Evolution of endoscopic surgical therapy for Zenker's diverticulum

Abstract

Zenker's diverticulum is a rare anatomic defect that physicians have confronted for almost 250 years. Its location at the interface of the pharynx, neck, and mediastinum makes surgical access difficult and risks severe morbidity. Minimally invasive endoscopic surgical repair of Zenker's diverticulum has been attempted for more than a century as an alternative to reduce morbidity of an open transcervical approach. However, limitations due to available antibiotics, instrumentation, and laryngoscopes, as well as a general discomfort with a sutureless closure of the mucosal excision, have delayed widespread adoption of minimally invasive repair until the last 10 to 15 years. This manuscript will detail the historical evolution of endoscopic surgical therapy for Zenker's diverticulum and highlight the work of two otolaryngologists, Chevalier Jackson and Gosta Dohlman, who were critical in advancing the surgical technique and reducing morbidity. Lastly, this manuscript will analyze the delay in widespread application of endoscopic surgical repair of Zenker's diverticulum.

Does residual wall size or technique matter in the treatment of Zenker's diverticulum?

“…Zenker's diverticulum develops as an outpouching in a triangular area of anatomical weakness (Killian's dehiscence) between the inferior pharyngeal constrictor muscle and the cricopharyngeus muscle. Although first described by Ludlow in 1764, it was not until 1877 that Zenker described the clinical features and basic pathophysiology of the hypopharyngeal pouch as a pulsion diverticulum . This pathology is most commonly seen in men older than 50 years and characteristically presents with symptoms including dysphagia, regurgitation of undigested food, weight loss, coughing, and recurrent aspiration pneumonia.…”

Surgical Treatment of Zenker's Diverticulum

“…Over the past several decades, the pathophysiology of this entity has evolved significantly. The most popular pathogenesis theories are structural abnormalities [4], increased hypopharyngeal pressure, increased cricopharyngeal tone and gastroesophageal reflux [5]. Since the first successful resection of ZD by Wheeler [6] in 1886, different surgical techniques have been indicated for the management of ZD, including diverticulectomy, diverticulopexy, diverticular inversion (all with or without cricopharyngeal myotomy), and myotomy alone.…”

Killian‐Jamieson diverticulum

“…Traditional management of pharyngoesophageal diverticuli was through an open transcervical approach. The first recorded procedure was an attempt to create a controlled fistula by Nicolandi in 1877 7. This attempt, followed by several others, resulted in high morbidity and mortality.…”