Zenker's Diverticulum

Zenker's diverticulum is a pulsion (false) diverticulum that herniates through Killian's triangle, a posterior pharyngeal weak point above the cricopharyngeus muscle. The pathophysiology is reduced compliance of the cricopharyngeus, so swallowing-related pressure drives the mucosa and submucosa outward. Most patients are over 60, with a slight male predominance.

Symptoms develop gradually: dysphagia, regurgitation of undigested food, halitosis, recurrent aspiration pneumonia, and weight loss. Diagnosis is most reliably made by barium swallow with lateral views; upper endoscopy can confirm but may miss small diverticula. The cricopharyngeal bar separating the diverticulum from the esophagus is the operative target.

Treatment is divided by approach. Surgical options include open or transcervical stapler-assisted diverticulectomy and cricopharyngeal myotomy. Endoscopic options have grown rapidly: rigid endoscopic stapler diverticulotomy (Dohlman procedure) and flexible endoscopic septotomy (using needle-knife, hook-knife, or stapler) are increasingly preferred in appropriately selected patients given lower morbidity and shorter recovery. Per-oral endoscopic septotomy (Z-POEM) is the newest option, providing a fully endoscopic submucosal-tunnel approach.