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Websurg, e-Surgery 關於腹腔鏡手術
Clinical Case
EPIPHRENIC DIVERTICULUMM Vix, MD, M Henri, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France 1. Summary Epiphrenic diverticula are pulsion diverticula. They represent 20% of esophageal diverticula. They are symptomatic in 50% to 60% of cases, and should be treated by laparoscopy or thoracoscopy. Treatment most often associates resection of the diverticulum with myotomy and an antireflux procedure. 2. KeywordsEsophagus, diverticulum 3. Patient70-year-old male 4. History of present illnessThe patient has gone through several bouts of dysphagia for 5 years. For a few months, he has complained of painful episodes of food blockage and nocturnal regurgitation. Investigation indicated the presence of a diverticulum, a mega-esophagus and a hiatal hernia. Achalasia was diagnosed which lead to multiple endoscopic dilatations in an attempt to treat achalasia and reduce the diverticulum. 5. Past medical history- cutaneous T-cell lymphoma; combined radiation therapy and chemotherapy (Endoxan); - c urrently i n remission, receiving treatment of cyclophosphamide with corticosteroids. 6. Examinations6.1. Barium swallow and gastroduodenal follow-throughBarium swallow and gastroduodenal follow-through shows the presence of an epiphrenic diverticulum and a large hiatal hernia with reflux.6.2. GastroscopyUpper GI endoscopy shows grade II esophagitis.6.3. CT scanCT scan confirms the existence of the intrathoracic diverticulum.
7. Treatment: explorationThe procedure is performed by laparoscopy. Exploration shows the presence of a large hiatal hernia. (37 seconds)
8. Resection of the diverticulumThe first step of the procedure allows for dissection and reduction of the hiatal hernia, and dissection and resection of the diverticulum with the endo-GIA stapler under endoscopic control. (45 seconds)
9. Heller myotomyTreatment of achalasia responsible for the lower esophagus stenosis and pulsion diverticulum is performed by Heller myotomy. (30 seconds)
10. Closure of cruraThe first step of cardia repair is performed by closure of the crura. Some stitches are mounted on patches to make sure they are anchored without division of the crura. (46 seconds) 11. Toupet fundoplicationTreatment is completed with a posterior partial fundoplication (Toupet) as the cut margins of the myotomy are grasped to hold it open. (40 seconds) 12. PathophysiologyEpiphrenic diverticula are usually pulsion diverticula. They are commonly associated with other anomalies:
13. DiscussionEpiphrenic diverticula represent 20% of all esophageal diverticula. They affect twice as many men as women (sex ratio 2/1), usually between the ages of 25 to 80. The patient is symptom-free in 45% of cases. In 35% of cases, clinical signs are severe (dysphagia, regurgitation, respiratory disorders, thoracic pain, pyrosis), and in 20% of cases, clinical signs are mild. Multiple therapeutic modalities are employed depending on clinical repercussions and associated pathologies. Conservative treatment is proposed in the absence of functional disorders. Simple diverticulectomy is not indicated as the procedure has a 20% major complication rate and a 16% recurrence rate. The most common options associate diverticulectomy and myotomy, myotomy and diverticulopexy or even (as in our case) diverticulectomy, myotomy and fundoplication. This can be performed by laparoscopic or thoracoscopic approach. The most common complications of surgery (Benacci et al. , 1993) are esophageal fistulas and peri-operative deaths (9%). Long-term follow-up (7 years) of patients shows excellent results in 48% of cases, good results for 28%, satisfactory results for 17% and poor results for 7% of cases. 14. References
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