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Decisions Regarding Choice of Open Surgical or Rigid Transoral Approach
The most important decision in the management of ZD is whether to use an open or transoral approach. Several factors need to be considered. The first is whether clear visualization of the diverticulum can be achieved endoscopically. Although this may not be clear until transoral visualization is attempted, preoperative patient characteristics are predictive of a lack of success. For example, in one study, rigid endoscopy was significantly less successful in patients with short necks, decreased hyomental distance, and/or a high body mass index. A second key factor favoring an open approach is insufficient protection of the diverticulum sac by the dorsal esophageal wall (in patients with small diverticula without a clearly defined shelf). In other words, unless the medial wall of the diverticular sac is adhesed and fibrosed against the esophageal wall, cutting through this wall to create a common channel results in frank perforation. Similarly in patients with a small diverticulum where cricopharyngeal myotomy is performed solely, an open approach is often necessary. Finally, in patients who require additional surgery, such as diverticulectomy, diverticulopexy, or inversion of the diverticulum, an open operation is needed. Indications for an open approach include primary therapy or secondary therapy in the event of a failed endoscopic approach, which occurs in 16% to 68% of patients. Clearly, physician expertise in the transoral approach influences this variability to a large degree.
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