Alecu L, Bărbulescu M, Ursuţ B, Braga V, Slavu I
Chirurgia (Bucur). 2015 Jan-Feb;110(1):72-7.
Epiphrenic diverticula (ED) represent about 20% of oesophageal diverticula. They are considered to be pulsion diverticula, characterized by out pouchings of the oesophageal mucosa originating in the distal 10 cm of the oesophagus and are frequently associated with spastic oesophageal dysmotility. The most frequent clinical manifestations of ED are dysphagia, regurgitations and chest pain. Only symptomatic diverticula should be treated by surgery. The surgical procedure can be performed minimally invasively by robotic approach and consists of diverticulectomy,hiatus calibration and an antireflux procedure, usually adding an esophagomiotomy as well.
CASE-REPORT: We present the case of 43-year-old male patient who was admitted for a four-month history of epigastric pain, pyrosis and regurgitations. Preoperative investigation shave shown an epiphrenic diverticulum 6 cm large in diameter.A robotic-assisted transhiatal diverticulectomy with a linear endostapler, hiatal calibration and a Nissen-Rossetti fundoplication were performed using a three-arm da Vinci Robotic System. Operative time was 150 min. Postoperative course was uneventful and the patient was discharged on postoperative day 9, without complications. Ten days later,he came back and was readmitted under emergency status for right chest pain, dyspnoea and fetid breath, being diagnosed with a right empyema secondary to a delayed fistula of the oesophageal suture line. A right minimal pleurotomy and pleural drainage under local anaesthesia were performed and an intravenous antibiotherapy was started with complete remission of symptomatology, the patient remaining asymptomatic after 18 months of follow-up.
Robotic approach is a feasible and safe minimally invasive surgical option in the treatment of selected cases of ED. We consider transhiatal abdominal robotic approach possible in almost all cases of ED, regardless of size,thus avoiding thoracic approach and its possible major complications.The most common serious complication after surgery of ED is post diverticulectomy suture line fistula, but if properly and rapidly diagnosed it could be conservatively treated with very good results.
膈上憩室（ED）约占食管憩室的20%。它们被认为是膨出性憩室，其特征是食管黏膜在食管远端10厘米处向外膨出，且常与食管痉挛性运动障碍相关。ED最常见的临床表现是吞咽困难、反流和胸痛。只有有症状的憩室才应进行手术治疗。该手术可通过机器人手术微创进行，包括憩室切除术、裂孔校准和抗反流手术，通常还需加做食管肌切开术。
我们报告一例43岁男性患者，因上腹部疼痛、烧心和反流4个月入院。术前检查显示一个直径6厘米的膈上憩室。使用三臂达芬奇机器人系统进行了机器人辅助经裂孔憩室切除术，使用线性切割吻合器、裂孔校准和nissen-rossetti胃底折叠术。手术时间为150分钟。术后过程顺利，患者于术后第9天出院，无并发症。10天后，他因右胸痛、呼吸困难和口臭再次急诊入院，被诊断为食管缝合线延迟瘘继发右脓胸。在局部麻醉下进行了右胸小切口胸膜引流，并开始静脉抗生素治疗，症状完全缓解，患者在随访18个月后无症状。
机器人手术是治疗特定病例ED的一种可行且安全的微创手术选择。我们认为，几乎所有ED病例都可以采用经裂孔腹部机器人手术，无论其大小如何，从而避免开胸手术及其可能的主要并发症。ED手术后最常见的严重并发症是憩室切除术后缝合线瘘，但如果能正确、快速诊断，可采用保守治疗，效果良好。
