Management of pharyngoesophageal (Zenker's) diverticulum: which technique?

BACKGROUND: Incomplete symptomatic relief of pharyngoesophageal (Zenker's) diverticulum after endoscopic stapling or laser division has been reported by some authors. The clinical relevance of cricomyotomy, although supported by experimental data, remains controversial. METHODS: Operative procedures consisted of transcervical resection (n = 34, group I), transcervical resection plus cricomyotomy (n = 12, group II), transcervical cricomyotomy (n = 8, group III), transcervical cricomyotomy plus diverticulopexy (n = 47, group IV), endoscopic stapling division (n = 31, group V), and endoscopic laser division (n = 55; group VI). RESULTS: The percentage of totally asymptomatic patients was significantly (p or = 3 cm, 86% versus 50%). The percentage of patients with no or occasional (ie, fewer than twice a week) symptoms was significantly (p 0.286) after endoscopic stapling division and after endoscopic laser division ( or = 3 cm, 96% versus 80%). It was also similar (p > 0.197) after resection alone (group I) and after open operations including myotomy (combined groups II to IV) ( or = 3 cm, 92% versus 100%). Unlike endoscopic stapling and division, laser division was complicated by mediastinitis (2 patients), and 1 patient was referred because of cervical esophageal disruption during laser division. Five of six postoperative fistulas after resection occurred in patients who did not have myotomy, and 4 patients were referred 12 to 49 years after resection without myotomy for true recurrence of the pouch. CONCLUSIONS: Open techniques afford better symptomatic relief than endoscopic techniques, especially in patients with small diverticula. Endoscopic stapling and division is safer than laser division. Although very effective at midterm, resection without myotomy predisposes to the development of postoperative fistula and to recurrence of the pouch after many years