Surgical Management of a Giant Zenker's Diverticulum with Intrathoracic Extension: A Case Report

Abstract

Introduction: Zenker's diverticulum (ZD) is an acquired outpouching of mucosa and submucosa through the Killian triangle whose management, particularly for giant cases, remains a subject of discussion. Classic clinical signs, such as Boyce's sign, are crucial for diagnosis but are not always present. Aim: To report the clinical features and surgical management of a giant Zenker’s diverticulum with intrathoracic extension and discuss its challenges and outcomes. Case Presentation: We present the case of a 62-year-old male with a long-standing history of progressive dysphagia, regurgitation, and a positive Boyce's sign on physical examination. A contrast-enhanced computed tomography scan and a barium swallow study revealed a giant ZD with a remarkable caudal extension down to the T2 vertebral level. The patient was successfully managed with an open transcervical diverticulectomy associated to a cricopharyngeal myotomy. His post-operative course was uneventful. At one-year follow-up, he reported complete and sustained resolution of all symptoms and had resumed a normal diet. Conclusion: This case highlights that for giant Zenker's diverticula, the traditional open surgical approach remains a safe and highly effective treatment option. It provides the distinct advantages of complete excision and a controlled myotomy, leading to excellent long-term functional outcomes. Furthermore, it underscores the diagnostic importance of classic physical findings in the clinical evaluation of this condition. While minimally invasive endoscopic therapies are rightly the first choice for most standard cases, the open surgical approach should be considered the standard of care for patients with exceptionally large or complex diverticula and must remain an essential skill for surgeons managing this pathology.