Zenker's Diverticulectomy

Zenker’s diverticulectomy is a surgical procedure to remove an abnormal pouch called Zenker’s diverticulum (ZD) from your throat.

The lower part of the throat, called the hypopharynx, has muscles that control the movement of food from the throat into the oesophagus (food pipe). The upper part of the oesophagus has muscles called cricopharyngeal (CP) muscles that are under constant stress and help to hold the food between swallows. When you swallow food, your brain sends signals to the hypopharynx muscles to push the food into the oesophagus. Within milliseconds, your brain sends another signal to your CP muscle to open and allow the entry of food into your oesophagus. However, there is a weak triangular area, called Killian’s triangle, between the muscles in the lower part of the throat and upper part of the oesophagus that does not have any muscle. When the CP muscle does not relax completely or quickly while swallowing, food presses against the CP muscle at the upper part of the oesophagus, eventually causing the Killian's triangle to be pushed out to form a pouch called the zenker’s diverticulum (ZD).

In individuals with ZD, food tends to get stuck in the abnormal pouch, resulting in several symptoms including bad breath, cough and pain while swallowing. The symptoms are usually observed in individuals between 50 and 70 years of age. Treatment options for the condition include dietary modifications and surgery.

One of the surgical options of Zenker’s diverticulectomy involves the complete removal of ZD. However, many of the individuals who undergo this surgery experience recurrence of ZD symptoms. This issue is resolved with the cutting of CP muscles in an operation called Zenker’s myotomy. This surgery is performed alongside Zenker’s diverticulectomy to provide the most effective surgical treatment for individuals with ZD.

This surgery is recommended in individuals with ZD. The symptoms of ZD are as follows:

• Cough
• Bad breath
• Gurgling sound (occurs when air is passed through ZD)
• Pain while swallowing
• A feeling of food sticking inside the throat
• Regurgitation of swallowed food and saliva
• Weight loss
• Entry of foreign materials into the windpipe (pulmonary aspiration)
• Infection in the lungs due to pulmonary aspiration (entry of food or drinks into the wind pipe)

The surgery will be performed with caution in individuals who smoke, pregnant women or those with kidney, heart, or lung dysfunction.

Before the procedure, your doctor will perform several medical and imaging tests to ensure that you are an eligible candidate for the surgery. The tests that may be conducted include:

• Blood tests
• Barium swallow: It involves swallowing a liquid barium preparation and evaluating its movement in the oesophagus using an X-ray
• Oesophageal manometry: This test helps measure the strength and timing of relaxations and contractions of the oesophageal opening.
• Gastrointestinal endoscopy: In this test, a flexible tube is inserted into the digestive tract to look at the internal structures.
• 24-hour pH metry: It checks for gastroesophageal reflux disease (a disorder that develops when the stomach acid comes up into the oesophagus.

Moreover, you will be given certain instructions to prepare for the surgery. During the discussion, the surgeon will ask you to:

• Share your medical history and inform him/her if you have any pre-existing health conditions.
• Share a list of all the medicines that you take, including herbs, supplements, and over-the-counter medications.
• Stop taking medicines that thin the blood, including aspirin, warfarin, ibuprofen, and clopidogrel.
• Stop smoking.
• Tell them if you are pregnant or have any allergies.
• Take a shower and remove body piercings, nail polish, and make-up before arriving at the hospital on the day of the surgery.
• Arrange a family member, friend, or responsible adult to drive you home after the surgery.
• Inform him/her if you have a cold, flu, or fever on the days leading to the surgery. In such a case, the surgery can be postponed.
• Fast after midnight of the night prior to the surgery.

Once you have reached the hospital, the hospital staff will ask you to wear a hospital gown. They will start an intravenous (IV) line in your arm to supply essential fluids and medications during the surgery. The procedure is performed under general anaesthesia, a medicine that will make you fall asleep. Zenker's diverticulectomy can be carried out by any of the two methods, namely an open or endoscopic method. 

• Endoscopic surgery: This includes the following steps:
  • The surgeon will insert an endoscope (a flexible tube fitted with a camera) through your mouth into your throat. 
  • He/she will use a small medical knife to cut the muscle layer that separates the ZD from your oesophagus.
  • This muscle base is then clipped with a stapler to prevent any hole in its wall.
• Open surgery: Here, an incision (cut) will be made on the left side of your neck to access the ZD.

While most individuals who undergo the endoscopic procedure are discharged on the same day of surgery, some individuals (especially those with major health issues) are asked to stay overnight in the hospital. You will be allowed to eat normally after 24 hours of operation.

In case of an open surgery, you will need to stay in the hospital for one to two days and can expect the following:

• The hospital staff will insert a feeding tube into your stomach through your nose. This tube may be kept for a week so that the operated area can heal. A feeding tube is also placed after the endoscopic procedure.
• A test called leak study will be performed on the day after the surgery to ensure there is no leakage of fluids outside your oesophagus. This test is also performed after the endoscopic surgery.

Your surgeon will give you certain instructions to take care of yourself after this surgery. These include:

• If you have undergone an open surgery, keep the operated site dry for five days. You can shower 48 hours following the surgery. While taking a shower, cover the incision with a bandage for at least five days or until your doctor suggests you to. Avoid swimming or soaking yourself in the bathtub for at least two weeks.
• Antibiotics will be prescribed to you for a week after the surgery to prevent infection.
• It is normal to experience sore throat, pain at the operated site and in the ears. Your surgeon will prescribe medicines to reduce this pain. In addition, he/she may also recommend you to take stool softeners as some pain medications can cause constipation.
• For the first week after the surgery, keep your head raised while sleeping. This can be done by using two to three additional pillows.
• Avoid heavy lifting or strenuous exercises, especially those that involve the upper body for the first 14 days.
• It is normal to experience a rough or hoarse voice for two to four days after the surgery. Try not to cough or clear your throat for at least seven days.
• You should resume driving only after consulting with the surgeon.

The surgery helps to provide relief from the symptoms of ZD. Moreover, endoscopic surgery offers the following benefits over open surgery:

• Shorter hospital stay
• Shorter recovery time
• Faster return to regular diet and other everyday activities
• Reduced postoperative pain
• No outward incision on the neck

When to see the doctor?

You should contact the doctor if you experience any of the following:

• Fever above 101^°F (38^°C)
• Redness, tenderness, or swelling around the operated site
• Foul-smelling fluid or pus leaking from the incision
• Pain in the neck, upper back, or chest
• Blood in cough or blood in vomit
• Problem urinating
• Difficulty breathing

The surgery is associated with risks and complications such as:

• Perforation or hole at the operated site
• Infection
• Bleeding
• Vocal cord paralysis
• Dental injury
• Tear in the inner layer of the oesophagus

A follow-up appointment is usually scheduled in a week after this surgery, during the visit, the surgeon will perform the leak study test and remove your feeding tube and stitches.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.