Esophageal Diverticulum

An esophageal diverticulum is a pouch that bulges from the wall of the esophagus. The most common type, Zenker's diverticulum, forms at the top of the esophagus just above a tight cricopharyngeus muscle. Epiphrenic diverticula form just above the diaphragm, usually because of an underlying motility disorder such as achalasia, and mid-esophageal diverticula are less common. Symptoms include difficulty swallowing, regurgitation of undigested food, bad breath, cough and aspiration.

Surgery for an esophageal diverticulum treats both the pouch and its cause. Because most diverticula are pushed out by high pressure from a muscle that does not relax, dividing that muscle (a myotomy) is the key to lasting relief. See esophageal diverticulum for symptoms and diagnosis.

Types of Esophageal Diverticula

• Zenker's (pharyngoesophageal): the most common type, usually in people over 60. It forms just above the upper esophageal sphincter, where a stiff cricopharyngeus muscle fails to relax fully when swallowing.
• Mid-esophageal (traction): historically linked to inflamed lymph nodes in the chest pulling on the esophagus. These are often small and without symptoms.
• Epiphrenic: just above the diaphragm and almost always associated with a motility disorder, such as achalasia or spastic esophagus, that creates high pressure at the lower esophagus.

For Zenker's diverticulum, the wall between the pouch and the esophagus — which contains the tight cricopharyngeus muscle — is divided so the pouch and esophagus become one channel and the muscle no longer obstructs swallowing. For epiphrenic diverticula, the pouch is removed with a stapler, a long myotomy relieves the high-pressure segment below it, and a partial fundoplication (Dor or Toupet) prevents reflux.

Treating the Cause, Not Just the Pouch

Removing a diverticulum without dividing the tight muscle beneath it is the classic cause of recurrence and leaks, because the high pressure that created the pouch remains. For that reason, every repair includes a myotomy: of the cricopharyngeus for Zenker's diverticulum, or of the lower esophagus for epiphrenic diverticula, as in a Heller myotomy. A partial Dor or Toupet fundoplication is added after a lower esophageal myotomy to prevent reflux.

• Relief of swallowing difficulty and regurgitation
• Reduced risk of aspiration pneumonia
• Treatment of the underlying motility problem
• Minimally invasive options with short recovery

Choosing the Right Approach

For Zenker's diverticulum, the endoscopic approach (flexible septotomy or Z-POEM) avoids a neck incision and suits most medium-sized pouches, especially in older patients. Very small pouches, where there is little septum to divide, and very large or redundant pouches may do better with open cricopharyngeal myotomy and removal or suspension of the pouch. For epiphrenic diverticula, the laparoscopic approach through the abdomen reaches most pouches near the diaphragm and allows a long myotomy and fundoplication in the same operation. Higher pouches may require a thoracoscopic (chest) approach. The best option depends on the pouch's size and location, the motility findings and your overall health.

• Swallowing difficulty, regurgitation, cough or aspiration caused by a diverticulum
• Weight loss or recurrent pneumonia
• Large or enlarging diverticula
• Underlying motility disorder confirmed on manometry

Small diverticula without symptoms can usually be monitored.

How It Is Diagnosed

• Barium swallow (esophagram): shows the size and location of the pouch and how it empties
• Upper endoscopy: examines the lining and excludes other causes. It is performed carefully to avoid entering the pouch.
• High-resolution manometry: identifies the underlying motility disorder, especially for epiphrenic diverticula
• CT scan when anatomy is complex or aspiration is suspected

See dysphagia for other causes of swallowing difficulty.

Warning signs that make treatment more urgent include repeated pneumonia, choking at night, significant weight loss, or food that stays in the throat long after a meal. Patients with these symptoms should be evaluated promptly rather than monitored.

• Flexible endoscopic septotomy or Z-POEM for Zenker's: performed through the mouth under anesthesia, dividing the septum and cricopharyngeus with no incisions; symptom relief is reported in about nine in ten patients in pooled studies (Ishaq et al., Gastrointestinal Endoscopy, 2016).
• Open cricopharyngeal myotomy with diverticulectomy or diverticulopexy for very large Zenker's diverticula.
• Laparoscopic or thoracoscopic diverticulectomy with myotomy and partial fundoplication for epiphrenic diverticula (Zaninotto et al., World Journal of Surgery, 2011).

Evaluation before surgery includes a barium esophagram, upper endoscopy and high-resolution manometry, which guide the choice of approach.

• Leak from the staple line or myotomy site, the most important complication of diverticulectomy
• Bleeding, infection, and pneumonia from aspiration
• Injury to the recurrent laryngeal nerve, causing hoarseness, with open neck surgery for Zenker's
• Reflux after a lower esophageal myotomy, reduced by fundoplication
• Recurrence, more common after endoscopic treatment of very small or very large Zenker's diverticula

Careful technique, which includes always performing the myotomy and testing the repair before you eat, keeps these risks low. Most patients have an uneventful recovery.

• Endoscopic Zenker's treatment: often same-day or an overnight stay, with liquids the next day and soft foods for about a week
• Open neck surgery: one to two nights, with a short period of liquids
• Laparoscopic or thoracoscopic epiphrenic repair: one to three nights, often with a contrast study before eating, then a soft diet for about two weeks
• Most patients return to normal activity within one to three weeks

Most patients have lasting relief of swallowing symptoms. Recurrence is uncommon when the myotomy is complete. Patients with an underlying motility disorder may need ongoing follow-up.

Most patients swallow comfortably after repair and no longer regurgitate food or aspirate. Rarely, cancer arises in a long-standing diverticulum, which is one more reason symptomatic pouches are treated. Dr. de la Cruz-Muñoz treats diverticula as part of his foregut practice and sees patients from across the country. Call 305-692-0392.

What the Research Shows

• A meta-analysis of 20 studies and 813 patients found that flexible endoscopic treatment of Zenker's diverticulum relieved symptoms in 91% of patients. Adverse events occurred in about 11%, and recurrence in about 11% (Ishaq et al., Gastrointestinal Endoscopy, 2016).
• For epiphrenic diverticula, a series of 17 patients found an underlying motility disorder in 15. Staple-line leaks occurred when the myotomy was incomplete or abandoned, leading the authors to recommend a complete myotomy in every case (Achim et al., Surgical Endoscopy, 2017).

More in Esophageal Motility and Swallowing Procedures

Related procedures: Esophageal Dilation, Diagnostic Upper Endoscopy, Laparoscopic Heller Myotomy, POEM, Dor Fundoplication for Reflux and After Heller Myotomy. For an overview of all options, see Foregut Surgery.

Conditions treated: Achalasia, Dysphagia, Esophagogastric Junction Outflow Obstruction, Diffuse Esophageal Spasm, Jackhammer Esophagus, Esophageal Diverticulum.

Dr. de la Cruz-Muñoz is a nationally recognized bariatric, metabolic, and foregut surgeon with extensive experience in minimally invasive and endoscopic treatment of esophageal diverticula. He applies his expertise in esophageal motility and foregut anatomy with the goal of safe, effective, and durable outcomes. Our practice provides bilingual care for patients from Miami, Puerto Rico, the Dominican Republic, and Latin America.

Esophageal diverticulum surgery is delicate foregut work, and Dr. de la Cruz-Muñoz approaches it with over 25 years in practice and over 15,000 minimally invasive procedures behind him, spanning complex foregut, hernia, gallbladder, abdominal and bariatric operations.

International patients should plan their stay according to the approach: two to three days for endoscopic Zenker's treatment, and about one week for laparoscopic or thoracoscopic epiphrenic repair. Please send barium swallow images and manometry results ahead of time.