Subscribe to RSS
DOI: 10.1055/s-2005-872518
© Georg Thieme Verlag Stuttgart · New York
Therapie des Zenker-Divertikels
Therapy of Zenker's DiverticulumPublication History
Publication Date:
28 October 2005 (online)
![](https://www.thieme-connect.de/media/endoheute/200503/lookinside/thumbnails/10.1055-s-2005-872518-1.jpg)
Zusammenfassung
Das Zenker-Divertikel ist ein Pseudodivertikel mit Aussackung der Mukosa oberhalb des oberen Ösophagussphinkters. Die Symptomatik besteht in einer Dysphagie mit Regurgitieren von Speisen. Eine generelle Richtlinie zur Behandlung des Zenker-Divertikels existiert nicht. Für die Behandlung stehen momentan drei verschiedene Verfahren zur Verfügung. Das wahrscheinlich am häufigsten durchgeführte Therapieverfahren ist die transzervikale Resektion des Divertikelsackes. Ein weiteres Verfahren besteht in der endoskopischen Behandlung. Hierbei werden die flexibel-endoskopischen von den starr-endoskopischen Verfahren unterschieden. In dieser Arbeit werden die verschiedenen Verfahren dargestellt und die Ergebnisse aus der bislang veröffentlichten Literatur sowie eigene Daten miteinander verglichen. Unter Einschränkungen können folgende Schlussfolgerungen gezogen werden: Die endoskopischen Verfahren weisen ein kleineres Komplikationsspektrum auf als die klassische Operation. Flexibel endoskopische Methoden sind besser geeignet für risikoreiche Patienten und sie haben keine Einschränkung bei Patienten mit schweren degenerativen HWS-Veränderungen oder Divertikeln < 2 cm. Operative und starr-endoskopische Verfahren erzielen in der Regel bereits nach einer Behandlung gute Ergebnisse. Die flexibel-endoskopische Koagulation mit APC scheint mehr Behandlungssitzungen zu benötigen als die Inzision mit einem Nadelmesser.
Abstract
Zenker's Diverticulum is a pseudodiverticulum with herniation of the mucosa above the upper oesophageal sphincter. Dysphagia with regurgitation of swallowed food is the most common symptom. Three different treatment modalities are available. The most common treatment option is surgical resection of the diverticulum. Other treatment modalities are endoscopic therapy, using flexible or rigid endoscopes. So far, there are no guidelines with regards to the treatment of Zenker's diverticulum. We describe the different management strategies of Zenker's diverticulum and compare the results available from the literature with our own data. With exceptions, the following conclusions are made: Endoscopic procedures have a lower complication rate as compared to surgery. Treatment of Zenker's diverticulum with flexible endoscopy is recommended for patients with high operative risk and severe degenerative cervical spondylosis as well as for patients with a diverticulum smaller than 2 cm. Surgery and treatment with rigid endoscopes needed only single treatment session to yield good results. More treatment sessions are necessary using argon plasma coagulation (APC) as compared to myotomy performed with a needle knife.
Schlüsselwörter
Zenker-Divertikel - Ösophagus-Divertikel - Dysphagie
Key words
Zenker's diverticulum - hypopharyngeal diverticulum - dysphagia
Literatur
- 1 Zenker F, Ziemssen von H. Dilatations of the esophageus. Cyclopaedia of the Practice of Medicine. Low, Marston, Searle & Rivington, London 1878 ; 3: 46-68
- 2 Häring R, Baer U. Chirurgie. 4. Aufl. de Gruyter, Berlin 1997
- 3 Ellis F H, Crozier R E. Cervical esophageal dysphagia: indications for and results of cricopharyngeal myotomy. Ann Surg. 1981; 194 279-289
- 4 Kilman W J, Goyal R K. Disorders of pharyngeal and upper esophageal sphincter motor function. Arch Intern Med. 1976; 136 592-601
- 5 Lichter I. Motor disorder in pharyngoesophageal pouch. J Thorac Cardiovasc Surg. 1978; 76 272-275
- 6 Asoh R, Goyal R K. Manometry and electromyography of the upper esophageal sphincter in the opossum. Gastroenterology. 1978; 74 514-520
- 7 Frieling T, Berges W, Lubke H J, Enck P, Wienbeck M. Upper esophageal sphincter function in patients with Zenker's diverticulum. Dysphagia. 1988; 3 90-92
- 8 Overbeek J J van. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol. 1994; 103 178-185
- 9 Cook I J, Blumbergs P, Cash K, Jamieson G G, Shearman D J. Structural abnormalities of the cricopharyngeus muscle in patients with pharyngeal (Zenker's) diverticulum. J Gastroenterol Hepatol. 1992; 7 556-562
- 10 Cook I J, Gabb M, Panagopoulos V, Jamieson G G, Dodds W J, Dent J, Shearman D J. Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology. 1992; 103 1229-1235
- 11 Clagett O T, Payne W S. Surgical treatment of pulsion diverticula of the hypopharynx: one-stage resection in 478 cases. Dis Chest. 1960; 37 257
- 12 Orringer M B. Extended cervical esophagomyotomy for cricopharyngeal dysfunction. J Thorac Cardiovasc Surg. 1980; 80 669-678
- 13 Aggerholm K, Illum P. Surgical treatment of Zenker's diverticulum. J Laryngol Otol. 1990; 104 312-314
- 14 Belsey R. Functional disease of the esophageus. Cardiovasc Surg. 1966; 52 164-188
- 15 Bowdler D A, Stell P M. Surgical management of posterior pharyngeal pulsion diverticula: inversion versus one-stage excision. Br J Surg. 1987; 74 988-990
- 16 Mosher H. Webs and pouches of esophageus, their diagnosis and treatment. Surg Gynecol Obstet. 1917; 25 175-187
- 17 Dohlman G, Mattson O. The endoscopic operation for hypopharyngeal diverticula. A roentgencinematographic study. Arch Otolaryngol. 1960; 71 744-752
- 18 Weerda H, Schlenter W. Neues Divertikuloskop zur Schwellendurchtrennung des Zenkerschen Divertikels mit dem CO2-Laser. Arch Otorhinolaryngol. 1988; 2 269-271
- 19 Overbeek J J van, Hoeksema P E. Endoscopic treatment of the hypopharyngeal diverticulum: 211 cases. Laryngoscope. 1982; 92 88-91
- 20 Lippert B M, Folz B J, Gottschlich S, Werner J A. Microendoscopic treatment of the hypopharyngeal diverticulum with the CO2 laser. Lasers Surg Med. 1997; 20 394-401
- 21 Nyrop M, Svendstrup F, Jorgensen K E. Endoscopic CO2 laser therapy of Zenker's diverticulum - experience from 61 patients. Acta Otolaryngol Suppl. 2000; 543 232-234
- 22 Overbeek J J van. Microendoscopic CO2 laser surgery of the hypopharyngeal (Zenker's) diverticulum. Adv Otorhinolaryngol. 1995; 49 140-143
- 23 Krespi Y, Kacker A, Remacle M. Endoscopic treatment of Zenker's diverticulum using CO2 laser. Otolaryngol Head Neck Surg. 2002; 127 309-314
- 24 Collard J M, Otte J B, Kestens P J. Endoscopic stapling technique of esophagodiverticulostomy for Zenker's diverticulum. Ann Thorac Surg. 1993; 56 573-576
- 25 Dorion D, Brown D H, Gullane P J. How I do it: Zenker's stapler diverticulectomy. J Otolaryngol. 1994; 23 145-147
- 26 Luscher M S, Johansen L V. Zenker's diverticulum treated by the endoscopic stapling technique. Acta Otolaryngol Suppl. 2000; 543 235-238
- 27 Evrard S, Le Moine O, Hassid S, Deviere J. Zenker's diverticulum: a new endoscopic treatment with a soft diverticuloscope. Gastrointest Endosc. 2003; 58 116-120
- 28 Sakai P, Ishioka S, Maluf-Filho F, Chaves D, Moura E G. Endoscopic treatment of Zenker's diverticulum with an oblique-end hood attached to the endoscope. Gastrointest Endosc. 2001; 54 760-763
- 29 Peracchia A, Bonavina L, Narne S, Segalin A, Antoniazzi L, Marotta G. Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients. Arch Surg. 1998; 133 695-700
- 30 Baldwin D L, Toma A G. Endoscopic stapled diverticulotomy: a real advance in the treatment of hypopharyngeal diverticulum. Clin Otolaryngol Allied Sci. 1998; 23 244-247
- 31 Narne S, Cutrone C, Bonavina L, Chella B, Peracchia A. Endoscopic diverticulotomy for the treatment of Zenker's diverticulum: results in 102 patients with staple-assisted endoscopy. Ann Otol Rhinol Laryngol. 1999; 108 810-815
- 32 Cook R D, Huang P C, Richstmeier W J, Scher R L. Endoscopic staple-assisted esophagodiverticulostomy: an excellent treatment of choice for Zenker's diverticulum. Laryngoscope. 2000; 110 2020-2025
- 33 Chang C Y, Payyapilli R J, Scher R L. Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases. Laryngoscope. 2003; 113 957-965
- 34 Gross N D, Cohen J I, Andersen P E. Outpatient endoscopic Zenker diverticulotomy. Laryngoscope. 2004; 114 208-211
- 35 Ishioka S, Sakai P, Maluf Filho F, Melo J M. Endoscopic incision of Zenker's diverticula. Endoscopy. 1995; 27 433-437
- 36 Mulder C J, den Hartog G, Robijn R J, Thies J E. Flexible endoscopic treatment of Zenker's diverticulum: a new approach. Endoscopy. 1995; 27 438-442
- 37 Hashiba K, de Paula A L, da Silva J G, Cappellanes C A, Moribe D, Castillo C F, Brasil H A. Endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc. 1999; 49 93-97
- 38 Lerut T, Van Raemdonck D, Guelinckx P, Clooster P Van, Gruwez J A, Dom R, Geboes K, Mebis J, Janssens J, Vantrappen G. Pharyngo-oesophageal diverticulum (Zenker's). Clinical, therapeutic and morphological aspects. Acta Gastroenterol Belg. 1990; 53 30-337
- 39 Payne W S. The treatment of pharyngoesophageal diverticulum: the simple and complex. Hepatogastroenterology. 1992; 39 109-114
- 40 Laing M R, Murthy P, Ah-See K W, Cockburn J S. Surgery for pharyngeal pouch: audit of management with short- and long-term follow-up. J R Coll Surg Edinb. 1995; 40 315-318
- 41 Ellis F H, Gibb S P, Williamson W A. Current status of cricopharyngeal myotomy for cervical esophageal dysphagia. Eur J Cardiothorac Surg. 1996; 10 1033-1038
- 42 Bonafede J P, Lavertu P, Wood B G, Eliachar I. Surgical outcome in 87 patients with Zenker's diverticulum. Laryngoscope. 1997; 107 720-725
- 43 Crescenzo D G, Trastek V F, Allen M S, Deschamps C, Pairolero P C. Zenker's diverticulum in the elderly: is operation justified?. Ann Thorac Surg. 1998; 66 347-350
- 44 Zbaren P, Schar P, Tschopp L, Becker M, Hausler R. Surgical treatment of Zenker's diverticulum: transcutaneous diverticulectomy versus microendoscopic myotomy of the cricopharyngeal muscle with CO2 laser. Otolaryngol Head Neck Surg. 1999; 121 482-487
- 45 Gutschow C A, Hamoir M, Rombaux P, Otte J B, Goncette L, Collard J M. Management of pharyngoesophageal (Zenker's) diverticulum: which technique?. Ann Thorac Surg. 2002; 74 1677-1682
- 46 Bertelsen S, Aasted A. Results of operative treatment of hypopharyngeal diverticulum. Thorax. 1976; 31 544-547
- 47 Gullane P J, Willett J M, Heeneman H, Greenway R E, Ruby R R. Zenker's diverticulum. J Otolaryngol. 1983; 12 53-57
- 48 Feussner H, Siewert J R. [Traditional extraluminal operation for Zenker's diverticulum]. Chirurg. 1999; 70 753-756
- 49 McConnel F M, Hood D, Jackson K, O'Connor A. Analysis of intrabolus forces in patients with Zenker's diverticulum. Laryngoscope. 1994; 104 571-581
- 50 Payne W S, King R M. Pharyngoesophageal (Zenker's) diverticulum. Surg Clin North Am. 1983; 63 815-824
- 51 Huang B, Payne W S, Cameron A J. Surgical management for recurrent pharyngoesophageal (Zenker's) diverticulum. Ann Thorac Surg. 1984; 37 189-191
- 52 Payne W S, Reynolds R R. Surgical treatment of pharyngoesophageal diverticulum (Zenker's diverticulum). Surg Rounds. 1982; 5 18-24
- 53 Peracchia A, Bonavina L, Narne S, Segalin A, Antoniazzi L, Marotta G. Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients. Arch Surg. 1998; 133 695-700
- 54 Ishioka S, Sakai P, Maluf Filho F, Melo J M. Endoscopic incision of Zenker's diverticula. Endoscopy. 1995; 27 433-437
- 55 Wahab P J, Mulder C J, den Hartog G, Thies J E. Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences. Endoscopy. 1997; 29 176-181
- 56 Mulder C J. Zapping Zenker's diverticulum: gastroscopic treatment. Can J Gastroenterol. 1999; 13 405-407
Dr. S. Groth
Prof. Dr. N. Soehendra
Klinik und Poliklinik für Interdisziplinäre Endoskopie · Universitätsklinikum Hamburg-Eppendorf
Martinistraße 52
20246 Hamburg
Phone: 0 40/4 28 03/48 28
Fax: 0 40/4 28 03/44 20
Email: soehendr@uke.uni-hamburg.de
Email: groth@uke.uni-hamburg.de