An esophageal diverticulum is an abnormal pouch or sac that forms when the inner lining of the esophagus pushes outward through a weak spot in the muscle layer of the esophageal wall. These pouches can occur anywhere along the food pipe, with the most common type, Zenker’s diverticulum, forming at the very top near the throat. While the condition is relatively rare, it can cause significant problems for some people. Treatment is typically reserved for those experiencing bothersome symptoms, with the goal of restoring comfortable swallowing and preventing complications.
When Treatment Becomes Necessary
The decision to treat an esophageal diverticulum is primarily driven by the severity of the patient’s symptoms. Many people with a diverticulum, especially those located in the middle or lower esophagus, have no symptoms and are often managed with a conservative approach known as “watchful waiting.”
Non-operative management focuses on lifestyle and dietary adjustments to reduce the risk of food trapping and alleviate mild discomfort. Patients are often advised to eat a bland diet, take smaller bites, chew food thoroughly, and drink water after each bite to help flush residual food. Active treatment, whether endoscopic or surgical, is indicated when patients experience severe or progressive symptoms like difficulty swallowing (dysphagia), regurgitation of undigested food, or aspiration, which can lead to pneumonia.
Minimally Invasive Endoscopic Procedures
Endoscopic procedures have become the preferred first-line treatment for Zenker’s diverticulum due to their minimally invasive nature, shorter recovery, and low complication rates. The procedure is performed by passing a flexible or rigid endoscope through the mouth, avoiding external incisions. The main goal is not to remove the pouch itself, but to divide the muscular wall, known as the septum, that separates the pouch from the main esophageal channel.
This septum division is paired with a myotomy, which involves cutting the cricopharyngeal muscle. This muscle, located at the top of the esophagus, is thought to cause the diverticulum by failing to relax. Cutting the muscle releases the underlying high-pressure zone, allowing food to pass directly into the esophagus instead of deviating into the pouch. Techniques like flexible endoscopic septotomy (FES) or Zenker-peroral endoscopic myotomy (Z-POEM) use specialized tools, such as surgical staplers, electrocautery, or lasers, to perform this division, creating a common channel that immediately alleviates symptoms.
Traditional Surgical Intervention
Traditional surgical intervention is used for very large diverticula or those located in the middle (midesophageal) or lower (epiphrenic) sections of the esophagus that are not easily accessible endoscopically. These external approaches are typically performed using minimally invasive laparoscopic or thoracoscopic techniques, though open surgery may be necessary in complex cases. Accessing the esophagus occurs through the chest or abdomen, depending on the diverticulum’s location.
The operation generally includes two main components: diverticulectomy (physical removal of the pouch) and a myotomy. The myotomy, an incision in the muscle layer, is performed to address the underlying motility disorder and prevent recurrence of the pouch. For lower esophageal diverticula (epiphrenic), the myotomy is often extended onto the stomach. A partial fundoplication—a surgical wrap of the stomach around the esophagus—is frequently added to prevent post-operative acid reflux.
Recovery and Long-Term Follow-Up
Following any procedure, the immediate post-operative phase involves careful monitoring to ensure proper healing. Patients are typically restricted to nothing by mouth (NPO) for 24 to 48 hours to allow the surgical site to heal. The hospital stay for endoscopic procedures can be as short as one night, while traditional surgery requires a slightly longer stay.
The patient’s diet is gradually advanced, starting with clear liquids and progressing to a full liquid and then a soft diet over two to four weeks. Long-term follow-up is important, often involving yearly check-ups and repeat imaging, such as a barium swallow study. This monitoring assesses the procedure’s success, manages residual symptoms, and detects the possibility of recurrence, a known risk, particularly with some endoscopic techniques.