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1 All authors: Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104.
Received April 27, 2001;
accepted after revision May 18, 2001.
Address correspondence to M. S. Levine.
Abstract
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MATERIALS AND METHODS. Sixteen patients who underwent various procedures for repair of Zenker's diverticulum (diverticulectomy and cricopharyngeal myotomy in [n = 8], diverticulopexy and cricopharyngeal myotomy [n = 4], endoscopic stapling diverticulotomy [n = 3], and cricopharyngeal myotomy alone [n = 1]) had radiographic studies with water-soluble contrast material, barium, or both during the early postoperative period (n = 7), late postoperative period (n = 4), or both (n = 5). The radiologic reports and images were reviewed to determine the postoperative findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum.
RESULTS. Radiographic studies revealed leaks during the early postoperative period in three (27%) of 11 patients after surgical repair of Zenker's diverticulum and in zero of three patients after endoscopic diverticulotomy. Pharyngeal dysfunction (pharyngeal paresis, decreased epiglottic tilt, laryngeal penetration, or tracheobronchial aspiration) was detected in seven (54%) of 13 patients after surgery and in one (33%) of three patients after endoscopic diverticulotomy; five of these eight patients had follow-up barium studies during the late postoperative period, and all five showed marked improvement in pharyngeal function. An extrinsic cricopharyngeal impression was detected in six (38%) of these 16 patients, a remnant diverticulum in four (25%), and mucosal beaking in three (19%). A suspended or inverted diverticulum was detected in one of the four patients who underwent surgical diverticulopexy.
CONCLUSION. Radiologists should be aware of the various postoperative findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum so that appropriate interventions can be taken in patients with this condition.
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Endoscopic procedures have also increasingly been advocated as a less invasive form of therapy associated with fewer complications than open surgical procedures [6]. In 1960, Dohlman and Mattson [7] described a novel technique that used endoscopic diathermy to obliterate the diverticulum by dividing the common wall between the diverticular sac and adjacent esophagus. A more recent variation of the Dohlman procedure uses endoscopic stapling in place of diathermy to separate this common wall [8,9,10]. Despite advances in endoscopic technology, debate continues about the best form of therapy for patients with diverticula. Radiographic studies with water-soluble contrast material or barium are often performed to evaluate the postoperative anatomy and rule out complications after surgical or endoscopic repair of Zenker's diverticulum. Surprisingly, however, little has been written in the radiologic literature about the radiographic evaluation of patients after diverticulectomy and cricopharyngeal myotomy [11, 12] or endoscopic diverticulotomy [13]. Nor, to our knowledge, have the radiographic findings after diverticulopexy been reported in the radiologic literature. The purpose of this investigation, therefore, was to reassess the radiographic findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum.
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These 16 patients underwent a total of 41 radiographic examinations of the pharynx and esophagus, including 24 examinations with a high-density barium suspension (E-Z-HD; E-Z-EM, Westbury, NY), and 17 with water-soluble contrast material (diatrizoate meglumine and diatriazoate sodium solution, Gastroview; Mallinckrodt, St. Louis, MO) followed by high-density barium if no leak was identified with water-soluble contrast material. In all cases, the studies included spot images and video recordings of the pharynx and esophagus in frontal, lateral, or oblique projections. Seven patients had radiographic studies only during the early postoperative period (within 30 days after repair of the diverticulum), four had radiographic studies only during the late postoperative period (more than 30 days after repair of the Zenker's diverticulum), and five had radiographic studies during the early and late postoperative periods. The average number of radiographic studies per patient was 2.6 (range, 1-4). Seven (44%) of the 16 patients also had preoperative barium studies that revealed the Zenker's diverticulum (Figs. 1A and 2A). The average diameter of the diverticulum in these seven patients was 3.3 cm (range, 2-5 cm). In all patients, the original radiographic reports were reviewed to determine the postoperative complications associated with surgical or endoscopic repair of Zenker's diverticulum. The radiographic images were also reviewed to assess the postoperative findings in these patients.
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A review of medical and surgical records revealed that 13 (81%) of the 16 patients underwent surgical repair of the Zenker's diverticulum, including a combined diverticulectomy and cricopharyngeal myotomy in eight, a combined diverticulopexy and cricopharyngeal myotomy in four, and cricopharyngeal myotomy alone in one. The remaining three patients (19%) underwent endoscopic stapling diverticulotomy and cricopharyngeal myotomy. Medical records were also reviewed to determine the postoperative course of these patients.
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In the two patients who underwent divertic-ulectomy, the leaks were detected on the initial radiographic studies 5 and 9 days after surgery. Both patients were treated with parenteral nutrition and antibiotics. Although follow-up studies showed no substantial healing of the leaks, both patients did well clinically and were placed on liquid and then solid diets before being discharged from the hospital. These leaks, therefore, presumably healed on conservative therapy.
In the remaining patient who underwent diverticulopexy, a postoperative leak was not suspected at the time of the initial hospital admission. However, the patient returned to the hospital soon after discharge because of increasing drainage from the incision site, and a radiographic study 10 days after surgery showed the leak. It, therefore, is unclear whether this was a clinically silent leak during the early postoperative period or a delayed leak. Whatever the explanation, the patient underwent repeated surgery for débridement of a neck abscess and was discharged from the hospital 8 days later in satisfactory condition, although no subsequent radiographic studies were performed.
Postoperative pharyngeal dysfunction.—Pharyngeal dysfunction was detected in seven patients (54%) of 13 patients who underwent open surgical repair, including diverticulectomy and cricopharyngeal myotomy in four, diverticulopexy and cricopharyngeal myotomy in two, and cricopharyngeal myotomy alone in one. Three of these patients had preoperative barium studies, and all three showed normal pharyngeal function. The indications for the postoperative radiographic studies in these seven patients included left vocal cord paralysis in one and routine follow-up in six. Four of these patients showed pharyngeal dysfunction on the initial radiographic studies obtained during the early postoperative period, an average of 6.3 days (range, 1-15 days) after surgery. The other three patients had pharyngeal dysfunction on radiographic studies performed during the late postoperative period, an average of 1.9 months (range, 1.2-3 months) after surgery. The findings in these seven patients included pharyngeal paresis in three, decreased epiglottic tilt in five, laryngeal penetration in six, and tracheobronchial aspiration in six (Fig. 4A). In four patients, repeat barium studies an average of 8.6 months later (range, 1-36 months) revealed marked improvement in pharyngeal function (Fig. 4B), so the initial findings were attributed to the prior pharyngeal surgery. In the remaining three patients, repeat barium studies were not performed. One of these patients had a poor postoperative course, complicated by cardiac arrest, pancreatitis, sepsis, and death 2 months after surgery.
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Endoscopic Stapling Diverticulotomy (Three Patients)
Postoperative leaks.—No leaks were detected on radiographic
studies during the early or late postoperative periods in any of the three
patients who underwent endoscopic stapling diverticulotomy.
Postoperative pharyngeal dysfunction.—Pharyngeal dysfunction was detected on a barium study in one patient (33%) with reflux symptoms who underwent endoscopic stapling diverticulotomy 2 months earlier; findings included laryngeal penetration and trace aspiration into the trachea. A repeat barium study 9 months later revealed normal pharyngeal function.
Other Findings After Surgical Repair or Endoscopic Diverticulotomy
(16 Patients)
Remnant diverticulum.—A remnant diverticulum was detected on
radiographic studies in four patients (25%) who underwent surgical or
endoscopic repair of Zenker's diverticulum, including endoscopic stapling
diverticulotomy in two, surgical diverticulectomy in one, and surgical
diverticulopexy in one. The indications for postoperative barium studies in
three of these four patients included reflux symptoms in two and dysphagia in
one. In the fourth patient, the barium study was performed as a routine
follow-up examination.
The average diameter of the remnant diverticulum was 2.3 cm (range, 1-4 cm). In all four patients, the diverticulum arose from the posterior aspect of the pharyngoesophageal segment and extended inferiorly in the retropharyngeal space, with slightly delayed emptying of contrast material from the diverticulum into the pharynx (Fig. 1B). In three of these patients, radiographic studies were performed during the late postoperative period, an average of 5.7 months (range, 2-11 months) after surgery. In the remaining patient, the study was performed during the early postoperative period, 5 days after surgery.
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Suspended diverticulum.—A suspended or inverted diverticulum was observed on radiographic studies in one of the four patients who underwent surgical diverticulopexy. This patient had a residual diverticulum that had been suspended from the posterior aspect of the pharyngoesophageal segment, so that the base of the diverticular sac was located above the orifice, with rapid emptying of contrast material from this structure (Fig. 2B). The initial radiographic study was performed to rule out a leak during the early postoperative period 2 days after surgery. Two follow-up studies during a 6-month period revealed progressive shrinkage of the inverted diverticulum (Fig. 2C).
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Mucosal beaking.—Mucosal beaking was detected on radiographic studies in three patients (19%) who underwent surgical or endoscopic repair of Zenker's diverticulum, including diverticulopexy in one, endoscopic diverticulotomy in one, and cricopharyngeal myotomy alone in one. The indications for these studies included left vocal cord paralysis in one and routine follow-up in two. In all three patients, mucosal beaking was characterized on radiographic studies by triangular outpouching or tenting of the posterior aspect of the pharyngoesophageal segment just above the level of the cricopharyngeus (Fig. 5), with rapid emptying of contrast material from this beaklike outpouching. In all patients, the radiographic studies were performed during the early postoperative period, an average of 4.3 days (range, 1-9 days) after surgery.
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Cricopharyngeal impression.—A smooth, extrinsic cricopharyngeal impression was detected on the posterior aspect of the pharyngoesophageal segment in six patients (38%) who underwent surgical or endoscopic repair of Zenker's diverticulum and cricopharyngeal myotomy (Figs. 1B and 5), including endoscopic stapling diverticulotomy in three, open diverticulectomy in one, diverticulopexy in one, and cricopharyngeal myotomy alone in one. The indications for radiography in these six patients included reflux symptoms in one, dysphagia in one, vocal cord paralysis in one, and routine follow-up in three. Of the three patients who underwent endoscopic diverticulotomy, this cricopharyngeal impression was associated with a remnant diverticulum in two and mucosal beaking in one.
In two patients, the cricopharyngeal impression was detected during the early postoperative period 2 days and 7 days after surgery. One of these patients underwent a repeat myotomy the same day as the initial radiographic study, and a follow-up study 5 days later showed no evidence of a residual cricopharyngeal impression. In the remaining four patients, the cricopharyngeal impression was detected during the late postoperative period an average of 3.9 months (range, 1.5-8 months) after surgery. During the early postoperative period (1 day and 2 days after surgery), two of these patients also had radiographic studies, which showed no evidence of a cricopharyngeal impression, so this finding developed in the interim. One of the patients with a cricopharyngeal impression during the late postoperative period underwent repeat endoscopic diverticulotomy, and a follow-up radiographic study 6 months later revealed a persistent cricopharyngeal impression on the posterior aspect of the pharyngoesophageal segment. A dilatation procedure, therefore, was performed.
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Some leaks may be suspected after surgical or endoscopic repair of Zenker's diverticulum because of fever, neck pain, excessive drainage from the incision site, or the development of a neck abscess or pharyngocutaneous fistula [12]. However, other leaks that originate from the posterior aspect of the pharyngoesophageal segment and are confined to the retropharyngeal space may not be recognized from clinical evidence, as occurred in two of our patients. We, therefore, believe that radiographic evaluation of these patients with water-soluble contrast material is warranted on a routine basis during the early postoperative period even in the absence of clinical signs of a leak.
Functional impairment of the pharynx or larynx is another common complication of surgery for Zenker's diverticulum; both vocal cord paralysis and swallowing dysfunction (aspiration, pharyngeal paresis, and defective relaxation or premature closure of the cricopharyngeus) have been documented in the surgical and radiologic literature [11, 17,18,19,20,21]. Because of the proximity of the recurrent laryngeal nerve to the operative field, damage to this structure could account not only for vocal cord paralysis but also for some of the swallowing abnormalities in these patients [11, 17,18,19]. In one study from the surgical literature, vocal cord paralysis was observed as a temporary finding after open surgical repair of Zenker's diverticulum; full recovery of vocal cord function occurred within 3 months after surgery [19]. In our series, seven (54%) of the 13 patients who underwent open surgical procedures had pharyngeal dysfunction, manifest on radiographic studies by pharyngeal paresis, decreased epiglottic tilt, laryngeal penetration, and tracheobronchial aspiration (Fig. 4A). However, four of these seven patients had marked improvement in swallowing function on follow-up radiographs (Fig. 4B). Our findings, therefore, suggest that pharyngeal dysfunction commonly occurs as a transient phenomenon after surgery for Zenker's diverticulum. Although one of our three patients who underwent endoscopic stapling diverticulotomy also had transient pharyngeal dysfunction, it remains unclear whether this procedure is associated with a comparable frequency of swallowing abnormalities.
A variety of anatomic abnormalities may also be detected on radiographs after surgical or endoscopic repair of Zenker's diverticulum. Some patients have a residual outpouching from the posterior aspect of the pharyngoesophageal segment, also known as a "remnant" diverticulum [8, 13, 17, 22, 23]. A remnant diverticulum is particularly common after endoscopic diverticulotomy because this procedure entails separating the partition between the diverticulum and adjacent esophagus without resecting the diverticulum [13, 23]. If a remnant diverticulum is identified on radiographic studies after endoscopic diverticulotomy, however, the partition between the diverticulum and adjacent esophagus may have a reduced height in relation to preoperative studies, with improved emptying of contrast material from the residual pouch [13]. As a result, this remnant diverticulum often is not associated with postoperative symptoms of dysphagia or regurgitation [23]. In our series, remnant diverticula were observed in two of three patients after endoscopic diverticulotomy (Fig. 1B) and in one of eight patients after surgical diverticulectomy. Remnant diverticulum, therefore, represents a frequent finding on radiographic studies after endoscopic diverticulotomy or incomplete surgical diverticulectomy.
When patients undergo diverticulopexy (in which the diverticulum is suspended in the prevertebral fascia to facilitate emptying of its contents and to alleviate symptoms such as dysphagia, regurgitation, and aspiration), a residual diverticulum may also be shown on postoperative radiography [5]. In our series, however, the suspended diverticulum was recognized in one of four patients as an inverted diverticular sac with the base of the sac located above the orifice, so that on radiographic studies, contrast material emptied from this structure into the esophagus (Fig. 2B). In this patient, the inverted diverticulum was also found to shrink considerably on two follow-up barium studies during a 6-month period (Fig. 2C). Radiologists, therefore, should be aware of the expected appearance of the suspended diverticulum after diverticulopexy and of the temporal changes that may occur in this structure on serial radiography.
Mucosal beaking is another previously unreported radiographic finding that was detected during the early postoperative period in three patients (19%) after surgical or endoscopic repair of Zenker's diverticulum. Mucosal beaking was characterized on radiography by a distinctive triangular outpouching from the posterior aspect of the pharyngoesophageal segment just above the level of the cricopharyngeus (Fig. 5). This finding most likely results from postoperative edema or scarring in the region of the diverticulectomy or cricopharyngeal myotomy and is of doubtful clinical importance.
A prominent cricopharyngeal impression on the posterior aspect of the pharyngoesophageal segment is another common postoperative finding that was seen on radiographs in six (38%) of our patients [12, 17] (Figs. 1B and 5). When this finding is detected during the early postoperative period, it could indicate an incomplete cricopharyngeal myotomy, as presumably occurred in one of our patients who underwent repeat myotomy with no residual cricopharyngeal impression on a follow-up study. However, our series also included two patients who had cricopharyngeal impressions that were detected during the late, but not the early, postoperative periods. In such cases, this finding could be related to gradual regeneration or fibrosis of the cricopharyngeal remnant [12, 24]. A cricopharyngeal impression may even be more likely in patients who undergo endoscopic stapling procedures, in which only a partial endoscopic myotomy is performed. In our series, all three patients who underwent endoscopic stapling diverticulotomy had cricopharyngeal impressions on the posterior aspect of the pharyngoesophageal segment associated with a remnant diverticulum or mucosal beaking.
In conclusion, Zenker's diverticulum may be repaired by open surgical procedures (either diverticulectomy or diverticulopexy with cricopharyngeal myotomy) or by endoscopic stapling diverticulotomy. Radiologists should be aware of the various postoperative findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum, so that appropriate interventions can be taken in patients with this condition.
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