Staged Zenker's diverticulectomy with cervical esophagostomy and secondary esophagostomy closure for treatment of massive diverticulum in severely debilitated patients.

Cricopharyngeal myotomy and diverticulectomy have become the standard therapy for the vast majority of patients with pharyngoesophageal diverticula. Potential complications from this approach, however, may be devastating in debilitated, elderly patients with massive Zenker's diverticula. Because of potentially fatal complications, we advocate a staged approach to treat debilitated patients with massive Zenker's diverticula. In the first stage, myotomy, diverticulectomy, and cervical esophagostomy are performed, and a gastric feeding tube is positioned through the esophagostomy. After recovery from pulmonary complications and nutritional improvement, the feeding tube is removed and the esophagostomy is closed. From 1987 to 1992, we treated five severely debilitated patients, four men and one woman with massive Zenker's diverticula, with this novel approach. Age of the patients averaged 80 years, range 58 to 93. All patients had symptoms of pulmonary aspiration requiring multiple hospitalizations for life-threatening pneumonia. Three patients had severe malnutrition associated with major weight loss and cachexia. All patients underwent first stage repair without morbidity or mortality. After an average of 7 weeks, patients had significant nutritional improvement and the esophagostomy was closed. Local wound care adequately treated one wound infection after esophagostomy closure. Although myotomy and diverticulectomy are safe procedures, a staged approach, diverticulectomy and cervical esophagostomy, followed by esophagostomy closure, is advocated for the elderly, severely debilitated patient with massive Zenker's diverticulum.