This procedure does not get the respect it deserves, probably because on some days the operation can be remarkably easy. At other times, however, it can be distressingly difficult, and many a surgeon has been humbled by it. Several issues raised by the authors deserve comment. Whoever is performing the preoperative endoscopy should be advised of the diagnosis, as perforation can result from forceful entry into the diverticulum while mistaking it for the esophageal lumen. Except in unique circumstances, general anesthesia should be employed. The authors' recommendation for laryngoscopy at this point with suctioning and packing of the diverticulum seems to be an excellent one, as initial identification of the sac can occasionally be difficult. Although the authors hedge a bit regarding transection of the strap muscles, this step plus ligation of the middle and inferior thyroid vessels enhances exposure significantly. I must admit that I have never identified a recurrent laryngeal nerve solely by palpation—but whatever means are used, this is a critical step, as injury to this structure represents the most serious complication of the procedure. Another important step emphasized by the authors is the posterior placement and length of the myotomy. I am a bit puzzled by their insistence on a proximal myotomy, if indeed a "Zenker diverticulum is a pulsion diverticulum due to an outflow obstruction caused by a noncompliant fibrotic cricopharyngeal sphincter." I have never performed this step and, to my knowledge, none of my patients has suffered a recurrence. I agree with the authors that most diverticula should be treated by suspension to the prevertebral fascia rather than excision. Not only does this simplify the procedure, but also it eliminates the possibility of leakage from the esophageal suture line. In my opinion, drainage should only be employed if an excision has been carried out or if the mucosa has been entered and repaired during performance of the myotomy. Last, the authors' recommendations regarding postoperative care seem quite conservative. Not allowing a patient with a diverticulopexy liquids until postoperative day 2 and then insisting on the presence of a physician implies at least a 2-day hospitalization for these patients, many of whom could be safely discharged on the first postoperative day. This article represents an excellent description of the operative treatment of patients with a Zenker diverticulum from one of our country's premier esophageal groups, and it should be closely studied by every surgeon attempting this procedure.
Pickleman J. Zenker Diverticulum—Invited Critique. Arch Surg. 1998;133(10):1133. doi:10.1001/archsurg.133.10.1133