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Zenker’s diverticulum (ZD) is a rare disease with a reported prevalence of 0.01% to 0.11% which typically presents in elderly individuals. Classical symptoms of ZD are dysphagia, regurgitation, halitosis, chronic cough, foreign body sensation, aspiration pneumonia, and weight loss. In the past, the mainstay of management for ZD was an open surgical approach through a neck incision and subsequent myotomy of the upper esophageal sphincter (UES) and removal or suspension of the diverticulum. Therapy of symptomatic ZD, however, has evolved over the last 30 years from an open surgical approach to less invasive, incisionless, transoral endoscopic techniques. Transoral endoscopic approach by using rigid instruments is performed primarily by otorhinolaryngologists, whereas transoral therapy using flexible endoscopes is performed by endoscopists with devices developed for advanced tissue resection. The common goal of both transoral modalities is severing of the septum between the esophageal lumen and the diverticulum containing the cricopharyngeal muscle. The potential advantages of flexible endoscopy over the conventional open surgical approach or rigid endoscopy are the absence of cutaneous incision, shorter operative time, reduced postoperative discomfort, faster return to oral feeding, and shorter length of hospital stay.

Esophageal diverticula are outpouchings that protrude from the esophageal wall. They commonly are classified according to their anatomic location in the esophagus: Zenker’s diverticulum (ZD) in the upper esophagus, mid-thoracic or mediastinal diverticula in the mid-esophagus, and epiphrenic (ED) in the distal esophagus. Histologically, there are two types of esophageal diverticula: true diverticulum which consists of all layers of the esophagus and false diverticulum which includes only two layers, mucosa and submucosa. Etiologically, esophageal diverticula could be congenital, very rare, or acquired which is most common. Most esophageal diverticula are asymptomatic. However, when large, they are associated with symptoms including dysphagia, regurgitation, chest pain, and aspiration-related complications. A thorough evaluation involves a combination of contrast esophagogram and upper endoscopy to assess esophageal anatomy as well as an esophageal manometry to evaluate the functional status of the esophagus. Treatment is not required for most diverticula as they are asymptomatic. Large or symptomatic diverticula should be treated. Treatment is tailored to the pathophysiology and location of the diverticulum. Surgical options include diverticulectomy or diverticular suspension (in case of ZD) with a myotomy. Fundoplication, usually partial, is added in cases of epiphrenic diverticulum. Minimally invasive transoral endoscopic stapled diverticulectomy approach is increasing in popularity and has been performed in cases of ZD, especially in high-risk surgical patients.

Zenker’s diverticulum (ZD) is a rare acquired outpouching of esophageal mucosa that typically occurs during the 7th or 8th decade of life. The outpouching is associated with halitosis, dysphagia, and aspiration. The traditional approach to repair has been via cervical dissection with myotomy and excision of the diverticulum. Alternatively, both rigid and flexible endoscopic transoral approaches have been available for more than 20 years with demonstrated comparable efficacy and safety. Data to guide technique selection is currently limited to retrospective observational and case-control studies demonstrating a slight advantage in safety profile to favor use of transoral techniques; however, there are no randomized controlled trials comparing techniques. The requirement of specialized flexible endoscopic training has limited adoption of the flexible endoscopic technique in the surgical community. Appropriate technique selection should be based on local expertise, patient characteristics, and ZD characteristics.

Diverticula of the hypopharynx have been recognized for over 200 years. Zenker’s diverticulum (ZD) is by far the most common with an annual incidence of 2/100,000 individuals. Specifically, ZD is an outpouching of hypopharyngeal mucosa that protrudes through a weak area at the junction of the inferior constrictor muscle and the cricopharyngeus (CP) muscle, known as Killian’s dehiscence. Historically, ZD was first recognized by Abraham Ludlow in 1796 and was named after a German pathologist, Friedrich Albert Zenker, who reported a series of ZD patients in 1877. Wheeler reported the first successful open repair of a ZD in 1882. In 1917, Mosher first introduced the concept of endoscopic treatment of ZD that has now seen tremendous advances with respect to both instrumentation and technique. The most common method used for treatment of ZD, the endoscopic staple-assisted approach, was first reported by Collard in 1993. Since then, several retrospective studies have found both open and endoscopic techniques to be highly effective with comparable complication rates and lengths of hospital stay.

The upper esophageal sphincter (UES) is a complex muscle structure that is composed of the cricopharyngeus muscle, the inferior pharyngeal constrictor muscle, and the proximal cervical esophagus. The UES plays an important role in the swallowing process and marks the transition from the pharyngeal deglutitive phase to the esophageal phase. Adequate UES opening is therefore essential for an effective swallow. Failed or diminished UES opening results in incomplete pharyngeal clearance, post-deglutitive residual, and potential post-deglutitive aspiration. Disordered UES opening can be the result of abnormal UES distensibility, such as Zenker’s diverticulum, cricopharyngeal bar, or lack of neural relaxation, such as cricopharyngeal achalasia. Alternatively, it can be due to weak pharyngeal propulsion alone or in addition to failed UES relaxation. For this review, we focus on intrinsic UES restrictive disorders. Major diagnostic tools include videofluoroscopy, endoscopic evaluation of the pharynx and esophagus, and pharyngoesophageal manometry. Treatment options for UES restrictive disorders depend on the underlying etiology and may include surgical or endoscopic methods.

Zenker’s diverticulum (ZD), also called cricopharyngeal or pharyngoesophageal diverticulum, is an outpouching of the mucosa through Killian’s triangle. ZD is a relatively rare disorder and occurs most often in the aged. Its pathophysiology is not well understood but is thought to result from incoordination between pharyngeal contraction and upper esophageal sphincter relaxation.

Zenker’s diverticulum (ZD) often presents with symptoms of dysphagia, regurgitation, choking, and coughing. Open approaches to repairing the diverticulum have been plagued by high morbidity, leaving surgeons to search for other alternatives. Rigid endoscopic approaches are typically safe and produce good results, although they require the use of a diverticuloscope and the need for the patient to extend their neck. Using lessons learned from per-oral endoscopic myotomy (POEM), flexible endoscopic approaches have begun to be described. Although highly operator dependent, the flexible approach may have the highest success rate and the lowest morbidity rate.

Zenker’s diverticulum is a false diverticulum or pseudodiverticulum of the esophageal mucosa and submucosa occurring at Killian’s dehiscence, which lies at the junction between the oblique fibers of the cricopharyngeus muscle and the transverse fibers of the inferior pharyngeal constrictor (Fig. 11.1). The Zenker’s diverticulum is a pulsion diverticulum thought to occur as a result of inadequate coordination between these muscle fibers, with a resultant increased pharyngoesophageal intraluminal pressure. The advent of endoscopic techniques has transformed the surgical treatment of Zenker’s diverticula. Although the treatment paradigm has shifted to minimally invasive approaches with repair assisted by endoscopic stapling or lasers, traditional transcervical procedures can still play a role in selected cases. This chapter illustrates our tailored approach to patients with Zenker’s diverticulum and demonstrates the open surgical and endoscopic techniques.

The goal of this chapter is to describe the pathophysiology of Zenker’s diverticulum, their clinical presentation, and indications for treatment and provide an overview of the surgical management of patients with this rare esophageal pathology. Treatment approaches discussed include open transcervical resection, endoscopic stapled diverticulotomy, endoscopic harmonic scalpel diverticulotomy, and flexible endoscopic diverticulotomy. Finally, a comparison of the open and endoscopic approaches will be provided.