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      Giant epiphrenic diverticulum: a challenging case Translated title: Divertículo epifrénico gigante: un caso desafiante

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          Abstract

          Abstract A diverticulum is a limited saccular protrusion of the esophageal wall, communicating with its lumen. Anatomically, esophageal diverticula are classified into pharyngoesophageal, median, and epiphrenic. Treatment of esophageal diverticula is based on several basic pathophysiological principles. Small and asymptomatic diverticula do not require specific treatment. Large and symptomatic diverticula require surgical intervention, consisting of diverticulectomy combined with myotomy. Operations for symptomatic epiphrenic diverticula make up no more than 2% of all operations on the esophagus. We describe a case of an epiphrenic diverticulum with the dimensions 88x60x90 mm in a 54-year-old patient. Surgical treatment of this disease was performed according to the Lewis method. The article also describes methods of dealing with concomitant postoperative complications and a brief review of the literature on epiphrenic diverticula.

          Translated abstract

          Resumen Un divertículo es una protuberancia sacular limitada de la pared esofágica, que se comunica con su luz. Anatómicamente, los divertículos esofágicos se clasifican en faringoesofágicos, medianos y epifrénicos. El tratamiento de los divertículos esofágicos se basa en varios principios fisiopatológicos básicos. Los divertículos pequeños y asintomáticos no requieren tratamiento específico. Los divertículos grandes y sintomáticos requieren intervención quirúrgica, que consiste en diverticulectomía combinada con miotomía. Las operaciones por divertículos epifrénicos sintomáticos representan no más del 2% de todas las operaciones en el esófago. Describimos un caso de divertículo epifrénico de dimensiones 88x60x90 mm en un paciente de 54 años. El tratamiento quirúrgico de esta enfermedad se realizó según el método de Lewis. El artículo también describe métodos para tratar las complicaciones posoperatorias concomitantes y una breve revisión de la literatura sobre divertículos epifrénicos.

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          Epiphrenic diverticulum: results of surgical treatment.

          From 1975 to 1991, 112 patients (64 men and 48 women) were found to have an epiphrenic diverticulum. Symptoms were absent or minimal in 71 patients and incapacitating in 41. All patients with minimal symptoms were managed conservatively; 35 were available for follow-up, which ranged from 1 to 25 years (median, 9 years). None of these 35 patients had clinically significant progression of symptoms. Surgical repair was done in 33 patients with incapacitating symptoms. Achalasia was present in 8 of the surgical patients (24.2%), diffuse esophageal spasm in 3 (9.1%), hypertensive lower esophageal sphincter alone in 1 (3.0%), and nonspecific motor abnormalities of the esophageal body in 7 (21.2%). Diverticulectomy and esophagomyotomy were performed in 22 patients, diverticulectomy alone in 7, esophageal resection in 3, and esophagomyotomy alone in 1. Concomitant hiatal hernia repair was done in 6 patients. Complications occurred in 11 patients; 6 had esophageal leaks. There were three operative deaths (9.1%), all occurring in patients with abnormal manometry. Follow-up was complete in 29 patients and ranged from 4 months to 15 years (median, 6.9 years). Long-term results were excellent in 14 patients (48.2%), good in 8 (27.6%), fair in 5 (17.2%), and poor in 2 (6.9%). We conclude that operation has significant risks and is not warranted in patients with minimal symptoms because progression is unlikely. Surgical treatment, however, is advisable in patients with incapacitating symptoms because most operative survivors will have long-term symptomatic palliation.
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            Oesophageal diverticula.

            Oesophageal pulsion diverticula, excluding pharyngeal types, are uncommon sequelae of oesophageal dysmotility. Current opinion favours myotomy as effective therapy, but the role of diverticulectomy, myotomy selection and placement, and the need for fundoplication remain unresolved. A Medline search and review of references identified relevant English language articles. Data on epidemiology, aetiology, oesophageal motility, pathology, symptomatology, investigations, surgical management and outcome were examined. Data were largely retrospective. Significant morbidity and mortality were associated with pulmonary aspiration and diverticulectomy site leaks. Surgical outcome was similar whether or not a diverticulectomy was added to a myotomy, but a myotomy clearly reduced the risk of leaks. Fundoplication reduced the incidence of postcardiomyotomy reflux symptoms. Results from minimally invasive techniques were similar to those of open surgery. Surgery should be reserved for symptomatic patients; asymptomatic patients may benefit from surveillance. Pulmonary aspiration mandates surgical intervention. Myotomy remains the mainstay of treatment and an adequate subdiverticular extension is crucial in relieving obstruction. A partial fundoplication is preferred in selected patients. Minimally invasive techniques should become the routine approach for oesophageal pulsion diverticula.
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              Surgical treatment of epiphrenic diverticula: a 30-year experience.

              Epiphrenic diverticula are rare and associated with esophageal motility abnormalities. Their optimal surgical treatment is debated, mortality being 9% in the largest reported surgical series of 33 patients. Our experience with a traditional thoracic approach was reviewed to provide benchmark data against which newer surgical techniques can be measured. A retrospective review of 35 patients operated on for epiphrenic diverticula from 1976 to 2005 was conducted. All underwent open transthoracic operations: resection of the diverticulum, long esophagomyotomy, and antireflux operations (modified Belsey, 29 patients; Nissen, 4 patients) in 33 patients; resection and long myotomy alone in 1 patient; and plication, long myotomy, and Collis-Nissen in 1 patient. Preoperative assessment included barium esophagogram, flexible esophagoscopy, manometry, and standard acid reflux test. Operative complications and functional results were assessed. Median age was 71 years (range, 36 to 87 years). Diverticulum size averaged 6.4 cm (range, 3 to 14 cm). Sixty-eight percent presented to the right of the esophagus. The median duration of symptoms was 3 years. Presenting complaints included dysphagia (83%), regurgitation (69%), and chest pain (26%). Eighteen had a mean weight loss of 19 pounds. There was 1 perioperative death (2.8%) from a plicated diverticulum leak and one nonfatal suture line leak. Median hospital stay was 7 days. Mean follow-up was 45.3 months. Twenty-six patients (74%) had an excellent result (no residual symptoms). Seven required a periodic esophageal dilatation for intermittent mild dysphagia. Traditional transthoracic resection, long esophagomyotomy, and an antireflux procedure provide excellent long-term functional results with relatively low postoperative morbidity in patients with epiphrenic diverticula.
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                Author and article information

                Journal
                ijm
                Iberoamerican Journal of Medicine
                Iberoam J Med
                Hospital San Pedro (Logroño, La Rioja, Spain )
                2695-5075
                2695-5075
                2022
                : 4
                : 2
                : 118-122
                Affiliations
                [2] Moscow orgnameBotkin Clinical Hospital orgdiv1Department of Emergency Surgery №75 Federación de Rusia
                [1] orgnameNorth Caucasian State Academy orgdiv1Department of Hospital Surgery with the Course of Anesthesiology and Intensive Care Federación de Rusia
                [3] Domodedovo orgnameState Central Hospital of Domodedovo orgdiv1Department of General Surgery Federación de Rusia
                [4] Moscow orgnameBotkin State Clinical Hospital orgdiv1Department of Oncology №71 Costa Rica
                Article
                S2695-50752022000200007 S2695-5075(22)00400200007
                10.53986/ibjm.2022.0014
                9c91c4cb-64b6-4e6f-8439-5799a4110297

                This work is licensed under a Creative Commons Attribution 4.0 International License.

                History
                : 10 March 2022
                : 05 November 2021
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 17, Pages: 5
                Product

                SciELO Spain

                Categories
                Case Report

                Eventración,Epiphrenic diverticula,Lewis operation,Eventration,Divertículo epifrénico,Operación de Lewis

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