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the advanced diverticulum may come to lie in the same vertical axis as the pharynx, permitting selective filling of the sac, which may compress and angulate the adjacent esophagus anteriorly. These anatomic changes obstruct swallowing. Moreover, because the mouth of the diverticulum is above the cricopharyngeus, spontaneous emptying of the diverticulum is unimpeded and often associated with laryngotracheal aspiration as well as regurgitation into the mouth.

Several investigators have commented on the high incidence of anatomic sliding esophageal hiatal hernia in association with Zenker's diverticulum [ ] ; however, contrary to the findings of Henderson and Marryatt,[ ] few except Belsey,[ ] Hunt and associates,[ ] and Smiley and coworkers [ ] noted clinically significant symptoms or complications of gastroesophageal reflux in patients with a diverticulum. Unfortunately, a diverticulum has posed technical difficulties in the accomplishment of detailed preoperative manometric and pH studies, and the available information in this regard is limited.

Furthermore, various cricopharyngeal and oropharyngeal functional abnormalities have been identified secondary to a host of neurologic conditions. 1 ' 1 ' These abnormalities have not been associated with pharyngoesophageal diverticulum. Indeed, patients with a Zenker's diverticulum rarely have any definable neurologic deficit or disease. Other than the fact that a neurologic deficit can produce abnormalities in the pharyngeal phase of swallowing that can be managed by cricopharyngeal myotomy, the inclusion of such cases in a discussion of patients with a diverticulum may be a seriously misleading non sequitur.

In summary, a Zenker's diverticulum is currently defined as an acquired pulsion diverticulum of the hypopharynx that develops near the midline just cephalad to the transverse fibers of the cricopharyngeus muscle. Transient obstructive abnormalities probably contribute to the generation of increased intraluminal forces that lead to herniation of pharyngeal mucosa through muscle fibers that are usually supportive. Symptoms and Diagnosis

Although the diverticulum may be asymptomatic, most patients develop symptoms early in the course of the disease. When the condition is established, it progresses in size ( Fig. 17-1 and Fig. 17-2 ), frequency, and severity of symptoms and complications. Characteristically, the symptoms consist of high cervical esophageal dysphagia, foul breath, noisy deglutition, and spontaneous regurgitation with or without coughing or choking episodes. The regurgitated food is characteristically fresh and undigested and is not bitter, sour, or contaminated by gastroduodenal secretions. If the condition is neglected, weight loss, hoarseness, asthma, respiratory insufficiency, and pulmonary sepsis leading to abscess are all potential complications. A palpable cervical mass is rarely noted. The chief complications of pharyngoesophageal

diverticulum are nutritional and respiratory. Carcinoma arising in a pharyngoesophageal diverticulum is extremely uncommon. Diverticular perforation may occur with any

Figure 17-1 Evolution of pharyngoesophageal diverticulum from small to large. Note the prominence of the cricopharyngeus muscle within the spur between the esophagus and the diverticulum.

Figure 17-2 Radiographic appearance of various sizes of pharyngoesophageal diverticula. A, Small. B, Moderate. C, Large. (A and C from Payne, W.S.: Diverticula of the esophagus. In Payne, W.S., and Olsen, A.M. [eds.]: The Esophagus. Philadelphia, Lea & Febiger, 1974, with permission; B from Payne, W.S., and Clagett, O.T.: Pharyngeal and esophageal diverticula. Curr. Probl. Surg., 1-81, Apr., 1965, with permission of Year Book Medical Publishers.)

Figure 17-2 Radiographic appearance of various sizes of pharyngoesophageal diverticula. A, Small. B, Moderate. C, Large. (A and C from Payne, W.S.: Diverticula of the esophagus. In Payne, W.S., and Olsen, A.M. [eds.]: The Esophagus. Philadelphia, Lea & Febiger, 1974, with permission; B from Payne, W.S., and Clagett, O.T.: Pharyngeal and esophageal diverticula. Curr. Probl. Surg., 1-81, Apr., 1965, with permission of Year Book Medical Publishers.)

Figure 17-3 Surgical exposure of the retropharyngeal space is gained through an oblique left cervical incision oriented along the anterior border of the sternomastoid muscle (inset). Retraction of the sternomastoid and carotid sheath laterally and the thyroid, pharynx, and larynx medially provides necessary exposure of the diverticulum, which is located at a cervical level where the omohyoid crosses the surgical field. (Note that the omohyoid has been retracted cephalad to show the diverticulum.)

Figure 17-4 After connective tissue is dissected from the mucosal sac to identify the defect in the posterior pharyngeal wall, a posterior midline extramucosal myotomy is effected with a scalpel from the neck of the small sac inferiorly for a distance of 4 cm (A). After retraction of the edges of the cut muscle with a peanut dissector, an almond-shaped diffuse bulge of mucosa through the myotomy is seen (B). A small Jackson-Pratt drain is brought from the region of the myotomy and retropharyngeal space through a counterincision to the outside, and the platysma and skin are closed in layers.

Anus Extramucosal

Figure 17-5 One-stage pharyngoesophageal diverticulectomy with myotomy. This procedure is used in the management of medium and large diverticula. Medium diverticulum exposed through a left cervical incision, as for myotomy alone (A). Note that the omohyoid has been retracted cephalad and that a finger is used to retract the thyroid, rather than a metal instrument, to avoid injury to the recurrent nerve. The diverticulum has been dissected out to its neck, and its apex is held cephalad; with a No. 36 French catheter in the esophagus, an extramucosal myotomy with the scalpel is completed for a distance of 4 cm (B). Depending on the size of the diverticulum, a TA-15, TA-30, or TA-55 stapling device has been selected. Most require TA-30 with 4.8-mm staples. Note that the staple line is oriented along the long axis of the esophagus and that an indwelling No. 36 French esophageal catheter is used to prevent stenosis and minimize the length of any luminal narrowing (C). The mucosal closure is left uncovered. Drainage and closure are effected, as with myotomy alone.

Figure 17-5 One-stage pharyngoesophageal diverticulectomy with myotomy. This procedure is used in the management of medium and large diverticula. Medium diverticulum exposed through a left cervical incision, as for myotomy alone (A). Note that the omohyoid has been retracted cephalad and that a finger is used to retract the thyroid, rather than a metal instrument, to avoid injury to the recurrent nerve. The diverticulum has been dissected out to its neck, and its apex is held cephalad; with a No. 36 French catheter in the esophagus, an extramucosal myotomy with the scalpel is completed for a distance of 4 cm (B). Depending on the size of the diverticulum, a TA-15, TA-30, or TA-55 stapling device has been selected. Most require TA-30 with 4.8-mm staples. Note that the staple line is oriented along the long axis of the esophagus and that an indwelling No. 36 French esophageal catheter is used to prevent stenosis and minimize the length of any luminal narrowing (C). The mucosal closure is left uncovered. Drainage and closure are effected, as with myotomy alone.

Anus Extramucosal

Figure 17-6 Esophagus with huge epiphrenic diverticulum occupying about half of the right thorax. Note the associated sliding esophageal hiatal hernia. (From Payne, W.S.: Esophageal diverticula. In Shields, T. W. [ed.]: General Thoracic Surgery, 3rd ed. Philadelphia, Lea & Febiger, 1983, p. 859, with permission.)

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