveiculum may be sutured in the inveed position to the preveebral fascia using a permanent suture (i.e., diveiculopexy). - diveiculopexy avoids the complication of infection due to leak from a resected diveiculum (diveiculectomy) c) Myotomy with excision of sac - done for large (> 5 cm) diveicula - If the diveiculum is excessively large so that it would be redundant if suspended a diveiculectomy should be performed. d) Diveiculo-esophagostomy using a linear cutting staple gun the septum between the esophagus and the diveicula is divided also known as Dohlman procedure advantage is that it takes less time to complete, does not require an incision, and therefore may have less morbidity. This is an impoant consideration since this disease most commonly presents in the elderly. - This procedure is effective for diveicula >2 cm, and may be impossible to perform for the small diveiculum. Sabiston writes- " For these reasons, this technique has gained or and is advocated in patients with diveicula between 2 and 5 cm." Also know Cervical webs are seen associated in 50% of patients with Zenker's diveicula and can cause dysphagia postoperatively if not treated.
It is asymptomatic
Occurs in the mid-esophagus
Treatment is simple excision
It occurs in children