Unfortunately, with any Zenker's treatment including ESD, there is a small percentage (~10%) that the Zenker's diverticulum recurs typically within one year of treatment (average 8.5 months).
Why might that be?
There are some known (and unknown) issues that may lead to recurrence including:
• Incomplete division of the cricopharyngeus muscle: If the pouch is small, the cricopharyngeus muscle may not be completely divided using the ESD method. It is a shortcoming inherent to the method itself and not a lapse on the surgeon's part. The only way to completely address the muscle when the pouch is small (less than 1 .5cm) is via external approach or use of a laser with its associated increased risk of complications.
• Unaddressed or persistent laryngopharyngeal reflux: Proton pump inhibitor medications are ALWAYS prescribed before and after surgery... even if heartburn symptoms are absent. However, even with such medications, there may be a certain sub-population that suffer from persistent throat-level reflux that may trigger the Zenker's diverticulum to reform. This factor is probably the single most important reason why recurrence may occur within months.
• Loose staples: After surgery is performed, all loose staples are removed to minimize recurrence from this factor.
• Idiopathic scarring of the common wall: Some unindentified inflammatory process leads to restenosis of the common wall.
• Unknown: Whatever factor lead to the Zenker's formation in the first place may cause it to happen again. Indeed, we actually don't precisely know what causes the Zenker's pouch to occur in the first place.
As such, if recurrence occurs years after treatment, it usually will suggest an incomplete cricopharyngeus muscle division. Repeat ESD can be performed with good results.
If recurrence occurs within one year of treatment, I typically will consider the possibility of persistent throat-level reflux (laryngopharyngeal reflux) that was not or incompletely addressed with reflux medications. Before performing ESD again after a recurrence, I will obtain a few studies to determine how significant throat-level reflux may be present.
That typically entails getting a 24 hour multi-channel pH and impedance testing with manometry. The most important result from this study is the frequency of proximal esophageal reflux events and as such, any other type of reflux study that does not include proximal esophageal or hypopharyngeal sensors would be considered inadequate. Ideally, it should be as close to zero as possible. If proximal esophageal reflux events are present, this needs to be thoroughly eliminated prior to revision Zenker's surgery... otherwise, the Zenker's pouch may yet again recur.
Manometry is performed to ensure the cricopharyngeus muscle (if present) is adequately "loose".
Of course, the barium swallow needs to be repeated as well.
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