Mandovra P, Kalikar V, Patel A, Patankar R V
Zen Hospital , Mumbai , India.
Ann R Coll Surg Engl. 2019 Apr;101(4):256-260. doi: 10.1308/rcsann.2019.0007. Epub 2019 Feb 18.
Epiphrenic diverticulum (ED) is an uncommon disease that is invariably associated with an underlying oesophageal motility disorder such as achalasia. Management of ED should always be accompanied by treatment of the underlying motility disorder to prevent recurrence of symptoms. Traditionally, ED were approached via a left thoracotomy but as laparoscopy offers better access to the distal oesophagus, its use is becoming more widespread.
A total of 72 patients with oesophageal achalasia underwent laparoscopic surgery at our centre over a period of 7 years. Five (6.9%) of these had associated symptomatic ED. These patients were treated with a laparoscopic transhiatal epiphrenic diverticulectomy using intraoperative oesophagoscopy guidance, combined with a Heller myotomy and Dor fundoplication. Patients were followed up regularly and symptoms were assessed at 12 months.
The median age of the five patients with associated symptomatic ED was 56 years (range: 38-69 years). Three were male. The mean duration of surgery was 150 minutes (range: 120-180 minutes). One patient (20%) developed a postoperative oesophageal leak. The mean follow-up duration was 25 months (range: 12-36 months). At 12 months, the mean Eckardt score reduced from 6.8 to 1.6. Three patients (60%) reported an excellent outcome, one (20%) reported a good outcome and one (20%) reported a fair outcome.
Along with diverticulectomy, treating the underlying motility disorder with an adequate Heller myotomy and partial fundoplication is of prime importance for a good surgical outcome without symptom recurrence. Laparoscopy offers better access to the distal oesophagus than the conventional thoracic approach for ED.
膈上憩室（ED）是一种罕见疾病，总是与诸如贲门失弛缓症等潜在的食管动力障碍相关。ED的治疗始终应伴随对潜在动力障碍的治疗，以防止症状复发。传统上，ED通过左胸切开术进行处理，但由于腹腔镜检查能更好地进入食管远端，其应用越来越广泛。
在7年时间里，共有72例食管贲门失弛缓症患者在我们中心接受了腹腔镜手术。其中5例（6.9%）伴有有症状的ED。这些患者在术中食管镜引导下接受了腹腔镜经裂孔膈上憩室切除术，同时进行了Heller肌切开术和Dor胃底折叠术。对患者进行定期随访，并在12个月时评估症状。
5例伴有有症状ED的患者的中位年龄为56岁（范围：38 - 69岁）。3例为男性。平均手术时间为150分钟（范围：120 - 180分钟）。1例患者（20%）发生术后食管漏。平均随访时间为25个月（范围：12 - 36个月）。在第12个月时，平均埃卡德特评分从6.8降至1.6。3例患者（60%）报告结果极佳，1例（20%）报告结果良好，1例（20%）报告结果尚可。
除憩室切除外，通过充分的Heller肌切开术和部分胃底折叠术治疗潜在的动力障碍对于获得良好的手术效果且无症状复发至关重要。对于ED，腹腔镜检查比传统的开胸手术能更好地进入食管远端。
