What Is the Best Technique for Diagnosing Esophageal Diverticulum?

Dr. Chhetri said that knowing the exact size of the diverticulum before he heads into surgery is not necessary. My approach is that if the diverticulum is large enough that I can staple, then I staple it, he said. If it’s small and the stapler doesn’t fit, I use the carbon dioxide laser. If one is prepared for both possibilities, then the technique used to treat the diverticulum can be chosen accordingly in the operating room.

Dr. Postma prefers to prepare his patients before surgery regarding the approach he will take, and the barium swallow allows him to do this with 97% certainty, he said. A patient with a ZD large enough to receive the stapling approach will be fed soon after surgery and sent home either the same day or the next morning, whereas a patient receiving the laser myotomy will not receive food until the day after. There could be other concerns related to this diagnostic and treatment approach, noted Dr. Postma. For instance, the barium swallow is less costly than TNE; obtaining a barium swallow could be wise from a medicolegal standpoint should there be a misadventure during surgery; and certain payers may not reimburse for both endoscopic procedures performed on the same day for the same diagnosis.

Dr. Chhetri added that he doesn’t advocate deleting use of the barium swallow altogether. If you see someone who has dysphagia and you’re not sure of the etiology based on FEES and TNE, then you can always obtain a barium esophagogram or a modified barium swallow study, he said. In his experience, diagnosis of ZD is pretty straightforward using his techniques. Dr. Chhetri estimated that in the past year, he diagnosed and treated approximately one patient per month with Zenker’s. It’s not an everyday thing, but it is a highly treatable condition.

Endoscopic Approach Now Accepted in Surgical Management

According to an historical review of the evolution of endoscopic surgical management for Zenker’s diverticulum written by Alexander T. Hillel, MD, and Paul W. Flint, MD,(2) traditional surgical approaches including the two-stage open diverticulectomy were utilized into the 1950s. By the late 1950s and early 1960s, surgeons began to realize that the diverticulectomy required a myotomy to address the discoordination of the inferior pharyngeal constrictor and spastic cricopharyngeus muscles.

Gösta Dohlman, MD, pioneered an endoscopic esophagodiverticulostomy and myotomy using electrocautery. Then, in the mid-1990s, the endoscopic stapler-assisted diverticulostomy was introduced, simultaneously dividing and stapling the mucosal edges of the esophagodiverticular wall. The stapler alleviated concern with sutureless division of electrocautery and laser techniques. Collard published the first studies validating this approach in 1993.4