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1990:70109-11

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Anesthetic Implications of Zenker's Diverticulum

Somasundaram Thiagarajah,
MD, FFARCS,

Erwin Lear,

MD,

and Margaret Keh,

MD

Key Words: GASTROINTESTINAL TRACT, ESOPHAGUS-Zenker'S diverticulum.

Zenker's diverticulum, seen in 1of 800 upper gastroconsists of an outpouchintestinal barium studies (l), ing of the pharyngeal mucosa through the posterior wall of hypopharynx and was first described by Zenker and Von Ziemssen in 1874 (2). The diverticulum tends to occur in elderly patients, the age at which coronary artery disease is common (3), and may often be associated with recurrent aspiration pneumonitis and malnutrition (4). The implications for the anesthesiologist and the potential for perioperative complications in patients presenting for surgical resection of their Zenker's diverticulum have not been reported previously. We report a case to underscore possible complications and the salient features of the disease based upon a review of the literature and the experience gained in the anesthetic care of 33 patients with Zenker's diverticulum (Table 1).

Case Report
A 74-yr-old man was scheduled for resection of a large Zenker's diverticulum that extended into the upper mediastinum. His symptoms included dysphagia, regurgitation of food, gurgling noise in the throat, and bouts of coughing on lying down. On physical examination, he was 160 cm in height and weighed 47 kg. Blood pressure was 130/70 mm Hg with a heart rate of 78 beatdmin. He was breathing 20 times per minute and his temperature was 36.5"C. Preoperative laboratory data and the electrocardiogram were reported as normal. Chest x-ray revealed a sizable diverticulum in the upper mediastinum.
Received from the Department of Anesthesiology, Beth Israel Medical Center, New York, New York. Accepted for publication August 28, 1989. Address correspondence to Dr. Thiagarajah, Department of Anesthesiology, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003.
01990 by the International Anesthesia Research Society

The patient was premedicated with 25 mg IM hydroxazine 90 min before induction of anesthesia. On arrival in the operating room, the patient was encouraged to regurgitate the diverticular contents. On the operating table he was positioned with lo" head up and oxygen was administered via a face mask. Anesthesia was induced with I00 pg IV fentanyl, 75 mg lidocaine, and 200 mg thiopental. The trachea was intubated with a 7.5-cm (internal diameter) Portex endotracheal tube after achieving relaxation with 80 mg of succinylcholine. The tracheal cuff was inflated to achieve an airtight seal. Pressure was applied to the cricoid cartilage during induction of anesthesia until the cuff of the endotracheal tube was inflated. There were no food particles or fluid in the oropharynx during intubation. The lungs were clear to auscultation immediately after intubation and throughout the operative course. Anesthesia was maintained with 50% nitrous oxide in oxygen and isoflurane. Intraoperatively, at the request of the surgeon, a 38 F bougie was placed in the esophagus to help in identification of the diverticulum. The resection was carried out through an incision in the neck. After excising the diverticular sac, the suture lines on the pharyngeal wall were tested for air leaks. The operation lasted -70 min. At the end of surgery, with the patient awake and responsive, the trachea was extubated. On admission to recovery room, the patient was tachypneic (breathing 26 times per minute) and restless. A chest x-ray revealed a right mid- and upper zonal density (Figure 1) and an arterial blood sample obtained while breathing 40% oxygen via face mask had a pH of 7.38, Pao, of 67 torr, and Paco, of 42 torr. Blood pressure was 180/90 mm Hg and heart rate 72 beats/min. He was closely observed for signs of increasing respiratory distress and had frequent chest physiotherapy. The chest x-ray on the next day showed the density in the right upper and middle lobes to have decreased in size; arterial blood had a pH of 7.39, a Pao, of 100 torr, and a Paco, of 40 torr while breathing 40% oxygen by face mask. The sub-

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CLINICAL REPORTS

Table 1. Zenkers Diverticulum Resection (1981-1988)

Number of patients (n = 33) Age group: 62-80 yr (70*2) Sex Female 30% Male 70% Associated medical diseases Coronary heart disease Weight loss Recurrent aspiration pneumonitis Average size of diverticulum (cm) Length 2.8 0.75 Width 2.8 ? 0.5 Anesthetic technique for intubation Awake intubation General anesthesia With cricoid pressure Without cricoid pressure (not documented) Postoperative complication: respiratory distress due to spillage into lung lobes

3
3

6 6 21
1

Figure 1. Chest x-ray showing right upper and mid-zonal opacities immediately after surgery in the recovery room.

sequent hospital course was uneventful and the patient was discharged on the fifth postoperative day.

Discussion
The pharynx, extending 12-14 cm from the base of the skull to the lower border of the cricoid cartilage (C-6), is composed of skeletal muscle forming superior, middle, and inferior constrictors. The inferior constrictor has two components, the thyropharyngeus and cricopharyngeus muscles. The cricopharyngeus has an oblique and horizontal component with an area of muscle weakness between these two

groups of muscles (Killians dehiscence). The Zenkers diverticulum is an outpouching of the mucosa that develops in this weak area. Early symptoms may be nonspecific with complaints of food sticking in the throat and increased swaIlowing time. The sac frequently enlarges with time and may be associated with noisy swallowing, regurgitation, and bouts of coughing when lying down. Compressible swelling may develop as the sac enlarges. Recurrent pneumonia and lung abscess may develop in later stages. X-rays of the neck may disclose a collection of air anterior to the fifth and sixth cervical vertebrae. A barium swallow examination is usually diagnostic. Treatment is surgical. The sac is identified by a lower collar skin incision and after retracting the sternocleidal muscle and the carotid contents the sac is identified, dissected from the esophagus, and resected. Compromised cardiovascular, pulmonary, and nutritional states are problems often seen in patients with Zenkers diverticulum (4).Recurrent aspiration of food particles from this pouch into the pharynx may lead to pneumonitis or even lung abscess formation (4). Dysphagia frequently causes malnutrition with resultant hypoproteinemia and muscle wasting. In the preoperative preparation, nutritional and pulmonary status must be evaluated. The presence of a diverticular pouch in the pharynx poses a number of problems for the anesthesiologist. Oral premedications are not suitable as the tablets may get lodged in the pouch and either be ineffective or be aspirated into the lungs (5). Regurgitation of liquid or solid material from the pouch into the lungs during anesthetic induction is the major concern for the anesthesiologist. If the aspirate is solid, atelectasis with resultant hypoxemia and infection will ensue. If the aspirate is liquid, the infective material in aspirate may cause pneumonia. The secretions in the pouch tend to be alkaline, similar to saliva, and therefore chemical pneumonitis is unlikely to develop; antacids are of no value. Regurgitation may also occur during induction of anesthesia, during intubation, or even after successful intubation due to seepage of fluid around the cuff of the endotracheal tube during surgical manipulation. In the above case, aspiration did not occur during induction or intubation but most likely occurred during surgical manipulation. Therefore, fasting before surgery is extremely important. Voluntary, self-induced regurgitation of food by the patient before induction should be encouraged; this may empty the pouch. Awake intubation has been advised (4). Cricoid pressure may or may not be effective depending on whether the body of the sac is at the level of cricoid cartilage (Figure 2). If the sac is

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thyroid cartilage

g u s o p h a e -/\Zenkeis

Figure 2. The Zenkers pouch in the hypopharynx, with the opening at the level of cricoid cartilage.

small, the body of the pouch will be at the level of the cricoid cartilage in which case cricoid pressure will compress the body of the pouch, spilling the contents into the pharynx. If the sac is large, the neck of the pouch will be under the cricoid cartilage and cricoid pressure will not empty the pouch. Once the endotracheal tube is in place, a moist gauze pack placed to surround the tube will prevent regurgitation during surgery. Perforation of the diverticulum is another potential complication. If a nasogastric tube is inserted, caution and gentleness must be exercised; during a difficult intubation, blind attempts at intubation of the trachea may perforate the pouch resulting in mediastinitis. As in any surgery of the neck, blood loss and air embolism may occur if major vessels are inadvertently severed and with retraction of the carotid sheath the baroreceptors may initiate tachyrhythmia or bradyarrhythmias. During 1981-1988 in our institution 33 patients had surgical resection of Zeckers diverticulum under general anesthesia. Premedications were administered parenterally. Before induction of anesthesia,

voluntary emptying of the diverticula was encouraged. The significant associated medical disorders are summarized in Table 1. The anesthetic techniques for tracheal intubation varied depending on the size of the diverticulum. Patients with diverticula that extended into the mediastinum were either intubated awake or after intravenous induction with cricoid pressure. The patient presented in this case history had respiratory distress owing to the spilling of diverticular contents into the lungs most probably during surgical manipulation. In summary, patients with Zenkers diverticulum may have cardiac and pulmonary complications and suffer from malnutrition. Review of the patients barium swallow x-ray will indicate the size and the position of the pouch opening. Voluntary, selfinduced emptying of the pouch before induction, gentleness during intubation, and packing around the endotracheal tube will minimize spillage of pouch contents into the pharynx and decrease the risk of aspiration.

References
1. Dorsey JM, Randolph DA. Long-term evaluation of pharyngoesophageal diverticulectomy. Ann Surg 1971;173:680-5. 2. Zenker FA, Von Ziemssen H. Krankheiten des Oesophagus. In: Von Ziemssen H, ed. Handbuch der speciellen Pathologie und Therapie. Volume 7, Part I, Supplement. Leipzig: Vogel, 1874: 50-87. 3. White IL. Severe complications of a Zenkers diverticulum with endoscopic diverticulotomy rescue. Laryngoscope 1981;91:70& 19.

4. Payne WS, King RM. Pharyngoesophageal (Zenkers) diverticulum. Surg Clin North Am 1983;63:815-24. 5 . Baron SH. Zenkers diverticulum as a cause for loss of drug availability. A new complication. Am J Gastroenterol 1982;77: 1524.