Minimally invasive surgery
Long-term results of minimally invasive surgery for symptomatic epiphrenic diverticulum

https://doi.org/10.1016/j.amjsurg.2010.03.016Get rights and content

Abstract

Background

The real incidence of epiphrenic diverticulum is unknown, and only 15% to 20% of cases are symptomatic.

Methods

From January 1994 to May 2009, 20 patients were treated laparoscopically for this condition.

Results

The most common operation performed was transhiatal diverticulectomy with myotomy and partial fundoplication. No case was converted to open surgery. Esophageal leak occurred in 1 patient (5%). The postoperative courses were uneventful in the remaining 19 patients. After a median follow-up period of 52 months (range, 1–141 months), 1 patient had died of squamous cell carcinoma, 1 had mild solid-food dysphagia, 1 had chest pain, and 1 had heartburn. Manometry was performed postoperatively in 7 patients; all had normal lower esophageal sphincter pressure. In 5 patients who underwent 24-hour postoperative pH monitoring, pathologic reflux was absent.

Conclusions

In patients with symptomatic epiphrenic diverticulum, laparoscopic surgery is feasible, providing good access to the distal esophagus and inferior mediastinum. Long-term outcomes are satisfactory.

Section snippets

Methods

From January 1994 to May 2009, 20 patients (13 men, 7 women; median age, 62 years; range, 43–82 years) with symptomatic epiphrenic diverticulum underwent laparoscopic surgery in our department. Diverticulectomy, myotomy, and partial fundoplication were performed in 18 patients (90%). Two patients (10%) received laparoscopic myotomy and partial fundoplication only. Preoperative workup included symptom recording, radiographic and endoscopic examinations, and manometry. Symptoms at the time of

Results

Associated procedures were performed in 3 patients (15%): simultaneous cholecystectomy was performed in 2 patients with symptomatic gallstones, and adhesiolysis to clear the abdominal cavity after a previous open cholecystectomy was performed in another patient. The median length of myotomy was 9 cm (range, 5–13 cm). Partial fundoplication consisted of 90° anterior procedures (Dor) in 14 patients (70%) and 270° posterior procedures (Toupet) in 6 patients (30%). There was no conversion to open

Comments

Our experience is that resection of diverticula up to 12 cm above the LES, with myotomy (the longest myotomy was 13 cm in length in the highest diverticulum of the series) and antireflux wrap, can be performed laparoscopically by the transhiatal approach, safely and without undue difficulty, provided that the entire diverticulum can be dissected free of surrounding structures. An angled scope is needed to afford adequate exposure of the proximal margin of the diverticular neck. Even so, it may

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